pathophysiology of shock
TRANSCRIPT
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Definition :- shock is a syndrome in which
there is inadequate tissue perfusion
associated with reduction of cardiac
output (absolute or relative )
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Inadequate perfusion and oxygenation and supply of nutrients to cells vital organs › Cellular dysfunction and damage
› Organ dysfunction and damage
› High mortality - 20-90%
› Early intervention reduces mortality
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Tissue perfusion is determined by Mean Arterial Pressure (MAP)
MAP = CO x SVR
Heart rate Stroke Volume
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Four categories depending on cause of
reduced CO
1. Hypovolaemic shock
2. Cardiogenic shock
3. Distributive shock
4. Obstructive shock
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Reduced CO is due to low blood volume
AKA cold shock
Causes
1. Hemorrhagic shock
2. Surgical shock
3. Burns shock
4. Dehydration shock
5. Traumatic shock
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Excessive vasodilatation due to toxic
substances or neural regulation
Increased in capacitance of vessels
CO decreases in spite of normal blood
volume
AKA warm shock
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four types:-
I. Neurogenic shock
II. Anaphylactic shock
III. Septicaemic shock
IV. Endotoxic shock
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Causes :-two types
1. Marked reduction in sympathetic
vasomotor tone
a) Deep general anesthesia
b) Spinal anesthesia
c) Brain damage
2. Increased vagal tone :- vasovagal
syncope , emotional fainting
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Acute allergic reaction
Large quantities of histamine
Widespread vasodilatation
Reducing peripheral resistance
Increased capillary permeability
Reduction in blood volume
Leading to shock
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Septicaemia ?
Bowel perforation , peritonitis
Toxins produced by bacteria
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Heart’s pumping ability is reduced
Severe systolic dysfunction
Venous return is not pumped out
So reduced CO
Congestion of lungs and vicera
AKA congested shock
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1. Myocardial infarction
2. Cardiac arrhythmias
3. Congestive heart failure
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External pressure on the heart which
reduces CO
Reduces ventricular filling
› Pericardial tamponade
› Tension pneumothorax
› Constrictive pericarditis
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1. Non –progressive shock
2. Progressive shock
3. Refractory shock
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AKA compensated shock
Moderate reduction in CO
Occurs after loss of 10-15% of blood vol
Leading to compensatory mechanisms
1. Immediate compensatory mechanisms
2. Long term compensatory mechanisms
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Includes three nervous reflexes
› Baroreceptor reflex
› Chemoreceptor reflex
› CNS ischemic response
› Others responses
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Baroreceptors – stretch receptors which
sense change in pressure
Chemoreceptor – detects change in
chemical composition of blood
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Carotid body (chemoreceptor )
Carotid sinus ( baroreceptor)
Aortic arch contains both baro&
chemoreceptor
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Carotid sinus – glossopharyngeal nerve
corotid body
Aortic arch – vagus nerve
Aaorti sinus
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When the BP falls
Barorecptors gets inactivated
They reduce their inhibitory effect on
VMC
so increase in BP and HR
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Due to hypoxia
When the blood pressure fall below
70mm/hg
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When the BP falls below 40mm/hg
Ischemia of VMC
Activation of VMC
Increases symp dischrage
Increases BP , HR , CO
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Occurs in all vessels except cerebral and
coronary vessels
So it increases venous return
In turn increases CO
Skin becomes pale and cold
Vasoconstriction of kidney reduces gfr
Vasoconstriction of skeletal muscle
So bypassing of blood to vital organs
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Due to chemoreceptor reflex
Also because of hypoxia
And by increasing thoracic pumping
action
Increases CO
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Person becomes restless
Increases pumping
Increases venous return
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From adrenal medulla
Increases symp drive
i.e. vasoconstriction and increased HR
Stimulates RAS
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ADH from posterior pituitary
Increases water absorption
Pressor action of vessels
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Increased glucocortioids
Increases sensitivity of vessels to
catecholamines
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RAAS
Reverse stress relaxation
Capillary fluid shift mechanism
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Restoration of plasma volume and
proteins
› Plasma volume by 12 – 72 hours
› Proteins by 3-4 days by liver
Restoration of red cell mass – will occur
within 10 days and fully restored by 4-8
wks
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Occurs after 15-25% loss of blood volume
Compensatory mechanisms are not effective
Despite Intense vasoconstriction
Not able to maintain BP , CO
CVS begins to deteriorate
Due to positive feedback cycles
Timely intervention is needed
Or will progress to refractory shock
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Cardiac failure
Due to severe dec in BP
Diastolic BP falls
Blood supply to heart falls
Weakens myocardium
Leading to heart failure
Acts as positive cycle
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There occurs a point where body fails to
circulate the vital organs
Failure of VMC will produce widespread
vasodilatation
So CO and BP are further decreased
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Due to hypoxia and metabolites
accumulation vasodilatation occurs
Capillary permeability increases
Pooling and sluggish blood flow
Intravascular clotting occurs
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Hypoxia in GIT
Damage to mucosal barrier
Leading to entry of bacteria thro’ portal
circulation
Damage liver and reaches systemic
circulation
Systemic toxemia and septicemia
Leading to irreversible shock
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Widespread tissue damage
Liver (first) , heart , lung
Failure of Na-K pump
Reduced mitochondrial activity
Activation of lysosomes
Depleted nutrients (glucose mainly)
Depleted action of hormones (insulin)
Hypoxia – anaerobic metabolism – lactic acid accumulation – Pco2 increase –acidosis – vasodilatation (vicious cycle )
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Therapeutic interventions are ineffective
and patient dies eventually
Point of no return – severe depletion of
ATP
Leading to necrosis (death of tissues )
Multi-organ failure
Death
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Correcting a cause & helping
physiological compensatory
mechanisms
General measures
1. Prevent sweating
2. Trendelenburg position
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Transfusion of whole blood
Plasma
Dextran
Ringer lactate
Normal saline
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Adrenaline
Nor-adrenalin
Dapamine
Oxygen therapy
Gluocorticoids
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Intestinal circulation
Hepatic circulation
Splenic circulation
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Normal intestinal blood flow is 20% of CO
Which increases to 50 during digestion
60 – 70 % of blood flow is to mucosa
Countercurrent exchanger system in villi
noted
Supply of oxygen to tip of the villi is
reduced
i.e. intestinal necrosis is common in shock
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Gastric – 40ml/100g/min
Intestinal – 60ml/100g/min
Pancreatic – 80ml/100g/min
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Neural
Autoregulation
Metabolic regulation
› Adenosine
› Osmolarity
› Potassium
By GI activity – functional hyperemia
› Due to gastric hormones
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28% of cardiac output
Blood derived from two sources
› Portal – 75% (less oxygen content)
› Hepatic artery – 25% (rich in 02)
1500ml/min or 58ml/100g/min
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Hepatic arterial buffer response
Neural
Metabolic
Autoregulation
Regulation by intestinal activity
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Filters blood
Detoxification
Metabolism and storage
Reservoir of blood
Contribute 60% of blood during shock
Hepatomegaly
Portal hypertension and ascitis
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Splenic artery
Sympathetic vasoconstrictor fibers
Splenic capsule contraction
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