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Shock is defined as o Any condition wheren there's decreased tissue perfusion That lower tissue perfusion Tonicity of blood

od vessel wall (decreased tonicity) esp of the artery Types of shock with dec tonicity Neurogenic shock Septic shock Early - dec tonicity of the blood vessel wall due to to in being secreted by bacteria (endoto in) al late Anaphylactic shock - allergic reaction !ypovole"ic - #ost i"portant factor in surgery$ decrease in blood volu"e leads to hypotension$ blood vol -- lose fluid content --dec %& !e"orrhagic shock 'unction of the !eart (f "alfunctioning of "yocardiu" esp ische"ia) atherosclerosis of coronary artery ---low *+ *ardiac co"pressive shock - pericardial ta"ponade !eart is nor"al &ericardial cavity is filled up with blood -effusion --li"iting distension of ventricle during diastole --so *+ is also low ---blood clogged in venous side of circulation &atient of a surgeon now

,ifferent Types of Shock o !ypovole"ic shock --lose volu"e of blood !e"orrhagic shock -ow preload - than you'll have low *+$ low syste"ic arteriole pressure$ sensed by the carotid sinus) by atrial receptors) and receptors in kidney Now sti"ulates hypothala"us *ould also directly sti"ulate the adrenal "edulla by passing the pituitary causing release of epineph and noreph --sti"ulation of heart to co"pensate --tachycardia Epi and nor also cause vasoconstriction -inc. vascular resistance (f you touch e tre"ity of in/ury) it's cold ---artery is constricted Trau"atic shock Al"ost sa"e as hypovole"ic shock

(n addition) there's an in/ured tissue0organ$ there are i""ediate release of "ediators (cytokines) ---increases intravascular coagulation --clogging of blood in that area #ost "ediators causes vasodilatation (nc seepage of plas"a outside of blood vessel 1e"ove dead tissue in brain to re"ove cytokines$ dead cells secrete these "ediators 2ith help of "onocytes) t cells

*ardiogenic Shock &ertaining to the function of heart that's no longer do"ain of surgeons &u"ping action of heart fails$ blood clogged behind the heart &reload aread elevated Surgery onlyl participates if need for us to i"prove perfusion of heart "uscle ---cardiac bypass ---use saphenous vein to bypass obstruction of coronary artery *ardiac *o"pressive Shock !eart is nor"al %ut low cardiac return due to e trinsic co"pression of heart &ericardial cavity filled up with fluid in case of infecti --pericarditis 'illed with blood in case of blunt or penetrating trau"a (stab0gunshot) aka pericardial ta"ponade Septic Shock ,ue to effect of to in being released by the bacteri (f gra" 3 ) then e oto in release (f gra" -) then endoto in released

Neurogenic Shock -oss of arterial and venous tones Tonicity of veins also decreased &ooling of blood in the peripheral venous syste" esp in splanchnic vessel ---veins of the 4(T tract &ooled there

*ellular *hanges in patients body if perfusion of blood not opti"u" o (f you have hypotension) it causes death to the cell because ,ue to he"e part of he"oglobin carrying +5 (in cytoplas" of 1%*) not being carried to tissues 5 organs to "aintain good o ygen level %rain !eart 2hy there's redirection of blood fro" other tissues to these 5

The o ygen is the end electron receptor of ET* (electron transport chain) (f you don't have +5 there) than entire ET* chain stopped (to produce AT&) Aerobic "etabolis" - using glucose 67 - 5 8 69 Anaerobic "etabolis" :-;< only #ost "etabolis" in cell are active processes$ so you need AT& for it to work Na = "e"brane pu"p Active process seen in cell "e"brane *ontinues to pu"p Na out and pu"p = in (f doesn't work) Na continues to enter and s"all = out (f Na in) drags in water (too "uch Na out$ if pu"p not work) Na keeps going in dragging in water) ---resulting to cellular swelling ---cell dies ----brain dies

1enal response o (f you lose blood) one of the organs &erfusion of glo"erulus goes down o =idney can survive ;>-?< "inutes if you put kidney in cold te"p (""ersed in ice bag area &rolonged hypoperfusion of kidney 'unctional0anato"ical changes ---a@ote"ia (elevated creatinine) ("portant for surgeon to know whether a@ote"ia &reload - treat by giving blood and fluid =idney parenchy"al da"age - don't give fluid$ kidney already working ---kidney ede"a &oor perfusion of glo"erulus Ase 1enal 'ailure (nde to see if preload Na of urine And plas"a creatinine (f B ;) prerenal oliguria =idney still functioning) poor perfusion of glo"erulus$ give fluid (f C ; acute renal failure (59 hrs) !ave to give fluid si"ultaneously with antidiuretics$ if keep giving fluid) pt "ight die of pul"onary ede"a &ul"onary response o ,a"age alveolar-capillary interface Acute diffuse lung in/ury

Seepage of fluid entering the interface Alveoli ,ue to "ediators) plas"a will now fill up the interface) "aking it wider$ so the +5 transport fro" alveoli goes to capillary that will link to he"oglobin not opti"u" ---hypo ia ---big gap btw alveolar line ep and epitheliu" of capillary -eekage of proteous fluid into interstiu" and alveolar space Acute respi distress syndroo"e + ygen won't go to alveoli &t goes to hypo ia ,ec pul"onary co"pliance !igh airway pressure to attain adeDuate tidal volu"e

#ultiple organ failure =idney and lungs

&athophysiology of Shock o !ypovole"ic -- "ost co""on !e"orrhagic "ost co""on -ose blood fro" the venous side (><E)$ veins "ore superficially located (f artery involved) pt will "ost likely die ,ecrease cardiac return -ow *+ -ow blood pressure ("portant of doctor to tell what stage he"orrhagic shock #ild - lose B 5< E of blood loss > liters ti"e .5< ---if lose B ; liter of blood) there will be co"pensation --release of E NE) adrenergic constriction of blood vessel$ cold skin Thirsty - good clue that pt in shocking condition 1e"e"ber bp) pulse rate nor"al$ urine nor"al *onstriction of blood vessel --cold e tre"ity #oderate 5<-9<E blood vol lost Eiters *old e tre"ity %p still nor"al) but pt will start to have low urine output due to aldosterone and antidiuretic hor"one Severe C9<E of blood vol lost +nly ti"e that bp of patient goes down Signs of #(

F waves and depressed St seg"ents 2hy surgeon always ask pt if cold ar") and asks for urine "easure"ent

*o"pensatory #ech o Adrenergic discharge - to co"pensate to have higher bp o !yperventilation 2hat happens - you inhale and e hale rapidly -onger inhalation and faster e hales 2hen inhale) thoracic pressure goes down so that lungs will e pand$ higher respi rate) longer ti"e of having dec thoracic pressure - helps venous blood to go fro" periphery to go to right side of heart -- better cardiac return ---better cardiac output o &t will collapse + ygen level of brain not opti"al -- unconscious (f lie down) better return of blood to heart not against gravity !ave to elevate the lower e tre"ity o 1elease of fluid fro" interstitiu" into intervascular space (n case of shock) inc epinephrine --causes constriction (pre capillary sphincter)$ True capillaries - carrying fluid o ygen to cell$ brings waste product of cell back to blood Gascular shunt -- bypasses the tissue0cell %etween shunt and true cap) you have precapillary sphincter$ in shock) epinep causes constriction of sphincter$ so instead of going to tissue) goes to vein and back to heart i""ediately (f that happens) hydrostatic pressure decreases so hydrostatic pressure in intercellular space (;>E) could go fro" half side of capillary to replenish fluid --so better cardiac return Gasoactive hor"ones and catabolic hor"ones (cataboli@e carb) pro) lipid resulting glycogen to glucose) a"ino acid)$ s"all solutes$ now go to intercellular space by e ocytosis$ goes out and oncotic pressure will increase (nc oncotic pressure) by os"osis (9<E of our fluids inside cell)$ now getting fluid co"ing fro" intracell co"pt to supply decrease of fluid in vessel So neuroendocrine syste" is reason why you have nor"al bp for "ild and "oderate shock %ut in severe) it can no longer co"pensate (nc hydrostatic pressure forcing water and protein to go to ly"phatics and replenishing the plas"a of the patient 'unction of kidney

("portant

,eco"pensation of hypovole"ic shock 1ela ation of arteriole) pre capillary spas" (nstead of constricting pre cap) it now rela es --bad ,eterioration of cell "e"brane function Na = pu"p no longer working$ cell dies 5 "ost sensitive signs of hypovole"ia *utaneous vasoconstriction +liguria #ost pts usually are alcoholics -- alcohol causes vasodilatation and inhibits secretion of A,! (nstead of oliguria) pt will have polyuria S"ell alchol in breat) put central venous pressure to check if pt has been corrected or still needs fluid resucitation

#onitoring &t (n case of shock o Ad"it pt o !ave to put 5 or 6 lines and have to use a wider gauge needle (gauge ;7);:);?) o ,on't give ,>-1) ,>N#S %etter use lactate without de trose &lain NSS witout de trose ,e trose causes os"otic diurses o &ut a folicatheter -- "onitor urine output hourly Nor"al urine output -- 6< "l0"inute (low li"it)$ if lower than that) then oliguria (n book ; "l 0 "inute 8 7< "l 'or neonates) 5.> "l 0 "inute o (f elderlly) check heart status =idney function --seru") creatine and bu" o Treat in/ured tissue or organ (f need for patient to receive whole blood or packed 1%*) carries +5

#anage"ent o *orrect dehydration --give crystalloid o ,isadvantage of giving colloid &ost resuscitation of !&N (nc intravascular volu"e at the e p ,epression of albu"in synthesis ,ep of circulation i""unoglobulin #ore e pensive and less easier to titrate &osition of &atient o 'owler position - put the foot down$ fowler foot - foot down

Trendule"burg -- put the head down Supine and elevate the leg Not good they said now$ increasing venous return) but abdo"inal organ is also pressing the diaphrag" so inhalation of pt co"pro"ised$ so best position is Supine &osition Elevate lower e tre"ity *heck heart Arryth"ia -- put in (*A --

(f old o o

Steroids not indicated in case of shock +5 inhalation but correct vascular volu"e o (f low 1%*) won't work *auses of 1efractory Shock o *ontinuing blood loss o (nadeDuate replace"ent of fluid o #assive trau"a or derange"ent -- /ust correct fluid but didn't do debrig"a of organ$ if still in/ured) organs will for" cytokines$ so you re"ove dead tissue o o (n elderly) heart didn't co"pensate "uch --heart failure (nfection -- co""unity acDuired (outside bacteria)$ sensitive to antibiotic (f pt stayed in hospital for week) bacteria is now hospital bourne$ resistant to drugs

Trau"atic Shock o -ose blood (plas"a) o (n addition) presence of in/ured tissue (trau"ati@ed) -- secretes "ediators which inc pul"onary vascular resistance due to tu"or necroting factor and interleukin ; - vasoconstriction of pul"onary vessle (nc seepage of fluid$ pt perfusion down due to third space loss (fluid enters into nonfunctional co"part"ent) !ave "icrothro"bi esp cytokines o Treat"ent !ave to correct fluid) hypovole"ia and debride"ent - re"ove cytokine source

*ardiogenic Shock o All signs and sy"pto"s of #( o (ncreased central venous pressure$ blood clogged on right side of heart &ut catheter at superior vena cava$ "ake incision in basilic vein$ put catheter and it will end in superior vena cava Nor"al :-;< c" water

(f B :) preload down *ardiac return not good (f C ;<) preload elevated *logging on the right side of hear So incase of hypovole"ic) he"orrhagic shock it will be decreased - lose blood --preload not good ---so B : (n cardiogenic shock) elevated due to clogging &icture of heart and superior vena cava description &ut catheter and it ends in sup vena cava$ :-;< B where water should be

o o o o o

*atheter placed even in pul"onary artery but it's e pensive &ut in (*A) give analgesics to relieve pain ("a/or sti"uli) #onitor cardiac function of pt Arryth"ia - give digitalis) dopa"ine) etc (f *+ not opti"u") refer to cardiologist to place pace"aker *ardiologis will refer pt for invasive cardio to chec) status of coronary artery if there's need to do bypass operation

*ardiac Ta"ponade ,ecreased cardiac co"pliance on right atriu" ,ec !eart not receiving opti" blood during diastole - cannot dilate opti"ally *ardiac Signs and sy"pto"s o Neck vein engorge"ent o ,istant heart sound (caused by valve closure)$ if blood not opti"u" closure of valves are low o (f cardiac return low) low *+ --- hypotension +ther signs o Tachycardia) oliguria) cold o &ulsus parao icus - when you inhale) your pulse pressure will be higher becaue inhalation --- thoracic pressure lower --venous return -so better *+ - nor"al %ut pulsus) when you inhale) filling pericardial cavity - low ventricular e pansion --- so it beco"es low pressure ,iagnosis o *linical presentation o !istory of in/ury o *ardinal signs o 2ater bottle shape -- reD for chest ray #anage"ent o %ring pt to +1 o ,o an anterolateral trachoto"y -- depress pericardial cavity --re"ove blood there and fi whatever trau"a done --cardiac return better -better *+ E"ergency o Ase pericardiocentesis

Ase spinal needle$ connect it to wide barrel syringe$ palpate for sternu" (costal angle) left side$ put needle 9> degrees directed to left shoulder$ hook the needle to E*4 "achine$ if you insert you won't hit the lung due to lingula of the left lung$ resistance of skin) "uscle -- no "ore resistance --now in pericardia$ cavity --pull the plunger 88 if blood there) aspirate the blood -to "ake sure in cavity -- push farther after the five$ look at E*4 -- if pure 1S pronounced -- you're hitting the ventricle -so you pull the needle back out a bit 88 now you're back in the right space ("proves neck vein engorge"ent *+ better -- hypotension lessens therapeutic (f no recurrence) /ust observe the patient$ so"eti"es in/ured vessel da"aged already

Septic Shock o *aused by bacterial infection 4ra" positive --e oto in 4ra" negative - endoto in o 4ra" negative sepsis "ore co""on in surgical pts o Asual source 4enitourinary tract --put folicatheter 1espiratory - pts who've had abdo"inal surgery$ contraction of diaphrag" li"ited by pain$ e pansion of basal lobe not opti"u" -- atylectesis - pneu"onitis ---pneu"onia 2hy in ab surgery) tell pt to have pul"onary therapy --deep breathing) nebuli@ation -- to prevent proble" in respi Ali"entary (ntegu"entary o Early Septic Shock !ave a war" e tre"ity Nor"ovole"ic +nly sy"pto"s !ypotenision - due to vasodilatation fro" endoto in ---have dec *+ with "ini"al resitance) inc heart rate) inc contractility %p of patient -- due to vasodilatation ,ecreased tonicity o -ate Septic Shock (f doctor failed to catch the sepsis) cold e tre"ity &t start to have hypovole"ia --inc seepage of fluid outside blood vessel - -third space loss *ause of hypertension (nc vascular per"eability ,ecrease cardiac output due to in pul"onary vascular resistance (nc peripheral resistance -- cold cyonotic e tre"ity (nc peripheral pressure o Treat"ent

(dentify organ0tissue where infection co"ing fro" 1eplace fluid - in late septic - lose fliud fro" dec *+ and third space loss 1eDuesting for culture and sensitivity *ulture - id bacteria Sensitivity -- antibiotic where bacteria is susceptible Early sign of gra" - infection !yperventilation 1espiratory alkalosis Altered sensoriu" of patient

Neurogenic Shock o Seen in spinal cord in/uries o &t nor"ovole"ic and so"eti"es hypovole"ic o &ooling of blood in syste"ic venules --*+ not good -- pulled in splanchnic area due to spinal cord in/ury o +nly type of shock wherein you're /ustified to give vasoconstrictor i""ediately ,ecreased tonicity of artery -- so /ust i"protve tonicity by giving vasoconstriction o Treat"ent 4ive fluid 4ive vasoconstrictor --have to give it To i"prove *ardiac return) elevate the lower e tre"ity