MANAGEMENT OF

SHOCK

- GARGYA

 SHOCK....syndrome resulting from inadequate perfusion of tissues. Aim of management.restoration of perfusion of the tissues. Restoration would be complete only after knowing the cause for shock Etiology is established by taking history, clinical features, lab investigations, radiographic studies and other tests. Once the cause is known, the approach of treatment varies based on the type of shock.

CARDIOGENIC SEPTIC NEUROGENIC TRAUMATIC HYPOADRENAL ANAPHYLACTIC

HYPOVOLEMIC

The most fundamental emergency management of any case would be the ABCs.i.e.
Airway.maintaining a patent airway, may be with endotracheal intubation Breathingproper ventilation of lungs, may be with assistance Circulationmaintaining the blood circulation, which in this context mainly means maintenance of blood volume and also prevention of pooling of blood.

The main TARGET of management of shock is

Mean arterial pressure at 60-80 mm of Hg Maximize the oxygen delivery
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HYPOVOLEMIC ......!!!
Diagnosis
Hemodynamic instability. Obvious source of volume loss.(u/s scan for abd.aneurysm, endoscopy for GI bleed, X-Ray, pregnancy test for ectopic pregnancy, etc.) Lab investigations CBC, electrolytes, PT, aPTT, ABGs, urine analysis, blood grouping and cross matching.

Treatment
At a prehospital level
prevent further loss, immobilize, ensure ventilation, and immediate transport to a hospital

At the emergency dept.

assess airway and stabilize it, asses the RR and breath sounds High flow supplementary oxygen to all and assisted ventilation to the needed Obtain IV access, start fluid resuscitation with an isotonic crystalloid (RL, NS), 1-3 lit in 30 mins If hemodynamic stability doesnt restore with crystalloids transfuse blood

 Identify the source of bleeding and control bleeding

Direct pressure for external bleeding.
Surgical intervention for internal bleeding.

Various other concepts in controlling bleeding are

Vasopressin and H2 blockers for GI bleed.
Traction in case of long bone fracture. Surgery in case of all Gync. bleeds.

If hypovolemia is severe or prolonged IONOTROPICS

are to be used to maintain ventricular performance after blood volume is restored.

As an adjunct the TREDELENBURGs position is to be

maintained ( elevating the legs alone is the optimal position..transient effectdelays recovery if prolonged.) This is mainly useful to regain consciousness after a syncopal episode.
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Cardiogenic shock......!!!
Two types are the
Intrinsic Compressive

There would be no absolute or relative hypovolemia in this case.

Diagnosis of intrinsic type

H/O heart disease, Hemodynamic changes, ECG, Xray, Echocardiogram, Sr. cardiac markers

Target is to increase the CO without changing the HR

Treatment of intrinsic type

Airway patency and oxygenation Mech. Ventilation in max cases Fluid resuscitation (in the absence of pulm. edema) Central venous and arterial access, bladder catheterisation, pulse oximetry are routine. PAC (pulm. artery catheter ) needed for hemodynamic monitoring. Electrolyte abnormalities should be corrected #

 INOTROPES

The most important drugs in cardiogenic shock are the Inotropes i.e.
Dopamine, Dobutamine, Nor epinephrine, Vasopressin. vasoconstrictors and inotropes inotrope but a vasodilator.

Dopamine, nor epinephrine and vasopressin act by both Dobutamnie is used only when arterial pressure is restored as it is a
OTHER DRUGS

Furosemide is used in the presence of pulm. Congestion

Morphine for anxiolysis
IABP Intra Aortic Baloon Pumping, is done if the patient fails to
stabilise with the above treatment. The balloon is inflated during the early diastole to augment the coronary blood flow and hence helps recovery of myocardium Finally surgical interventions like revascularisation should be done basing on the etiology.

 Diagnosis of compressive type

H/O, clinical features, chest radiography, echocardiogram. Classical C/F in case of cardiac tamponade are hypotension, neck vein dilatation, muffled heart sounds.

Treatment of compressive type

Specific treatment in tamponade cases is immediate pericardiocentesis Chest decompression Release of air or other contents in cases like pneumothorax etc. #

Septic shock......!!!
There are two types
Hyperdynamic Hypodynamic

Clinical features
Hyperdynamic tachycardia, norm. or increased CO, decreased systmc vascular resistance and increased pulm. Resistance (oxygen delivery is good but extraction is bad) Hypodynamic vasoconstriction and decreased CO, inc. PR, febrile, cold n mottled cyanotic extremities, oliguria, renal failure, inc. Sr.lactate.

Diagnosis
By the C/F, leucocytosis or leucopoenia, thrombocytopenia. Definitive diag. by the isolation and identification of microbes and detection of endotoxin in blood

 Treatment

antibiotics and later based on the culture reports specific drug is to be given.

Antimicrobials initial therapy with brd spectrum

Removal of source of infection like sites of occult infns,

iv catheters, Foleys n drainage catheters etc.

Rule out other causes of sep[sis using X-ray, CT, U/S. Hemodynamic support
- IV fluids 1-2 lit of NS over 2hrs - Urine output maintained at >0.5 ml/kg/hr - Diuretic is used when needed. - If fluid resuscitation fails, inotropics and vasopressors are used.

Respiratory support by mechanical ventilation . If Hb <

7g/dL, packed RBC are given to maintain the oxygenation.

Metabolic support by bicarbonate admn (during acidosis) and fresh frozen plasma or platelets (in case of DIC)
STEROIDS inhibit the inflammatory rn. and their use is still limited

Other measures : Nutritional supplementation for fast recovery and

for prevention of death

Anti-endotoxin drugs bactericidal permeability

increasing (BPI) protein.

Anti-inflammatory drugs methyl prednisolone,

dexamethasone, hydrocortisone.

Anticoagulants recombinant activated protein C

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Traumatic shock ...... !!!

Hypovolemia due to plasma loss into injured tissues.

Management

The prehospital care as mentioned earlier The ABCs Control the hemorrhage by identifying the bleeding points. Early debridement of devitalized and injured tissues to reduce the inflammatory response Evacuation of any hematomas. Supplementing natural antioxidants to prevent further organ damage

Neurogenic shock ......!!!

Diagnosis

Characteristic C/F is warm and dry extremities, hypotension, bradycardia,

venous pooling etc.

Treatment

Fluid resuscitation to restore normal hemodynamic properties. Rule out hemorrhage

Nor epinephrine augments vascular resistance

Dopamine may be used as per requirement to augment the tone Atropine may be used to increase the HR and CO

Hypo adrenal shock ...... !!!

Its a complication due to unrecognized adrenal insufficiency Treatment

For hemodynamic instability IV dexamethasone sod. Phosphate..4mg Once insufficiency is confirmed hydrocortisone 100mg for 6-8 hrs. Volume resuscitation is needed

Pressor support is also needed

Anaphylactic shock ......!!!

First aid measure is rescue breathing

Primary treatment is EPINEPHRINE 0.3 -0.5 ml of 1:1000 (SC or IM) with

repeated doses at 20 mins interval. It causes bronchodilatation, vasoconstriction, increases HR (used cautiously as it causes vent. tachycardia)

Tourniquet may be applied if the site of antigen inj. was on an extremity If intractable hypotension is present, Ns and vasopressors may be used. Initial nasal catheter or intermittent positive pressure breathing of
oxygenif progressive hypoxia develops then endotracheal intubation or tracheotomy

Antihistamines for relieving urticaria-angioedema Glucocorticoids used later to prevent recurrence

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Adjunctive methods ......!!!

Tredelenburgs position Pneumatic anti-shock garments inflatable external compression devices
wrapped around legs and abd in prehospital setting for temp support of central hemodynamics..it also provides splintage in case of pelvis and lower extremity fractures

Rewarming extracorporeal counter current warmers through femoral artery

and vein cannulation.rewar.ming occurs from 300 to 350 in 30 mins. (Hypothermia depresses cardiac contractility and impairs coagulation pathway)