SHOCK

1. SHOCK Dela Cruz, Czarino Diaz, Mark Anthony Dela Cruz, Fatima Diaz, Mark Fernan Dela Cruz, Isabella Dimaunahan, Eric

2. A 47-year old male is admitted to the ER because of blunt injury to the left side of the chest and abdomen sustained in a vehicular accident 30 min prior. He is conscious, incoherent, disoriented, and agitated. Pallor and cold clammy extremities are noted. BP: 70, palpatory, pulses are faint and thready, RR: 12/mm. A violaceous contusion hematoma is noted over the 5th to 8th ICS, extending from the L midaxillary line to the L midclavicular line. The abdomen is flabby soft and distended; patient gets agitated whenever palpation is attempted.

3. 1. WHAT ARE THE SIGNS OF SHOCK PRESENT IN THE PATIENT?

4. 1. What are the signs of shock present in the patient? Recognition of Shock • Blood pressure • pulse rate • Pallor • Temperature • Mentation • Urine output • Central Venous Pressure / PCWP

5. 1. What are the signs of shock present in the patient? Recognition of Shock • Blood pressure (70, diastole) • pulse rate (faint and thready) • Pallor ( + ) • Temperature (cold) • Mentation (conscious, incoherent, disoriented, and agitated)

6. a. What type of shock is present? TRAUMATIC SHOCK • Hypovolemic Shock • direct soft tissue injury (violaceous contusion hematoma is noted over the 5th to 8th ICS, extending from the L midaxillary line to the L midclavicular line)

7. b. What degree (class) of shock will manifest these signs? Class III 3--40 % BV • classical clinical manifestations

8. c. Explain the etiology of each of the signs noted. Hypovolemic Shock Causes: • intravascular volume depletion -hemorrhage • plasma volume - • extravascular sequestration • GI,GU, insensible losses • Hypoperfusion • ↓ blood volume • ↓cardiac output • ↑ peripheral vasoconstriction (compensatory)

9. c. Explain the etiology of each of the signs noted. Low Blood pressure ( BV and CO) • faint and thready pulse rate ( BV and CO) • Pallor skin ( peripheral vasoconstriction) • Low Temperature ( BV and CO, peripheral vasoconstriction) • conscious, incoherent, disoriented, and agitated ( BV and CO)

10. d. Explain how the initial neurohormonal responses to injury allow this patient to survive.

11. Injury HYPOTHALAMUS Corticotrophin Releasing Hormone Anterior Pituitary ACTH Cortisol

12. CORTISOL PERIPHERAL: Induces proteolysis and lactate release in skeletal muscle. Induces lipolysis . Inhibit glucose uptake by adipose tissue . LIVER: Promotes enzymatic activities Leading to gluconeogenesis HYPERGLYCEMIA

13. Injury HYPOTHALAMUS Growth Hormone Releasing Hormone Promotes protein synthesis. Enhances mobilization of fat stores. Anterior Pituitary Growth hormone

14. Plasma Osmolality Effective Circulatory Volume POSTERIOR PITUITARY Reabsorption of water in the renal distal tubules and Collecting ducts. Splanchnic vasoconstriction Enhances glycogenolysis and gluconeogenesis. VP

15. Juxtaglomerular apparatus Decreased blood flow Renin Angiotensinogen Angiotensin I ACE Angiotensin II Aldosterone Restoration of blood volume

16. 2. WHAT ARE THE TWO BASIC PRINCIPLES IN THE MANAGEMENT OF HYPOVOLEMIC SHOCK?

17. Replace lost volume. Stop bleeding.

18. a. How will you apply these principles to this patient? • Maximizing oxygen delivery • The patient's airway should be assessed immediately upon arrival and stabilized if necessary. • The depth and rate of respirations, as well as breath sounds, should be assessed. If pathology (eg, pneumothorax, hemothorax, flail chest) that interferes with breathing is found, it should be addressed immediately. • High-flow supplemental oxygen should be administered to all patients, and ventilatory support should be given, if needed

19. Placement of an arterial line should be considered for patients with severe hemorrhage- provide continuous blood pressure monitoring and also ease arterial blood gas testing. • Once IV access is obtained, initial fluid resuscitation is performed with an isotonic crystalloid, such as lactated Ringer solution or normal saline.

20. Controlling further blood loss • Control of further hemorrhage depends on the source of bleeding and often requires surgical intervention. • In the patient with trauma, external bleeding should be controlled with direct pressure; internal bleeding requires surgical intervention • In the patient with GI bleeding, intravenous vasopressin and H2 blockers have been used.

21. b. What are the appropriate IV fluids to administer? • Conventional crystalloids • Balanced salt solutions (BSS) and hypotonic salt solutions • Balanced salt solutions include such fluids as 0.9% NaCl (normal saline), and Ringer's Lactate solutions. • Have an electrolyte composition or calculated osmolality approximating that of plasma (isotonic) • Distribute approximately ¾ of their volume to the extravascular space with ¼ of the volume remaining in the intravascular space. 

22. Colloid solutions • Solutions of proteins, starches, dextrans, and gelatins containing molecules sufficiently large enough so that they do not normally cross capillary membranes. • Most of the administered volume remains in the intravascular space (unless tissue is damaged and then it can cross membranes). • Once colloids have leaked into the interstitium, they must be removed by the lymphatic system or they will exert a reverse pressure gradient, drawing water from the vascular space.

23. Guidelines for replacement the amount of fluid to be given the time period over which the fluid is given the type of tubing and drop size

24. An initial bolus of 1-2 L is given in an adult (20 mL/kg in a pediatric patient), and the patient's response is assessed. 2-3 L over 20 to 30 mins should restore normal hemodynamic parameters

25. Continued hemodynamic instability- shock not reversed; ongoing blood or volume losses Continuing blood loss (hemogloblin concentrations declining to <10g/dL)- initiate blood transfusion Severe and/or prolonged hypovolemia- inotropic support with dopamine, vasopressin or dobutamine

26. Discuss the limitations of volume/volume replacement with crystalloids to correct the shock state. Crystalloids - aqueous solutions of mineral salts or other water- soluble molecules. - used in IV transfusion

27. Composition of Common Crystalloid Solutions

28. After infusion of 1L of IV fluid

29. TIP: Don’t start I.V. lines in the legs of a patient in shock who has suffered abdominal trauma because infused fluid may escape through the ruptured vessel into the abdomen.

30. Advantages - safe and inexpensive - equilibrates rapidly throughout the extracellular compartment, restoring the ECF deficit Disadvantages - because of the rapid equilibration of balanced salt solutions into the EC space, larger volumes may be required for adequate resuscitation resulting in decreased intravascular oncotic pressure

31. c. Where is the most probable site of bleeding?

32. c. Where is the most probable site of bleeding? LH region organs Stomach Spleen Tail of Pancreas Splenic flexure of the colon Hilus of left kidney Left adrenal gland

33. c. Where is the most probable site of bleeding? Hematoma at 5th ICS to 8th ICS extending from L midaxillary to L midclavicular As the blunt injury suggests, affected vessels may be the intercostal arteries resulting to hematome, otherwise if deeper vessels like splenic or superior mesenteric arteries, blood will accumulate on abdominal spaces

34. How do you stop the bleeding using the second principle? Management of Shock 1. Blood and fluid replacement 2. Stop further bleeding

35. How do you stop the bleeding using the second principle? While initial stabilization is taking place, attention should be directed to prompt arrest of bleeding Aggressive restoration of normal BP without arrest of internal hemorrhage will enhance further losses of blood volume by increasing flow and impeding coagulation at the site of injury.

36. How do you stop the bleeding using the second principle? Mild to moderate hypotension allows for clot formation and slows bleeding from injured blood vessels (hypotensive resuscitation). The hemodynamically unstable injured victim should be brought to surgery as soon as possible and the source of bleeding should be promptly identified and arrested.

37. 3. WHAT ARE THE CONSEQUENCES OF THE SHOCK STATE ON THE INDIVIDUAL ORGAN SYSTEMS,I.E., KIDNEYS, LUNGS? a. Discuss the etiopathogenesis of ARDS and ATN.

38. Shock serious, life-threatening condition where insufficient blood flow reaches the body hypoperfusion

39. Stages of Shock Initial Compensatory Progressive Refractory

40. Initial stage Hypoxia Unable to produce ATP Cell membrane become damaged and leaky to extracellular fluid Metabolic acidosis

41. Compensatory stage Hyperventilation Production of adrenaline and noradrenaline Vasoconstriction and increase heart rate Increase BP Renin-angiotensin system activation to conserve fluid Diversion of blood flow to the heart, lungs and brain

42. Progressive stage Arteriolar and precapillary sphincters constrict Blood remains in the capillaries Increase hydrostatic pressure will lead to leakage of fluid and protein in the surrounding tissue Blood viscosity increases

43. Refractory stage Irreversible Death

44. ARDS (Acute Respiratory Distress Syndrome) breathing failure that occurs when there is severe fluid buildup in the lungs tiny blood vessels or the air sacs are damaged Fluid leaks from the blood vessels into air sacs lungs can no longer fill properly with air and the lungs become stiff

45. Causes of ARDS • Direct • from breathing in harmful substances or an infection in the lungs • Example: • Breathing in vomited stomach contents • A severe blow to the chest or other accident that bruises the lungs • Indirect • happen in people who are very ill or who have been in a major accident. • Example: • Severe and widespread bacterial infection in the body • Severe injury with shock

46. ATN (Acute Tubular Necrosis) a kidney disorder involving damage to the tubule cells of the kidneys Lead to kidney failure caused by lack of oxygen to the kidney tissues (ischemia of the kidneys), or by exposure to materials that are poisonous to the kidney

47. 4. WHAT IS THE PRINCIPLE OF PASG (PNEUMATIC ANTI-SHOCK GARMENT)?

48. PASG medical device which may increase peripheral resistance reduce the effort with which the heart must pump blood to perfuse the vital organs reduce the available area into which a patient may hemorrhage effectively increase the blood pressure

49. Indications for use patient's systolic blood pressure falls below 60 mmHg patient presents with signs and symptoms of shock Unstable pelvis fracture with suspected intra-pelvic hemorrhage Unilateral or bilateral femur fracture

50. Contraindications Pulmonary edema Cardiogenic shock Penetrating intrathoracic trauma Major blunt intrathoracic trauma Patients with chronic obstructive pulmonary disease Patients with possible cerebral edema Patients suspected of having a CVA Pregnancy Abdominal evisceration