A SEMINAR ON SHOCK

by, Dr.Prasanna Kumar Y.S Post-Graduate student Department of Preventive and Community dentistry

SHOCK Various attempts to define shock are; t is a !ondition in "#i!# !ir!u$ation fai$s to meet t#e nutritiona$ needs of t#e !e$$s and at t#e same time fai$s to remove t#e metabo$i! "aste produ!ts t is a !$ini!a$ !ondition !#ara!terised by si%ns and symptoms arisin% "#en t#e !ardia! output is insuffi!ient to fi$$ t#e arteria$ tree "it# b$ood under suffi!ient pressure to provide a$$ t#e or%ans "it# ade&uate b$ood f$o" Shock is c!assified into "arious t#pes dependin$ on the Causes%&he# are' Haemato$enic shock &raumatic shock Neuro$enic shock Vaso"a$a! shock (s#cho$enic shock Cardio$enic shock Septic shock Misce!!aneous t#pes Anaph#!actic shock Insu!in shock

Haemato%eni! or Hypovo$aemi! s#o!'( (athoph#sio!o$#' Such shock is usua!!# due to sudden !oss of )!ood "o!ume or !oss of f!uid from the "ascu!ar space%Most common causes inc!ude hemorrha$e*"omitin$ and other states of deh#dration% In case of hemorrha$ic shock there is !oss of )!ood resu!tin$ in decreased fi!!in$ to the ri$ht heart% &he decreased fi!!in$ resu!ts in an a drop of arteria! pressure and thus conse+uentia! h#potension% &he compensator# mechanisms put forth )# the )od# are' 1.Adrenergic discharge 2. Hyperventilation 3. Release of vasoactive amines 4. Collapse 5. Resorption of fluid from the intracellular and extracellular space . Renal conservation of !ody "ater and electrolytes ,% A-RENER.IC -ISCHAR.E t starts "it#in )* se!onds of b$ood $oss.+#e !onstri!tion of venu$es and sma$$ veins disp$a!es b$ood to t#e ri%#t atrium and ventri!$e.+#is !auses an in!rease in t#e diasto$i! b$ood pressure and stro'e vo$ume t#us !ompensatin% t#e systemi! #ypotension.

,drener%i! dis!#ar%e !onstri!ts sp#in!ters in t#e sp$an!#i! vis!era,'idneys and t#e s'in.+#is se$e!tive vaso!onstri!tion improves fi$$in% of t#e ri%#t #eart and in!reases !ardia! output. /%H0(ERVEN&I1A&ION +#is o!!urs in response to metabo$i! a!idaemia t#at deve$ops s#ort$y after #aemorr#a%e. Spontaneous deep breat#in% su!'s b$ood from e-trat#ora!i! sites to t#e #eart and $un%s.+#is resu$ts in in!reased fi$$in% to t#e $eft ventri!$e. 2oth adrener$ic dischar$e and h#per"enti!ation occur 3ithin one minute of )!ood !oss4 5%RE1EASE O6 VASOAC&IVE AMINES , #ormone 'no"n as ./0 0 is re$eased from t#e 'idney in response to $o" perfusion..enin re$eases Angiotensin# from t#e $iver "#i!# is !onverted to Angiotensin ## in t#e $un%s.+#is ,n%iotensin is a potentia$ vaso!onstri!tor. ,not#er #ormone of importan!e is 1,SOP./SS 0. t is re$eased in response to t#e stimu$ation of barore!eptors situated in t#e Carotid bodies of t#e aorti! ar!#. t a!ts as a systemi! vaso!onstri!tor and diverts t#e b$ood f$o" to"ards t#e brain and #eart in!reases !ardia! output.

$%#&$%HR#&$ is a!so a "asoacti"e hormone re!eased from the aderena! medu!!a as a conse+uence of dischar$e from the adrener$ic ner"ous s#stem% +#e re$ease of vasoa!tive amines usua$$y o!!urs after 2 to 3 minutes of Haemorr#a%e 7%CO11A(SE ,ssumption of t#e re!umbent posture due to !o$$apse automati!a$$y disp$a!es b$ood from t#e $o"er part of t#e body to t#e #eart and in!reases !ardia! output 8%RESOR(&ION O6 619I6ROM &HE IN&RACE1191AR AN- &HE E:&RACE1191AR S(ACE .e$ease of epinep#rine from t#e adrena$ medu$$a,!ortiso$ from t#e adrena$ !orte-and %$u!a%ons from t#e pan!rease resu$ts in #i%# e-tra!e$$u$ar %$u!ose !on!entration.+#is !auses #yperosmo$arity of t#e e-tra!e$$u$ar tissue "#i!# dra"s "ater out of t#e Ce$$s. nterstitia$ pressure in!reases as a resu$t "ater,sodium and !#$oride are for!ed into t#e vas!u$ar spa!e. ;%RENA1 CONSERVA&ION O6 2O-0 <A&ER ANE1EC&RO10&ES ,dreno!orti!otropi! #ormone is re$ease by any stress or s#o!'.+#is a$on% "it# ,n%iotensin stimu$ate t#e synt#esis and

re$ease of #ormone ,$dosterone "#i!# #e$ps in resorption of sodium and "ater by t#e Kidneys. C1INICA1 6EA&9RES O6 H0(OVO1AEMIC SHOCK 2ased on the de$ree of !oss of )!ood "o!ume and the duration=time e!apsed> the c!inica! features can )e descri)ed under 5 (hases% '#() *H+C, '+)$RA-$ *H+C, *$.$R$ *H+C, ,%MI1- SHOCK 1oss of !ess than /?@ of )!ood "o!ume is inc!uded under this cate$or#%&he c!inica! findin$s inc!ude' Pa$eness of e-tremities "#i!# be!ome !oo$-due to perip#era$ vaso!onstri!tion "#i!# in turn is due to t#ea!tion of adrener%i! dis!#ar%e +#ere is s"eatin% in t#e fore#ead and pa$ms a%ain due to adrener%i! dis!#ar%e. 4rinary output and pu$se rate and 5P remain norma$ Patient fee$s t#irsty and !o$d /%MO-ERA&E SHOCK 1oss of )!ood "o!ume from /?@ to 7?@ is seen% In consistence 3ith the features of mi!d shock 3hat is seen here is O1I.9RIA%

O$i%uria is due to adrener%i! dis!#ar%e a$on% "it# t#e effe!ts of !ir!u$atin% a$dosterone and vasopressin. +#e pu$se beats is around 2** beats per min. nitia$$y t#e 5P "i$$ be norma$ but pro%ressive$y fa$$s $ater on. 5%SEVERE SHOCK 1oss of )!ood "o!ume more than 7?@ usua!!# causes this form of shock% CharacteriAed )#' ,%(a!or=pa!eness of skin and eBtrmities> /%1o3 urinar# output 5%Rapid pu!se 7%1o3 2( C1INICA1 MONI&ORIN.' Measurement of 2( 2# measurin$ respirator# rate 9rine output Measurin$ centra! "enous pressure% &REA&MEN& ,%RES9SCICA&ION /%IMME-IA&E CON&RO1 O6 21EE-IN. 5%E:&RACE1191AR 619I- RE(1ACEMEN& C 4sua$$y 0orma$ sa$ine supp$emented "it# 2 or 3 ampu$es of Sodium bi!arbonate.

7%-R9.SCIn this case usua!!# on!# in the form of sedati"es% +.,46,+ C SHOCK (athoph#sio!o$#' +#e pe!u$iarity of t#is type of s#o!' is t#at t#e traumatised tissues a!tivate t#e !o-a%u$ation system and re$ease 6 C.O+H.O65 into !ir!u$ation. +#ese o!!$ude t#e pu$monary 6i!rovas!u$ature. +#e #umora$ produ!ts of t#e t#rombi in!rease t#e !api$$ary permeabi$ity resu$tin% in dep$etion of vas!u$ar vo$ume. C7 0 C,7 8/,+4./S &he features are "er# much simi!ar to that of h#po"o!aemic shock eBcept there are t3o differentiatin$ features% Presen!e of pu$monary and perip#era$ oedema in t#is type of s#o!' nfusion of $ar%e vo$umes suffi!ient for #ypovo$aemi! type is not suffi!ient for traumati! s#o!' &REA&MEN& 2..esus!itation 3.7o!a$ treatment of trauma and !ontro$ of b$eedin%

usua$$y by sur%i!a$ debridement of is!#aemi! and dead tissues

9.8$uid rep$a!ement

:.4se of anti!oa%u$ant t#erapy-One intravenous dose of 2*,*** units of #eparin. C,.D OG/0 C SHOCK (A&HO(H0SIO1O.0' +#is type of s#o!' is primari$y due to dysfun!tion of one of t#e ventri!$es. t may be be!ause of myo!ardia$ infar!tion,!#roni! !on%estive embo$ism. In cardiac compressi"e shock there is compression on the heart from outside resu!tin$ in decreased output% Causes ma# )e tension pneumothoraB and pericardia! tamponade4 C1INICA1 6EA&9RES n t#e be%innin% t#e s'in is pa$e and t#e urinary output is $o". Gradua$$y t#e pu$se be!omes rapid and t#e arteria$ pressure fa$$s. n !ase of ri%#t ventri!u$ar dysfun!tion t#e ne!' veins be!ome distended and t#e $iver is a$so en$ar%ed n $eft ventri!u$ar dysfun!tion t#e !#ara!teristi! t#ird #eart sound is #eard and presen!e of 5ron!#ia$ ra$es. &REA&MEN& &he treatment of cardio$enic shock in"o!"es; 2.,ir"ay !$earan!e for ade&uate o-y%enation #eart fai$ure,!ardia! arryt#mias or pu$monary

3. n !ase of massive pu$monary embo$us-7ar%e doses of Heparin is %iven intravenous$y 9.Pain is dea$t "it# by 6orp#ine :. Persistent pu$monary oedema s#ou$d be treated "it# a Diureti! NE9RO.ENIC SHOCK C,4S/S( 2.+rauma to t#e spina$ !ord su!# as in !rus# in;uries 3.,ny b$o!'ade to t#e sympat#eti! nervous system "#erein t#ere is $oss of arteria$ and venous tone resu$tin% in perip#era$ poo$in% of b$ood. 9.Parap$e%ia and &uadrip$e%ia a$so #ave been 'no"n to be invo$ved &3o t#pes of Neuro$enic shock are seen' ,%Vaso$enic t#pe' It occurs in case of periphera! di!atation of )!ood "esse! resu!tin$ in reduced )!ood f!o3 to the )rain Cere)ra! h#poBia9nconciousness /%(s#cho$enic t#pe' It fo!!o3s sudden fri$ht or uneBpected )ad ne3s In the ps#cho$enic t#pe there is di!atation of the s#stemic "ascu!ature 3hich !o3ers the s#stemic arteria! pressure% C7 0 C,7 8/,+4./S

&he pecu!iar feature is that the skin remains 3arm*pink and 3e!! perfused%9rine output is a!so norma! )ut the Heart rate is rapid and the 2( is !o34 &REA&MEN& 2.,ssumin% t#e +./0D/7/054.G position is an important aspe!t so as to disp$a!e b$ood from t#e systemi! venu$es and t#us in!rease t#e !ardia! fi$$in%. 3.4se of 1aso!onstri!tors saves t#e patient from sudden $o" 5P and $o" !ardia! output t#us savin or%ans su!# as 5rain,'idney and #eart from is!#aemi! dama%e. SE(&IC SHOCK Such a t#pe of shock is usua!!# due to .ramne$ati"e septicemia% &he common or$anisms responsi)!e for it are' ,%E%Co!i /%K!e)sie!!a aero)acter 5%(roteus 7%(seudomonas (A&HO(H0SIO1O.0 n t#is type of s#o!' t#ere is "ide spread dissemination of t#e e-oto-in e$aborated by t#e or%anism.Sometimes Gram positive su!# as C$ostridium tetani infe!tions resu$t in fu$minatin% infe!tions and sepsis.Here t#ere is massive f$uid $oss resu$tin% in pro%ressive #ypotension

C1INICA1 6EA&9RES It is often reco$nised )#' ,% -e"e!opment of chi!!s /% E!e"ated temp%a)o"e ,?? C &here are t3o t#pes here' /ar$y "arm s#o!'-Cutaneous vasodi$ation 7ate !o$d s#o!'- in!reased vas!u$ar permiabi$ity due to persisten!e of septi! fo!us. +./,+6/0+ Here there are t3o !ines of treatment' ,% &reatment of infection )# ear!# sur$ica! de)ridement or draina$e and use of anti)iotics /%9se of f!uid rep!acement for shock fo!!o3ed )# steroid therap# and administration of "asoconstrictors if necessar# COMMON EVEN&S O6 SHOCK ENCO9N&ERE- IN C1INICA1 (RAC&ICE &he incidence of shock !ike features or shock itse!f in c!inica! practice shou!d a!3a#s )e anticipated% +#ese in!$ude in order of !ommon o!!urren!e( 2.0ausea 3.Perspiration 9.,ppre#ension

+#ese features may subside or #era$d t#e onset of !omp$i!ations. &he comp!ications inc!ude; Syn!ope Hypertension fo$$o"ed by #ypotension

furt#er

Perip#era$ $oss of !o$or and %enera$ised pa$eness $ater on. 1isua$ disturban!es fo$$o"ed by di<<iness +#e features as mentioned are basi!a$$y due to A((REHENSION precipitated )# (AIN AN- S&RESS MEAS9RES &O 2E &AKEN' ,%&he patient shou!d first )e p!aced in &REN-E1EN29R. position so as to increase the )!ood f!o3 to the heart and to the )rain% In case of pre$nanc# the patient shou!d )e in 1E6& 1A&ERA1 -EC92I&9S (OSI&ION% /%Second!# monitorin$ of 2(*pu!se and respirator# rate shou!d )e done% #f the patient still continues to have /radycardia -hen0 A-R+%#&$12.5 to 1 mg should !e administered and repeated every 5 minutes to a maximum dose of 3mg.

6u!! reco"er# in this case shou!d occur after in /? minutes%If !oss of conciousness takes !on$er than /? minutes then Emer$enc# Medica! ser"ice shou!d )e ca!!ed upon =(rior!# informedDD> 6ina!!# 3hat can )e said is that the "er# 3ord SHOCK creates an impression of a 1ife threatenin$ procedure% It is so%)ut 3hat is needed is more of a pre"enti"e )ased approach keepin$ in mind the factors re!ated to shock that ma# )e encountered in da# toda# e"ents%A ca!m and ca!cu!ated approach from the C!inician as a resu!t of pre"ious trainin$ for such situations $oes a !on$ 3a# in sa"in$ !i"es%