Shock

Dr K Lakshman FRCS

klakshman58@gmail.com
Plan

● Define shock
● Types of shock
● Diagnosis
● Focus on 2 common surgical types
● Practical management
Definition

Shock is defined as a state of cellular and tissue hypoxia due to either reduced
oxygen delivery, increased oxygen consumption, inadequate oxygen
utilization, or a combination of these processes. This most commonly occurs
when there is circulatory failure manifested as hypotension (ie, reduced tissue
perfusion); however, it is crucial to recognize that a patient in shock can
present hypertensive, normotensive, or hypotensive. Shock is initially
reversible, but must be recognized and treated immediately to prevent
progression to irreversible organ dysfunction. "Undifferentiated shock" refers to
the situation where shock is recognized but the cause is unclear.

Gieski DF, Uptodate, 2020

Definition - 2

Shock is a clinical condition that is defined by the presence of:

● hypotension with a systolic blood pressure less than 90 mmHg or a

mean arterial pressure (MAP) less than 60 mmHg or reduced by
greater than 30%, for at least 30 minutes
● oliguria (urine output less than 0.3 ml/kg/hour for two consecutive
hours)
● poor peripheral perfusion.
Kalla M, Surgery (Ox), 2019
Classification

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Lack of oxygen for cellular metabolism

Classification

Creator: Sue
Information extracted from IPTC Photo Metadata.
Hypovolaemic Shock

● Blood Loss - trauma and ● Road traffic accident

Surgery ● Multiple fractures of long bones
● Fluid Loss - GI losses. ● Low thready pulse, Pale
● Hypotensive, Sweaty
Plasma loss in Burns ● Hyperpnoea
● Abdominal Distention
● RUQ tenderness
Cardiogenic Shock

● Myocardial infarction ● Chest pain, restless

● Toxic myocarditis ● Sweaty
● CCF ● Possible irregular pulse
● Hypotensive
● Rales in lungs
● Raised JVP
Obstructive Shock

● Cardiac tamponade ● Chest pain, restless, Sweaty

● Possible irregular pulse
● Pulmonary embolism
● Hypotensive
● Aortic Dissection ● Rales in lungs
● Raised JVP
● Need echo to differentiate from
cardiogenic shock
Distributive Shock

● Sepsis ● Hypotensive
● Large pulse pressure, low
● AV shunting
diastolic pressure
● Neurogenic - autonomic ● Warm extremities
tone ● Good capillary refill
Surgeon primarily deals with...

Haemorrhagic Septic
Hypovolaemic Distributive
 Frank Starling Law - Hypovolaemia

EDV

Vasoconstriction

SV reduction

Kalla M, Surgery (Ox), 2019

 Fick Principle - Oxygen Consumption

Aerobic

Anaerobic

Tissue death

Kalla M, Surgery (Ox), 2019

Clinical Stages of Shock
 ABCDE of Resuscitation

Thim T, IJGM,, 2012

 ABCDE of Resuscitation

Thim T, IJGM,, 2012

 ABCDE of Resuscitation

Thim T, IJGM,, 2012

Monitoring

● NIBP, Arterial catheter? ● S Lactate

● ECG ● Base deficit
● CVP ● Serial Hb
● Urinary catheter ● 1 or 2 large bore cannula
● Pulse oximeter
● Trans-oes Echo

Muscle PO2
Bladder Mucosa pH
Consensus ...
https://www.picuki.com/media/21853055
59188803841
Give priority to ...

● Arrest of haemorrhage
● Correcting coagulopathy
● Permissive hypotension - 80-90 systolic
● Permissive anaemia - 7-8 gm Hb
Blood Transfusion

● Preferably after stopping haemorrhage

● Earlier to keep patient alive
● Whole blood?
● 1:1:1 - Packed cells:FFP:platelets
● Anti fibrinolysin - stabilizes clots
● Calcium gluconate 1 amp for every 3 units of blood
Septic Shock - Distributive
 SIRS

McLelland, 2014
Sepsis
Sepsis - Pathophysiology

Sciencedirect
Investigations

CBC, RBS ECG, Echo

Urea Creatinine CXR

LFT, Amylase, Lipase Abdominal U/S

Coag Profile, D Dimer, platelet Count Urine and Blood Culture

S lactate CT Chest, Abdomen

Blood gases
Surviving Sepsis Campaign (SSC) Bundles
Surviving Sepsis Campaign (SSC) Bundles

Moreno, 2013
Vasopressors
Source Control

● Drain abdominal abscesses

● Clear soft tissue infections
● Perianal infections
● Infected Catheters
● UTI
● Chest infection
Cardiogenic shoch = Pathophysiology

Chioncel, Am j Therap, 2020

Cardiogenic shock

● 30-60% mortality
● Noradrenaline vasopressor drug of choice
● Dopamine and epinephrine - show higher mortality
● Early revascularization of ‘culprit’ lesion only
● Mechanical circulatory support devices - useful in
select cases
● VAD and ECMO better than IABP (?)
● Develop regional specialist centres

Chioncel, Am j Therap, 2020

Non Septic States
To Conclude …..

● Shock is a life threatening phenomenon

● Learn the diagnostic steps
● Learn to resuscitate
● Monitoring
● Principles of Fluid administration
● Vasopressor administration
● Source control in sepsis
Thank You