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7/20/09

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Alfred H Belmonte MD FPCS
UST Department of Surgery
SHOCK
Definition of terms
Recognition
Signs/symptoms
Types of Shock
Prevention
Management
Complications
SHOCK
Pathophysiologic condition
Disruption of homeostasis
Determines organism survival
inadequate tissue perfusion
Insufficient to maintain aerobic
metabolism
Substrate supply/demand
PHYSIOLOGIC RESPONSES
Neuroendocrine/inflammatory
Response intensity
Persistent hypoperfusion
Hemodynamic derangement
End organ dysfunction/failure
Cell death patient death
Response Phases
Compensated
Preservation of perfusion
Autonomic
Hormonal
microcirculation
Vasoconstriction
Fluid excretion inhibited
Fluid intravascular space
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Response Phases
Decompensation phase
Cell death/tissue injury
Reversible with reperfusion
Irreversible phase
Progressive tissue hypoperfusion
Unresponsive cardiovascular
decompensation
Types of Shock
Hypovolemic
Septic
Cardiogenic
Neurogenic
Obstructive
Traumatic
Recognition of Shock
Blood pressure
pulse rate
Pallor
Temperature
Mentation
Urine output
Central Venous Pressure / PCWP
Hypovolemic Shock
Causes:
intravascular volume depletion -
hemorrhage
plasma volume -
extravascular sequestration
asxites
peritonitis
GI,GU, insensible losses
intestinal obstruction
heat
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Hypovolemic shock
Hypoperfusion
! blood volume
! cardiac output
" peripheral vasoconstriction
(compensatory)
Hypovolemic shock
Classification
Class I 10-15 % BV
Class II - 20-30% BV
Class III 3--40 % BV
classical clinical manifestations
Class IV
Hypovolemic shock
A 35 yr old male is stabbed in
the left chest 10 minutes prior
to admission at the emergency
room.
PE: conscious, agitated
Vital Signs:
Thorax: symmetrical expansion,
1 cm lacerated wound ---------
Treatment
REPLACE LOST
VOLUME
STOP BLEEDING
VASOPRESSORS - ?
Inotropic support
AORTIC CROSS
CLAMPING
PASG
TRAUMATIC SHOCK
Hypovolemic Shock
+ direct soft tissue injury/
fractures
multiple inflammatory mediator
systems
higher incidence of SIRS/ MOFS
second hit phenomenon
CARDIOGENIC SHOCK
Intrinsic
Compressive
pump failure
normal circulating volume
no change in peripheral
resistance
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Septic shock
Host response to sytemic
infection
Warm shock (hyperdynamic)
inflammatory
severe vasodilatation ! peripheral
resistance
hypodynamic (cold) - gross
decompensation
Neurogenic Shock
Spinal cord/ head injury
Spinal anesthesia
Ablation of vascular sympathetic
tone
"venous capacitance, !peripheral
resistance
hypoperfusion is minimal, sequela
infrequent
Pitfall - undetected concomitant
hypovolemia