Management of patient in

shock

Prof. Syed. Asghar Naqi

Chairman, Deptt of Surgery
KEMU/Mayo Hospital
Objectives:
• Definition
• Pathophysiology
• Classification
• Clinical features of shock
• Severity of shock
• Management of shock
• End points of Resuscitation
Definition of Shock:
 Shock is defined as inadequate delivery of oxygen and nutrients to
maintain normal tissue and cellular function.

Demand Supply
Pathophysiology:
Effects on Organs:
Classification:
• Hypovolemic shock
• Cardiogenic shock
• Obstructive shock
• Distributive shock
• Endocrine shock
Hypovolemic shock:
 Haemorrhagic
Blood loss.
 Non-haemorrhagic
Vomiting.
Diarrhea.
Dehydration.
Third spacing.
Cardiogenic shock:
 Myocardial Infarction.
 Cardiac Arrhythmias.
 Valvular Heart Disease.
 Cardiomyopathy.
Obstructive shock:
 Reduction in preload due to mechanical obstruction of cardiac filling.

 Causes:
 Cardiac Tamponade.
 Tension Pneumothorax.
 Pulmonary Embolism
Distributive shock:
 Maldistribution of blood flow at a microvascular level with AV shunting
and dysfunction of cellular utilization of oxygen.

 Types:
 Anaphylactic shock.
 Neurogenic shock.
 Septic Shock
Endocrine shock:
 May present as combination of hypovolemic, cardiogenic or
distributive shock.

 Causes:
 Hypo & Hyperthyroidism.
 Adrenal Insufficiency.
Severity of shock:
 Severity of shock depends on the degree of loss of volume
& duration of shock.

 Types:
 Compensated shock.
 Decompensated shock.
Mild shock.
Moderate shock.
Severe shock
Features Compensated Mild Moderate Severe
( Class I ) ( Class II ) ( Class III ) ( Class IV )

Blood loss <15% 15-30% 30-40% >40%

( ml ) <750ml 750-1500ml 1500-2000ml >2000ml

Pulse <100/min 100-120 120-140 >140

Blood Pressure Normal Normal Increased Increased

Respiratory Rate 14-20 20-30 30-40 >40

Urine output >30 20-30 5-15 Anuric

( ml )

Conscious level Normal Mild Anxiety Drowsy Comatose

Fluid Replacement Crystalloid Crystalloid Crystalloid & Crystalloid &

Blood Blood
Management of shock:
Goals of Resuscitation:
a) Increase Cardiac Output.
b) Increase tissue perfusion.
c) Increase O2 delivery.
Principles of Resuscitation:
 Airway:
Patent upper airway.
 Breathing:
Adequate ventilation and oxygenation.
 Circulation:
Placement of adequate IV line.
Administration of IV fluids.
Fluid Therapy:
 Crystalloid Solutions:
Normal saline.
Ringer’s lactate.
Hartmann’s solution.
 Colloid Solutions:
Albumin or commercially available products.
 Blood Transfusion:
Oxygen carrying capacity of crystalloids and colloids
is zero, ideal replacement fluid is blood.
Dynamic Fluid Response :
 250-500ml of fluid is rapidly given over 5-10 mins and
CVS responses are observed.
 Responders:
Show improvement.
 Transient Responders:
Initially show improvement then revert back over
next 10-20mins.
 Non-Responders:
Show no improvement at all.
Vasopressor/ Inotropic support:
 Vasopressors - Phenylephrine/ Noradrenaline:

Distributive shock states.

 Inotropics - Dobutamine:

Cardiogenic shock.
Other Treatments:
• Correction of acid-base balance
• Steroids - Hydrocortisone
• Antibiotics
• Catheterization
• Nasal o2
• CVP line
• Control of pain
• Critical care management.
Monitoring:
Minimum:

• Heart rate
• Pulse oximetry
• Blood pressure
• Urine output
• ECG
Additional Modalities :
Cardiovascular:
• Central venous pressure
• Arterial line
• Cardiac output
• Pulse waveform analysis

Systemic perfusion:
• Base deficit
• Serum Lactate
• Mixed venous oxygen saturation
End points of Resuscitation :
Classic / Traditional:
• Restoration of blood pressure
• Normalization heart rate and urine output
• Appropriate mental status

Improved / Global:
• Normalization of serum lactate levels
• Resolution of base deficit
• Adequate mixed venous oxygen saturation
End points of Resuscitation :
Goal directed approach:

• Urine output: >0.5 ml/kg/hour

• CVP: 5-10 cmH2O

• Mean Arterial Pressure: 65-90 mmHg

• Central venous oxygen concentration >70%

Questions?