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Classifications of Shock
Hypovolemic shock Cardiogenic shock Obstructive shock Distributive shock
Hypovolemic Shock
Loss of circulating volume Empty tank decrease tissue perfusion general shock response Etiology:
Internal or External fluid loss Intracellular and extracellular compartments
Hypovolemic Shock
External loss of fluid Fluid loss
Nausea & vomitting Diarrhoea Massive diuresis
Plasma loss
Extensive burns
Blood loss
Blunt Penetrating
Hypovolemic Shock
Internal fluid loss Loss of vascular integrity Increased capillary membrane permeability Decreased Colloidal Osmotic Pressure (third spacing)
Fluid Intake
Average adult intake
2200-2700 ml/day
Oral : 1100-1400 Solid foods : 800-1000 Oxidative metabolism : 300
By-product of cellular metabolism of ingested foods
Skin
Regulated by sympathetic nervous system
Activates sweat glands
Sensible or insensible-500-600 ml/day Directly related to stimulation of sweat glands
Respiration
Insensible
Increases with rate and depth of respirations, oxygen delivery
About 400 ml/day
Gastrointestinal tract
In stool
Average about 100-200 ml/day GI disorders may increase or decrease it.
Fluid Balance
input
1100-1400 ml oral fuid 800-1000 ml solid food 300 ml oxidative metabolism
output
1200-1500 ml urine
500-600 ml sweat
400 ml respiration 100-200 ml stool
output
Urine Sweat Resp. Diarrhoea Vomitting Bleeding Internal fluid loss
Clinical Presentation
Tachycardia and tachypnea Weak, thready pulses Hypotension Skin cool & clammy Mental status changes Decreased urine output: dark & concentrated
Dehydration
Irritability Increased HR with Confusion decreased BP Dizziness Weakness Extreme thrist Fever Dry skin & mucus membranes Sunken eyeballs Poor skin turgor Decreased urine output
Daily weight
Same day Same clothes, etc same scale
Insert Foley catheter to monitor I & O Monitor vital signs closely IV therapy Monitor labs: Na+, serum osmolarity, urine specific gravity Provide skin & oral care frequently Auscultation of breath sounds ABGs for fluid overload Diuretics if fluid overload
Severe Hypovolemia
is a consequence of
Trauma Dehydration Shock syndrome - sepsis, cardiac Hemorrhage - intra-operative blood loss
Each cause may respond differently to different type of fluid Hypotension may be a late sign of Hypovolemia
Compensatory Mechanisms
Redistribution of blood flow
Heart Brain
Neurohormonal renin-angiotensin
double edge sword
Microcirculation
Endothelium cells or organ
Management of Hypovolemia
Current old Therapy is directed towards Optimize Macrocirculation Optimize Oxygen delivery
New - future Therapy is directed towards Optimize the Microcirculation Reducing the effect compensatory mechanisms
Management
Five major principles Prompt recognition Do not rely on BP!! Early institution of supportive measures
ABC Restore circulating volume
Determine primary problem leading to shock. Early correction of primary underlying problem.
Control vomitting, diarrhoea, hemorrhage
Management of complications.
Presence of pulmonary edema (cardiac or non-cardiac) is strong contraindication to more fluid admin without more hemodynamic informations
Dehydration
Mild (3-5% BW) Moderate (5-8% BW) Severe (> 8% BW)
Volume Replacement
Maintenance fluids Replace deficit:
Rapid : iv bolus Intermediate : replace deficit over 6-8 hrs Slow : remainder over 16-18 hrs
Replace ongoing losses: Insensible losses, GI losses, renal losses, burns. Fluid Na K+ Cl e.g.:
Gastric Bile 20-80 120-140 5-30 2-10 100-120 90-120
Ileostomy
100-140
5-15
80-120