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Definition and Definition and Classification of ShockClassification of Shock
ד"ר אסתר דהאןד"ר אסתר דהאן
Definition of ShockDefinition of Shock
Shock Shock is an acute clinical syndrome is an acute clinical syndrome initiated by ineffective perfusion, initiated by ineffective perfusion, resulting in severe dysfunction of resulting in severe dysfunction of organs vital to survivalorgans vital to survival..Shock is not a synonym to Shock is not a synonym to hypotensionhypotension!!
Ineffective perfusionIneffective perfusion
Organ perfusion compromised by an overall Organ perfusion compromised by an overall
decrease or maldistribution in cardiac decrease or maldistribution in cardiac
output Worsened by abnormalities of output Worsened by abnormalities of
distribution of blood flow within the distribution of blood flow within the
organsorgans..
Shock syndromesShock syndromes
Relatively constant set of signs Relatively constant set of signs and symptoms that predictably and symptoms that predictably result from pathophysiologic result from pathophysiologic events events
Clinical presentation can be Clinical presentation can be variablevariable
Severity of the perfusion defect Severity of the perfusion defect Underlying cause Underlying cause Prior organ dysfunctionPrior organ dysfunction
Symptoms/SignsSymptoms/Signs
Related to decreased tissue Related to decreased tissue perfusion perfusion Pale, cool, clammy skin Pale, cool, clammy skin capillary refill capillary refill urine output urine output mental statusmental status
ClassificationClassification
Hypovolemic Hypovolemic
Cardiogenic Cardiogenic
Extracardiac obstructive Extracardiac obstructive
Distributive Distributive
HypovolemicHypovolemic
Primary defect is a decrease in Primary defect is a decrease in intravascular volumeintravascular volume
Bleeding Bleeding GI losses GI losses Urinary Urinary ““Third spacingThird spacing””
MechanismsMechanisms
in cardiac diastolic filling pressures in cardiac diastolic filling pressures stroke volume stroke volume
CO partially maintained by HR CO partially maintained by HR PVR, myocardial contractility PVR, myocardial contractility
Brain, heart protected through auto Brain, heart protected through auto regulation Failure of compensation regulation Failure of compensation
20-25% 20-25%
Clinical manifestationsClinical manifestations
Tachycardia Tachycardia
Tachypnea Tachypnea
Flat veins Flat veins
Signs of hypo perfusionSigns of hypo perfusion
Effects of COEffects of CO
Decreased oxygen deliveryDecreased oxygen delivery
Tissues initially compensate through increased Tissues initially compensate through increased oxygen extraction oxygen extraction
Eventual tissue hypoxia and lactic acidosisEventual tissue hypoxia and lactic acidosis
Diversion of flow to brain, heartDiversion of flow to brain, heart
Eventually fails worsening COEventually fails worsening CO
Cardiogenic ShockCardiogenic Shock
Primary defect is CO with elevated Primary defect is CO with elevated cardiac chamber filling pressurescardiac chamber filling pressures
Pulmonary oedema Pulmonary oedema JVPJVP
Presentation otherwise similar to hypovolemiaPresentation otherwise similar to hypovolemia Can be confused by underlyingCan be confused by underlying
hypovolemia hypovolemia CI <2L/min/m2CI <2L/min/m2 PAOP >17-20 mmHgPAOP >17-20 mmHg
Causes of COCauses of CO
Contractile failureContractile failure Ischemia/infarction Ischemia/infarction Cardiomyopathy Cardiomyopathy
myocarditismyocarditis Arrhythmias Arrhythmias Conduction disturbances Conduction disturbances Valve lesions Valve lesions AMI complicationsAMI complications
Left ventricular MILeft ventricular MI
>40% of LV infracted>40% of LV infracted 10-20% of Q-wave AMI10-20% of Q-wave AMI
Mortality >75% unless surgically Mortality >75% unless surgically correctable lesion correctable lesion
Mortality associated with level of Mortality associated with level of acidosisacidosis
Right Ventricular AMIRight Ventricular AMI
RV involved in 50% of inferior RV involved in 50% of inferior infarctsinfarcts
10-20% results in cardiogenic shock10-20% results in cardiogenic shock Clear lungs Clear lungs JVP JVP Kussmaul’s signKussmaul’s sign
Prominent venous distention with inspirationProminent venous distention with inspiration
Extracardiac Obstructive Extracardiac Obstructive ShockShock
Impaired diastolic Impaired diastolic fillingfilling
Cardiac tamponade Cardiac tamponade Tension Tension
pneumothorax pneumothorax Constrictive Constrictive
pericarditis pericarditis Compression of Compression of
great vessels by great vessels by mediastinal massesmediastinal masses
Increase the R or L Increase the R or L ventricular after ventricular after load load
PE PE Acute pulmonary Acute pulmonary
hypertension hypertension Aortic dissection Aortic dissection Systemic Systemic
embolizationembolization
Varied Clinical Varied Clinical PresentationPresentation
Signs of decreased perfusion Signs of decreased perfusion Symptoms/signs related to causeSymptoms/signs related to cause
Neck veins may be present or absent Neck veins may be present or absent Muffled heart sounds Muffled heart sounds Pulses paradoxus Pulses paradoxus Symptoms of underlying causeSymptoms of underlying cause
Varied hemodynamic patternsVaried hemodynamic patterns
Distributive ShockDistributive Shock SIRSSIRS
Sepsis Sepsis Pancreatitis Pancreatitis Multitrauma Multitrauma BurnsBurns
Late hemorrhage Late hemorrhage Neurogenic Neurogenic Anaphylaxis Anaphylaxis AdrenalAdrenal
Hemodynamic patternHemodynamic pattern Hyperdynamic patternHyperdynamic pattern Primary defect is a in SVR Primary defect is a in SVR
secondary to NO productionsecondary to NO production in CO in CO Normal to low filling pressures Normal to low filling pressures Normal to mixed venous O2 tension Normal to mixed venous O2 tension
? AV shunt? AV shunt
Sepsis/SIRSSepsis/SIRS
Two or more of the following Two or more of the following Temp > 38C, < 36C Temp > 38C, < 36C Tachycardia Tachycardia Tachypnea or respiratory alkalosis Tachypnea or respiratory alkalosis WBC >12, <4, or >10% bands WBC >12, <4, or >10% bands
Severe sepsis Severe sepsis Hypotension or hypo perfusion Hypotension or hypo perfusion
Shock Shock Vasopressors or ionotropesVasopressors or ionotropes