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SHOCK
BY DR. OM LAKHANI , MD
IMPORTANT POINTS These notes are made from Standard Textbook of Medicine The current notes corresponds to Chapter 270 of Harrisons Internal medicine The Yellow shades refer to things you have to revise frequently (atleast once a week) The Blue shades refers to concepts The Pink shades refers to concepts that are not required for undergraduate level but useful for Postgraduate level.

Q. What is Shock ? It is syndrome arising because of Inadequate tissue perfusion. It is associated with MAP <60 mm Hg. Q. What is the vicious circle of Shock ?

Hypovolumeia

tissue injury Capillary leakage Release of DAMPs Danger associated molecular patterns

Inflammatory mediator release

Q. What are the major causes of Shock ? (classification of shock) 1. Hypovolemic shock 2. Cardiogenic shock DR. OM LAKHANI WWW.MEDICINENOTES.COM Page 1

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3. 4. 5. 6. Septic shock Neurogenic shock Hypoadrenal shock Traumatic shock

Q. Which two organs must continuously receive blood supply ? Blood to brain and heart must continue despite Hypotension. Else they develop ischemia very fast. Q. Which blood vessels maintain the Systemic vascular resistance ? Arterioles are responsible for maintaining the systemic vascular resistance. Alpha1 receptor present cause vasoconstriction while beta 2 sympathetic receptors cause vasodilatation. When there is reduced pressure, the blood to brain and heart is maintained while blood to other organs is impaired. Q. Which is the key process that ultimately causes Organ Failure ? Impairment of Microcirculation occurs in later stages of shock. This is responsible for the Organ failure that results from shock. Q. Which hormones are increased in shock ? 1. Cortisol (because of Increase ACTH release) 2. Glucagon 3. Catecholamines 4. Vasopressin 5. Aldosterone

CLINICAL PEARL : Increase LACTATE/PYRUVATE RATION is a marker of Hypoxia in shock Q. True or false- Serum triglycerides are reduced in Shock ? False- Triglycerides are typically increased in Shock.

Q . What agent is called as endogenous Pyrogen ? IL-1beta is marked as endogenous pyrogen

MANAGEMENT OF SHOCK
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Q. In which condition is Swan Ganz (Pulmonary arterial catheter) put in case of shock ? Conditions were PAC is put are : 1. Shock with on-going blood loss 2. Cardiac dysfunction 3. Rapid fluid shifts Q. What are the parameters required to determine the type of Shock ? To characterize the type of Shock you are dealing with you have to measure 1. 2. 3. 4. CVP PWCP (approximately equal to LA pressure) Systemic vascular resistance Venous Oxygen saturation

Q. In which type of Shock CVP and PCWP are increased ?

1. Cardiogenic shock 2. Sometimes in Septic shock Q. In which type of Shock is Cardiac output increased ? 1. Early septic shock 2. Shock with Liver failure Q. In which type of shock is SVR reduced ? 1. Early septic shock (hyperdynamic phase of septic shock) 2. Hypoadrenal shock

HYPOVOLEMIC SHOCK
Q. True or false Hypovolemic shock is the most common cause of shock ? True.

Q. What are the clinical features of reduce volume 20% reduction of Circulating volume Mild tachycardia Mild Anxiety

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20-40% reduction Anxiety Tachycardia Postural hypotension- normal blood pressure in supine position >40% reduction Reduce BP in supine position Confusion Agitation Oliguria

IMP PEARL: Loss of consciousness is a poor prognostic sign in Hypovolemic shock and must be dealt with aggressively Q. Is fall of Hematocrit or Fall in Hemoglobin reliable marker for Hypovolemia ? No. It can often be misleading. Fall of Hematocrit or Hemoglobin is often delayed in patients with Hypovolemia Q. What clinical signs must be searched for before starting aggressive fluid management in Hypovolemic shock ? Cardiogenic shock must be ruled out before starting aggressive fluid resuscitation for Hypovolemic shock. Presence of following signs points towards a possible cardiogenic shock 1. Raised JVP 2. Presence of S3 3. Presence of Basal crepitations

MANAGEMENT OF HYPOVOLEMIC SHOCK

Q. Give protocol for management of Hypovolemic shock ?

Fluid is started in form of Either Normal Saline or Ringer lactate @2 litres over 20 min Once volume is restored if the patient remain hypotensive then ionotropic agent is added Apart from this supplemetatory oxygenation and if required endotracheal intubation must be considered . WARNING ! Ionotropes are to be added only after fluid volume is restored Q. What is role of 3% NaCl in management of Hypovoluemia ?

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Small bolus of 3% NaCl has been found to improve survival in patients with traumatic brain injury Q. What is the role of Colloid in Hypovolemia ? In trauma especially traumatic brain injury Colloids have been found to be associated with increase mortality Hence in current view colloids are not recommended in Fluid resuscitation. Q. When should Packed cells be given ? PCV is given if the patient has Hb <10 gm% Once the volume is restored no further PCV is required unless patient has Hb <7gm% Q. What are precautions to be taken before PCV is given ?

Freshly banked (<14 days) old is ideal for patients who have had blood loss Recent studies recommend 1:1 ratio of PCV to FFP in patients with Shock to correct coagulopathy

OTHER FORMS OF SHOCK

Q. A patient has road traffic accident. Following this the patient is found to have distended neck veins , with muffled heart sounds and Hypotension. He also has Pulsus paradoxus. What do you suspect ? The patient could have a pericardial tamponade What is described above is known as Becks triad An urgent echocardiography is indicated and removal of the fluid must be considered earliest through Subxiphoid route. This is a form of Compressive cardiogenic shock Q. What are the other causes of Compressive cardiogenic shock ? Another important cause of Compressive cardiogenic shock is a Tension Pneumothorax. Q. What are the causes of Neurogenic shock ? Neurogenic shock can be caused by 1. Cephalad migration of spinal anaesthesia 2. Cervical spine injury 3. Head injury Q. What is the pathophysiology of Neurogenic shock ?

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Reduce sympathetic output leads to blood pooling in Veins and arteries This is the cause of the reduce perfusion Patient has Hypotension yet warm extremities and that is the characteristic finding of this condition. Q. What is the protocol for management of Hypoadrenalism in critically ill patient ?

If a patient with shock remains hypotensive despite fluid recitation then a possibility of Hypoadrenalism should be considered

suspected hypoadrenalism

CHECK Cortisol

<15 ug/dl

15-33 ug/dl

>33 ug/dl

Give Hydrocortisone

Go for Short synacten test Give 250 mcg of Synachten

No management

Cortisol increase >9 ug/dl

Cosrtisol increase <9 ug/dl

Give Hydrocort

No management

An alternative approach is to give a trial of 4 mg of Dexamethasone. If the patient responds then hydrocortisone is given. Dexamethasone is given as it doesnt interfere with Short Synachten test if required further. Hydrocortisone if required is given in dose of 100 mg IV 6 hourly.

Q. Which anaesthetic agent can lead to Hypoadrenalism ?

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Etomidate often used before intubation can lead to Hypoadrenalism. Q. What is the nature of various Inotropic agents used in treatment of shock ?

Dobutamine is Inotropic but can lead to drop is SVR (systemic vascular resistance) in some patients Dopamine is inotropic as well as Chronotropic. It also maintains the SVR (systemic vascular resistance) Noradrenaline increases SVR and also has ionotropic action without being chronotropic (Harrison 18th edition)

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