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MANAGEMENT OF SHOCK

MANAGEMENT OF SHOCK

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MANAGEMENT OF SHOCK

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  1. MANAGEMENT OF SHOCK Dr. Hanin Osama

  2. 1-Management of hypovolemic Shock • ABCs (Air way,Breathing ,Circulation ) • Establish 2 large bore IV cannula 16 gauge or larger or a central line (internal jugular and subclavian vein catheterization) • Crystalloids • Normal Saline or Lactate Ringers(Lactated Ringer's solution is a solution that is isotonic with blood and intended for intravenous administration. It may also be given subcutaneously.single dose container.(sodium chloride, soldium lactate, potassium chloride and calcium chloride) • 2-3 liters • Packed RBCs • O negative or cross matched • Control any bleeding • Arrange definitive treatment

  3. 2-Treatment of Cardiogenic Shock • Goals- Airway stability and improving myocardial pump function • Cardiac monitor, pulse oximetry (Pulse oximeters are non-invasive devices used to measure a patient's blood-oxygen saturation level and pulse rate.) • Supplemental oxygen • IV access • Diuretics • Positive inotropic drugs • IABP (Intra-Aortic Balloon Pump)is utilized if medical therapy is ineffective. • Catheterization if ongoing ischemia • Cardiogenic shock is the exception to the rule that NS (Normal saline)is always given for hypotension NS will exacerbate cardiac shock.

  4. Treatment of Cardiogenic Shock • AMI • Aspirin, statin, clopedogril, morphine, heparin • If no pulmonary edema, IV fluid challenge • If pulmonary edema • Dopamine – will ↑ HR and thus cardiac work • Dobutamine – May drop blood pressure • Combination therapy may be more effective • PCI (percutaneous intervention ) or thrombolytics • Right Ventricle infarct • Fluids and Dobutamine (no NitroGlycerine) • Acute mitral regurgitation or Ventral Septal Defect • Pressors (Dobutamine)

  5. 3. Distributive, A. Management of Septic Shock • 2 large bore Ivs • NS I/V bolus- 1-2 L wide open (A large volume of fluid or dose of a drug given intravenously and rapidly at one time. intravenous bolus,. a relatively large dose of medication administered into a circulation ) • Supplemental oxygen • Empiric antibiotics, based on suspected source, as soon as possible, Broad Spectrum Antibiotics • Cover gram positive and gram negative bacteria • Add additional coverage as indicated e.g. MRSA- Vancomycin, Asplenic- Ceftriaxone for N. meningitidis, H. infuenzae • Vasopressors e.g. dopamine to raise the BP • Bicarbonate if pH < 7.1

  6. B-Anaphylactic Shock- Treatment • ABC’s; Angioedema and respiratory compromise require immediate intubation(is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or 4 the purpose of adding & removing fluid)... • IV, cardiac monitor, pulse oximetry • IV Fluids, oxygen • Epinephrine • 0.3 mg IM of 1:1000 (epi-pen) • Repeat every 5-10 min as needed • Caution with patients taking beta blockers- can cause severe hypertension due to unopposed alpha stimulation • For CV collapse, 1 mg IV of 1:10,000 • If refractory, start IV drip • Corticosteriods

  7. Anaphylactic Shock - Treatment • H1 and H2 blockers • H1 blocker- Diphenhydramine 25-50 mg IV • H2 blocker- Ranitidine 50 mg IV • Bronchodilators; Albuterol nebulizer, Atrovent nebulizer, Magnesium sulfate 2 g IV over 20 minutes • Glucagon(May be used as an inotropic agent in beta-blocker overdose.) • For patients taking beta blockers and with refractory hypotension. • 1 mg IV q (each,every )5 minutes until hypotension resolves • All patients who receive epinephrine should be observed for 4-6 hours • If symptom free, discharge home • If on beta blockers or h/o severe reaction in past, consider admission. B-blk==hypoglycemia

  8. C-Neurogenic Shock- Treatment • A,B,Cs • Remember c-spine precautions • Fluid resuscitation • Keep MAP(mean arterial pressure ) at 85-90 mm Hg for first 7 days • Thought to minimize secondary cord injury • If crystalloid is insufficient use vasopressors • Search for other causes of hypotension • For bradycardia • Atropine • Pacemaker • Methylprednisolone • Used only for blunt spinal cord injury • High dose therapy • Must be started within 8 hours • Controversial- Risk for infection, GI bleed

  9. 4. Obstructive Shock • Tension pneumothorax Rx: Needle decompression, chest tube B. Cardiac tamponade ( In this condition, blood or fluid collects in the pericardium, the sac surrounding the heart. This prevents the heart ventricles from expanding fully.) Rx: Pericardiocentesis (Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac, the tissue that surrounds the heart) C. Pulmonary embolism Rx: Heparin, consider thrombolytics

  10. Resuscitation Fluids • Normal Saline, Crystalloids (used as a first line in the treatment of shock) • Blood (in case of bleeding/anemia) • Lactated Ringers • Colloids • Hetastarch • may aggravate bleeding • Dextran • use as plasma expanders • These solutions are not used as often as albumin or hetastarch for plasma expansion, possibly due to concerns related to aggravation of bleeding and anaphylaxis. • Hypertonic Saline • Blood Substitutes

  11. Autonomic Drugs in Shock