SHOCK

Introduction
Very common
High risk of death
 Def:
It is a situation in which there is inadequate tissue
perfusion that can result in hypoxia which leads to
cellular dysfunctioning or even organ failure if not
reversed.
It is not an event, it is a process…..
Non progressive- body compensate
Progressive- medical treatment required
Irreversible- death
Types of shock
Hypovolemic shock
Cardiogenic shock
Obstructive shock
Distributive shock .
-Anaphylactic shock
-neurogenic shock
-septic shock
 Hypovolemic shock
Major reduction in blood volume in
vascular system which makes heart unable
to pump enough blood to the body tissue.

Low venous return~⬇preload~⬇stroke

volume~⬇CO
Causes:
A) Haemorrhagic (blood loss)
a)Trauma b)GIT bleed- peptic
ulcer, abdominal aortic
aneurism
C)Postpartum haemorrhage
d) Ectopic pregnancy

e)Hemoptysis
 B)Non blood fluid loss:
b) Excessive
a)3 degree burn vomiting and
diarrhea
c) Bowel obstruction
d)Acute pancreatitis e) Diabetes ketoacidosis
Classification of hypovolemic shock
Parameters
Class1 Class ll Class lll Class lV
Blood loss% <15% 15-30% 30-40% >40%
Blood loss (ml) <750ml 750-1500ml 1500-2000ml >2000ml
Pulse rate <100/min <100/min 120-140/min >140/min
Bp N N ⬇⬇ ⬇⬇⬇
Pulse wave N ⬇ ⬇⬇ ⬇⬇
amplitude
Capillary refill N + + +
Respiratory R 14-20/min 20-30/min 30-40/min >40/min
Urinary output >30ml Decreased Oligonuria Anuria
Mental Status Mild anxiety Anxiety Confused Lethargic
Skin N Cool Cool Cool
compensate to Compensatory Compensatory Near to death
maintain mechanisms mechanism
All parameters start failing fails
Sign and symptoms:

1. Restless and irritantion

2. Altered level of
consciousness
3. Tachycardia
4. Rapid breathing
5. Dull and shrunken eyes
6. Weak/rapid pulse
7. Nausea and vomiting
8. hypothermia
Lets imagine a situation👀

A man has fallen on road side….he is

severely dehydrated ,unconscious, his
pulse is weak and rapid, his eyes is
shrunken., heart beat is fast.
What will you do?

How will you manage with that situation?

This way????

As expected from
today’s generation!
 Ofcourse not

• But for this we should

have the knowledge how
to manage it…..
• So lets learn the
management of
hypovolemic shock…..
Management of hypovolemic shock
A] ABC
B]Causative treatment
C]Volume repletion
D]Inotropic therapy
E]Vasopressor agents
 ABC…..???
A- airways
B- breathing
C- circulation

• First of all we should

stabilized vital
organs.
• Before proceeding
further , first
determine the
cause of
hypovolemia.
B] Causative treatment-
• Stop bleeding in case of any
hemorrhage.
• Along with this start volume
repletion

• Methods of control local bleeding

• Manual pressure
• Suturing
• Dressing
• Use local hemostatics(styptics)
C] Volume Repletion
1.Vascular access site
Peripheral VR Central VR
1.Multiple access(2-4 veins) It initiates after PVR .
2.Large peripheral catheter
3. EJV
Advantage • -less time
• -based on basic and
-fast administration
-catecholamines and
simple knowledge hypertonic solutions can
• -minor complications
be more effective
Disadvantage • Vascular access should -risk of complications high
be changed in 24hr
 2. Solutions:
Solutions Advantages Disadvantages

a. Isotonic 1. Normal saline • Easy available • Small volume

solutions (0.9%) • Reduced risks effect
1. Ringer solution • Cheap • Short duration
3. Lactate ringer effect
solution • High risk of
edema
b. Hypertonic Hypertonic saline
solutions. (4% dextrose) • No fluid overload
and edema

c. Colloid solution

d. Blood and
blood product
c) Colloid Advantages Disadvantage
solutions(volm
expander)

I. Dextrans- Plasma vol Interfere with

70 . Most expand for coagulation
commonly 24hrs and platelets
use function

II. Dextrans • Rapid acting • Shorter

40 • Prevent RBC duration
sludging action
• Tubular
obstruction
To be cont….
Colloid solution Advantages Disadvantage

III.Gelatine Degraded •Non antigenic Expensive than

gelatin polymer • expansion dextran
last for 24hr

IV. Hetastarch Hydroxyethyl • Side effects-

Less use starch • Salivary
gland
swelling
• Periorbital
edema
• rashes
• Chills & rigor
 To be cont….
Advantages Disadvantages

V. Human (20% human Expensive

Albumin albumin)= No risk of
400ml of frozen sensitization
plasma or with repeated
800ml of whole infusion
blood
 D) Blood and blood
products:
• It is definitive treatment for
haemorhagic shock.
• Packed RBC is best for
elavating O2 carrying
capacity.
• Best practice (if time allows
cross-match patient’s blood)
• Or use O- negative blood
 Method of administration;
Step 1: normal saline (200ml in first
15-30sec)
Step 2: continue according to
haemodynamic parameter and
clinical features.

Monitoring the treatment

efficiency:
• Clinical parameters
• Hemodynamic parameters
• Lab diagnosis
• C] Inotropic supports and vasopressors
only after volume replacement
used to improve CO

1. Dopamine
2.Noradrenaline
3.Adrenalime