Blok : Trauma and Emergency

SHOCK
dr. Imam Ghozali., M.Kes, Sp.An

Departemen Ilmu Anestesi
Fakultas Kedokteran Universitas Malahayati
Bandar Lampung
What is Shock?
Inadequate perfusion of body tissue
that begins at the cellular level and if
left untreated results in death of tissue,
organs, organ systems, and ultimately
the entire organism
IT IS NOT LOW BLOOD PRESSURE!
Shock is a result of many reasons:
Trauma
Fluid loss
MI
Infection
Allergic Reaction
Spinal Cord Injury
Other reasons
What is adequate perfusion?
Constant and necessary passage of
blood through the bodys tissue
Perfusion is dependent on a
functioning and intact circulatory
system
Components of circulatory system

The pump(heart)
The fluid(blood)
The container(blood vessels)
The Pump
The Heart is the pump of the
cardiovascular system
It receives blood from the venous
system then pumps the blood to the
lungs for oxygenation, then to the
peripheral tissues
Stroke Volume
The amount of blood ejected by the
heart in one contraction
Factors affecting stroke volume
Preload
Cardiac Contractile Force
Afterload
Preload
Amount of blood delivered to the heart
during diastole
Cardiac Contractile Force
The strength of contraction of the heart
It is affected by circulating hormones
called catecholamines
-Epinepherine
-NorEpinepherine
Frank Starling Mechanism
The greater the stretch of the cardiac
muscle, up to a certain point, the
greater the force of cardiac
contraction(I.E. the rubber band effect)
Afterload
Resistance against which the ventricle
must contract
Determined by the degree of peripheral
vascular resistance
Cardiac Output
Amount of blood pumped in one
contraction

Stroke volume x Heart rate=Cardiac
output
Peripheral Vascular Resistance
Pressure against which the heart must
pump
Blood pressure=cardiac output x
peripheral vascular resistance
Fluid
Blood is thicker and more adhesive than
water
Consist of plasma and formed elements:
Red cells, White cells, Platelets
Transports oxygen, carbon dioxide,
nutrients, hormones, and metabolic
waste
An adequate amount is needed for
perfusion

Container
Blood vessels serve as the container
Under control of the autonomic nervous
system they can adjust size and
selectively reroute blood through
microcirculation
Microcirculation is comprised of the
small vessels:
Arterioles, Capillaries, and Venules
Container cont
Capillaries have a sphincter between
the arteriole and capillary called the
pre-capillary sphincter
Pre-capillary sphincter responds to local
tissue demands such as acidosis,
hypoxia, and opens as more blood is
needed
Post-Capillary Sphincter
At the end of the capillary between the
capillary and venule
Opens when blood is needed to be
emptied into the venous system
Blood Flow Regulation
Peripheral Vascular Resistance
Pressure within the system
Major functions of Perfusion
Oxygen transport
Waste Removal
Inadequate Pump
Inadequate preload
Inadequate cardiac contractile strength
Inadequate heart rate
Excessive afterload
Inadequate Fluid
Hypovolemia (abnormally low
circulating blood volume)
Inadequate Container
Dilated container without change in
fluid volume
Leak in container
Shock at cellular level
The causes of shock vary, however the
ultimate outcome is impairment of
cellular metabolism
Impaired use of oxygen
When cells dont receive enough oxygen
or cannot use it effectively, they change
from aerobic to anaerobic metabolism


Glucose breakdown. (A) Stage one, glycolysis, is anaerobic (does
not require oxygen). It yields pyruvic acid, with toxic by-products
such as lactic acid, and very little energy. (B) Stage two is aerobic
(requires oxygen). In a process called the Krebs or citric acid
cycle, pyruvic acid is degraded into carbon dioxide and water,
which produces a much higher yield of energy.
Compensated and Decompensated
shock
Usually the body is able to compensate
but when these mechanisms fail shock
develops and may progress
Compensation Mechanisms
Catecholamines may be secreted ( I.E.
Epinephrine and norepinephrine)
The Renin-Angitensin system aids in
maintaining blood pressure
Endocrine Response by pituitary gland
results in secretion of anti-diuretic
hormone (ADH)
Catecholamine Release
Epinephrine and Norepinephrine release
affects the cardiovascular system,
causing increase in HR, increase in
Cardiac contractility strength, arteriolar
constriction which elevates blood
pressure
Renin-Angiotensin system
Renin is released from the kidneys and
acts on specialized plasma protein
called Angiotensin the produces
AngiotensinI.
AngiotensinI is converted to
AngiotensinII by enzymes in the lungs
called Angiotensin Converting Enzyme
(ACE)
Renin-Angiotensin System (cont)
AngiotensinII is a potent vasoconstrictor
Angiotensin II stimulates production of
aldostrone, which causes the kidneys to
reabsorb sodium
Anti-Diuretic Hormone
Causes the kidneys to reabsorb water
creating an additive to the aldostrone
Compensated Shock
Early stages of shock where the bodys
compensatory mechanisms are able to
maintain normal perfusion
Decompensated Shock
Advanced stage of shock that occurs when
the bodys compensatory mechanisms fail
to maintain normal perfusion
Irreversible Shock
Stage of shock that has progressed to the
point that the body nor medical
interventions correct the problem
Types of shock
Cardiogenic shock (Inadequate Pump)
Hypovolemic shock (Inadequate Fluid)
Neurogenic shock (Inadequate Container)
Anaphylactic shock
Septic shock
Cardiogenic Shock
The heart loses the ability to supply all
body parts with blood
Usually the result of left ventricular failure
secondary to acute MI or CHF
Many patients will have normal blood
pressures
S/S of Cardiogenic Shock
Major difference between other types of
shock is presence of Pulmonary Edema
Difficulty breathing
Wheezes, Crackles, Rales are heard as fluid
levels increase
Productive cough with white or pink-tinged
foamy sputum
Cyanosis
Altered mentation
Oliguria ( decreased urination)
TX for Cardiogenic Shock
Assure open airway
Adminster oxygen
Assist ventilations as needed
Keep patient warm
Place patient in position of comfort
Establish Iv with minimal fluid
administration
Monitor Vitals
May need to administer Dopamine or
Dobutamine
Hypovolemic Shock
Internal or external hemorrhage
Trauma
Long bone or open FXs
Dehydration
Plasma loss due to burns
Excessive sweating
Diabetic Ketoacidosis with resultant osmotic
diuresis
S/S of Hypovolemic Shock

Pale, cool, clammy skin
Blood pressure may be normal then fall
Pulse may be normal then become rapid,
finally slowing and disappearing
Urination decreases
Cardiac dysrhythmias may occur
Tx for Hypovolemic Shock
Airway control
Administer high flow oxygen
Control severe bleeding
Keep patient warm
Elevate lower extremities
Establish IV and administer bolus of
crystalloid solution for fluid replacement




Neurogenic Shock
Results from injury to brain or spinal cord
causing interruption of nerve impulses to
arteries
Arteries lose tone and dilate causing
hypovolemia
Sympathetic nerve impulses to the adrenal
glands are lost, which prevents the release
of catecholamines and their compensatory
effects

Neurogenic Shock (cont)
High cervical injuries cause interruption of
impulse to peripheral nervous system
causing
Neurogenic shock is most commonly due to
severe injury to spinal cord or total
transection of cord (spinal shock)
S/S of Neurogenic Shock
Warm, Dry, Red Skin
Low Blood Pressure
Slow Pulse
TX for Neurogenic Shock
Airway control
Maintain body temperature
Immobilization if indicated
Consider other causes of shock
IV and medications that increase peripheral
vascular resistance (I.E. Norepinephrine,
Dopamine)

Anaphylatic Shock
Severe immune response to foreign
substance
S/S most often occur within minutes but
can take up to hours to occur
The faster the reaction develops the
more severe it is likely to be
Death will occur if not treated promptly
S/S of Anaphylactic Shock
Skin
- Flushing
- Itching
- Hives
-Swelling
-Cyanosis





S/S of Anaphylactic Shock
Respiratory System
- Breathing difficulty
- Sneezing, Coughing
- Wheezing, Stridor
- Laryngeal edema
- Laryngospasm
S/S of Anaphylactic Shock
Cardiovascular System
- Vasodilation
- Increased heart rate
- Decreased blood pressure
S/S of Anaphylactic Shock
Gastrointestinal System
- Nausea, vomiting
- Abdominal cramping
- Diarrhea
TX for Anaphylactic Shock
Airway protection which may include
Endotracheal Intubation
Establish IV with crystalloid solution
Pharmacological interventions: Epinephrine,
Antihistamines(Benadryl),
Corticosteroids(dexamethasone),
Vasopressors(dopamine, Epinephrine), and
inhaled beta agonist(albuterol)
Septic Shock
An infection enters bloodstream and is
carried throughout body
Toxins released overcome
compensatory mechanisms
Can cause dysfunction of one organ
system or cause multiple organ
dysfunction
S/S of Septic Shock
Increased to low blood pressure
High fever, no fever, hypothermic
Skin flushed, Pale, Cyanotic
Difficulty breathing and altered lung
sounds
Altered LOC
TX of Septic Shock
Airway control
Administer oxygen
IV of crystalloid solution
Dopamine for blood pressure support
Monitor other vitals
Multiple Organ Dysfunction
Syndrome
MODS is the progressive impairment of
two or more systems from and
uncontrolled inflammatory response to
a severe illness or injury
Progression To MODS
Infection
Sepsis
Septic shock
MODS
Death(if not corrected early)
Primary MODS
Organ damage due to specific cause such
as ischemia or inadequate tissue
perfusion from shock, trauma, or major
surgery
Stress and inflammatory responses may
be mild or undetected
During the response, neutrophils,
macrophages, and mast cells are thought
to be primed by cytokines
Secondary MODS
The next time there is injury, ischemia, or
infection the primed cells are activated,
producing and exaggerated inflammatory
response
The inflammatory response enters a self-
perpetuating cycle causing damage and
vasodilation
And exaggerated neuroendocrine response
is triggered causing futher damage
24 hours post resuscitation
Low grade fever
Tachycardia
Dyspnea
Altered mental status


Within 24 to 72 hours
Pulmonary failure
begins
Within 7 to 10 days

Hepatic failure begins
Intestinal failure begins
Renal failure begins
Within 14 to 21 days

Renal and Hepatic failure intensify
Gastrointestinal collapse
Immune system collapse
After 21 days
Hematologic failure begins
Myocardial failure begins
Altered Mental status resulting from
Encephalopathy
Death