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Copy of Shock
Transcript of Copy of Shock
Anaerobic Metabolism Na+/K+ ATPase failure
Cellular edema Accentuation of cellular edema Stage of no return.
Calcium influx Cell death progression. Hypovolemic Shock Intravascular volume depletion that causes reduction in venous return. Causes:
1. Blood loss
2. Dehydration & electrolyte loss
Influx of water to the interstitial an intracellular spaces Hemodynamic parameters Primary reduction of preload Secondary reduction of cardiac output Increase in systemic vascular resistance Management Gutierrez G, Reines D, Wulf M; Clinical Review Haemorrhagic Shock; Critical Care 2004, 8;373-381 Gutierrez G, Reines D, Wulf M; Clinical Review Haemorrhagic Shock; Critical Care 2004, 8;373-381 The first goals in treatment of hypovolemic shock is to control the source (Bleeding, vomiting) and maintain intravascular volume. Four questions:
Which fluid to use?
What are the therapeutic end-points? There is no evidence that albumin reduces mortality compared with saline. The "Three-to-One" Rule for Resuscitation: 3 mls of crystalloid for every 1 mls of blood loss replaced Indications:
Estimated blood loose >30% of total blood volume. (Hemorrhage class III)
Hypotensive patient who fails to respond to 2L of normal saline in the faze of a possible hemorrhage. Fluid to use... Crystalloids The use of large volumes of normal saline is associated with hyperchloremic acidosis The efficiency of hypertonic saline in trauma patients is controversial. Colloids Blood Products Threshold for transfusion:
Hgb 6 - 8 mg/dL
Patients with hemoglobin levels greater than 10 mg/dl are unlikely to benefit from blood transfusion How much fluid... Third-space loss of liquids to the insterstitium and to the intracellular space. How fast... Immediate vs Delayed resuscitation Fluid resuscitation should be focused on injuries that will not undergo spontaneous hemostasis.
Aggressive resuscitation in less severe bleeding would be counterproductive. Therapeutic end-points >85% of patients are under-resuscitated when urine output and blood pressure are used as sole guides in fluid replacement. Other more sensitive end points for cellular resuscitation:
CVP a life-threatening medical condition that occurs due to inadequate substrate for aerobic cellular respiration. In the early stages this is generally an inadequate tissue level of oxygen. Tissue ischemia sensitivity time:
- heart, brain, lung: 4-6 min
- GI tract, liver, kidney: 45-60 min
- muscle, skin: 2-3 hours What is needed to maintain Perfusion? Pump
( Heart ) Pipes
(Blood Vessels) Fluid
(Blood) How can perfusion fail? X X X Classification of Shock Hypovolemic Cardiogenic Distributive Septic Anaphylactic Neurogenic Pump Failure
arrhythmias Septic Systemic infection Bacterial toxins – wound infections, invasive procedures, UTI, Respiratory infections. Associated with pyrexia, marked generalized vasodilation and intravascular micro-clotting Immunocompromised patients at risk Mass release of histamine due to allergic hypersensitivity reaction (foods, insect bites, blood transfusion, drugs) Increased capillary permeability with vasodilation reduces venous return and BP Anaphylactic Neurogenic Loss of tone of blood vessels Causes:
spinal cord damage, anaesthesia, pain, drugs, hypoglycaemia Low Volume
diarrhea ????? By: Kindra Celani MS, RN