2. DEFINITION
SHOCK IS A CIRCULATORY SYSTEM
ABNORMALITY THAT RESULTS IN
INADEQUATE OXYGEN PERFUSION AND
TISSUE OXYGENATION

3. PHYSIOLOGICAL EXHAUSTION-THE
TRIAD OF DEATH
HYPOTHERMIA
ACIDOSISCOAGULOPATHY

5.  HYPOPERFUSION STATE RESULTS IN CELLULAR
ANAEROBIC METABOLISM AND LACTIC
ACIDOSIS.ACIDOSIS LEADS TO DECREASED
FUNCTION OF COAGULATION PROTEASES-LEADS
TO COAGULOPATHY AND FURTHER
HAEMORRHAGE.

6. UNDERPERFUSED MUSCLE IS UNABLE TO
GENERATE HEAT AND HYPOTHERMIA
OCCURS.COAGULATION FUNCTIONS POORLY AT
LOW TEMPERATURE AND THERE IS FURHER
HAEMORRHAGE,HYPOPERFUSION AND
HYPOTHERMIA.THESE 3 FACTORS RESULT IN A
DOWNWARD SPIRAL LEADIING TO
PHYSIOLOGICAL EXHAUSTION AND DEATH

7. 1.HYPOVOLEMIC-HAEMORRHAGIC
NON-HAEMORRHAGIC
2.CARDIOGENIC SHOCK
3.OBSTRUCTIVE
3.DISTRIBUTIVE SHOCK-ANAPHYLACTIC
SEPTIC
4.ENDOCRINE SHOCK

8. STAGES OF SHOCK
 COMPENSATED-- HR, Vasoconstriction, CO,
normal BP
 DECOMPENSATED--, HR, hypothermia, blood
pressure, prolonged capillary refill time, poor
peripheral pulses, and eventually urine output.
 IRREVERSIBLE SHOCK

9. BLEEDING-TRAUMA,GI BLEED,RUPTURED
ANEURYSM
PROTRACTED VOMITING OR DIARRHEA
ADRENAL INSUFFICIENCY
THIRD SPACING-INTESTINAL
OBSTRUCTION,PANCREATITIS

10.  HAEMORRHAGIC SHOCK-COMMONEST CAUSE
OF SHOCK IN TRAUMA PATIENTS
 NON-HAEMORRHAGIC CAUSES
 CARDIAC PUMP PROBLEMS-CARDIAC
TAMPONADE,TENSION
PNEUMOTHORAX,MYOCARDIAL CONTUSION
 NEUROGENIC SHOCK
 SEPTIC SHOCK

11. HAEMORRHAGIC SHOCK
 HAEMORRHAGE MAY BE REVEALED OR
CONCEALED.
 HAEMORRHAGE –EXSANGUINATION FROM
OPEN ARTERIAL WOUND OR FROM
HAEMETEMESIS FROM A DUODENAL ULCER
 CONCEALED HAEMORRHAGE IS CONTAINED
WITHIN THE BODY CAVITY.EG-WITHIN
CHEST,ABDOMEN,PELVIS WITH CONTAINED
VASCULAR INJURY

12. PRIMARY,SECONDARY AND
REACTIONARY HAEMORRHAGE
 PRIMARY HAEMORRHAGE IS HAEMORRHAGE
OCCURING IMMEDIATELY AS A RESULT OF INJURY
 REACTIONARY HAEMORRHAGE (WITHIN 24 HOURS)
CAUSED BY DISLOGEMENT OF
CLOT BY RESUSCITATION,NORMALISATION OF BP AND
VASODILATATION
 SECONDARY HAEMORRHAGE IS CAUSED BY
SLOUGHING OF VESSEL WALL .IT USUALLY OCCURS
AFTER 7-14 DAYS AFTER INJURY BY FACTORS SUCH
AS INFECTION,PRESSURE NECROSIS(DRAIN)OR
MALIGNANCY

13. •BLOOD LOSS IN SITE
FRACTURE TIBIA/HUMERUS-750 ML BLOOD
FRACTURE FEMUR-1500 ML BLOOD
FRACTURE PELVIS-2 TO 3 LITRES
•OBLIGATORY EDEMA IN SOFT TISSUES

14. SBP<110mm Hg
Tachycardia>90/mt
Tachypnea
Oliguria
Metabolic acidemia
Hypoxemia
Cutaneous vasoconstriction
Mental changes-anxiety,agitation,lethargy

15. APPROPRIATE HISTORY AND CLINICAL
EXAMINATION
•ADJUNCTS FOR CONFIRMATION
CVP
CHEST/PELVIC XRAY
ULTRASOUND

16. MINIMUM REQUIREMENTS
MONITOR SBP,URINE OUTPUT,BP,HR,MENTAL
STATE
ADDITIONAL MODALITIES
CVP
INVASIVE BP MONITORING
CARDIAC OUTPUT
BASE DEFICIT
SERUM LACTATE

17. CLASSIFICATION OF DEGREE OF
HAEMORRHAGE

18. INITIAL MANAGEMENT OF
HAEMORRHAGIC SHOCK
 DIAGNOSIS AND TREATMENT IS DONE
SIMULTANEOUSLY
 2 BASIC PRINCIPLES ARE
• STOP BLEEDING
• REPLACE THE VOLUME
• ANY SHOCK SHOULD BE ASSUMED HYPOVOLEMIC
UNTIL PROVED OTHERWISE AND HYPOVOLEMIA
SHOULD BE ASSUMED TO BE DUE TO HAEMORRHAGE
UNTIL THIS HAS BEEN EXCLUDED

19. INITIAL MANAGEMENT OF
HAEMORRHAGIC SHOCK
 ASSESS ABCDE
 BASELINE RECORDINGS-BP,PR,URINE OUTPUT,LEVEL OF
CONSCIOUSNESS
 CONTROL OBVIOUS HAEMORRHAGE.DIRECT PRESSURE
SHOULD BE PLACED OVER SITE OF EXTERNAL
HAEMORRHAGE
 ADEQUATE IV ACCESS-2 LARGE BORE IV CANNULA(MINIMUM
16 GUAGE)
 IF PERIPHERAL LINE NOT POSSIBLE-CENTRAL LINE,VENOUS
CUT DOWN.BLOOD DRAWN FOR CROSS MATCHING
 ASSESS TISSUE PERFUSION

20. INITIAL FLUID THERAPY
 RINGER LACTATE IS THE FIRST CHOICE,2ND IS
NORMAL SALINE
 AN INTIAL BOLUS IS GIVEN AS RAPIDLY AS
POSSIBLE.DOSE OF 1 -2 LITRES FOR ADULTS
 20 ML/KG FOR CHILDREN.

21. DYNAMIC FLUID RESPONSE
 PATIENTS CAN BE DIVIDED INTO RAPID
RESPONDERS,TRANSIENT RESPONDERS AND
NON RESPONDERS BASED ON RESPONSE TO
FLUID THERAPY

22. RESPONSES TO INITIAL FLUID
RESUSCITATIONRAPID
RESPONS
E
TRANSIENT
RESPONSE
NO RESPONSE
VITAL SIGNS RETURN
TO
NORMAL
TRANSIENT
IMPROVEM
ENT
ABNORMAL
ESTIMATED
BLOOD LOSS
MINIMAL
(10 – 20 %)
MODERATE
AND
ONGOING
(20 – 40 %)
SEVERE
(>40%)
NEED FOR
MORE
CRYSTALLOID
LOW MODERATE IMMEDIATE
NEED FOR POSSIBLY LIKELY HIGHLY LIKELY

23.  EXCESSIVE BLOOD LOSS FROM FRACTURED BONE
MAY BE PREVENTED BY AVOIDING MOVING THE
PATIENT FROM ONE COUCH TO ANOTHER.
.FOR FRACTURES OF PELVIS,TEMPORARY
STABILISATION WITH AN EXTERNAL FIXATOR
HAS BEEN FOUND TO BE USEFUL IN REDUCING
HAEMORRHAGE

24. I.V. Solutions
 Crystalloid
 Colloid
 Whole Blood or Blood Products
 Water and Glucose

25. Crystalloids (Isotonic)
 Solutions of ions with an osmolarity similar to that
of plasma.
 Effective, short term, volume replacement
 Do NOT have O2 carrying capacity
 Do NOT contain protein

26. Crystalloids (Isotonic)
 Most common crystalloids
 Normal saline
 Fluid of choice in combat
 Ringers lactate
 Most physiologically adaptable
solution available
 Hartmann,s solution

27. Crystalloids (Isotonic)
 Precautions
 Always consider fluid volume overload
 Excessive infusion of electrolytes may cause
electrolyte imbalances
 DO NOT use in patient’s with
 Cardiac failure
 Liver disease
 0.9% NaCl is C/I in metabolic axidosis as it is an
acidifying solution, which may slow down the
resolution of the metabolic acidosis, so in that case
use RL

28. C OLLOIDS
 are large molecules that cannot freely diffuse through the
capillary membrane
 NO oxygen carrying capacity
 ALBUMIN
 HETASTARCH – SYNTHETIC
 The advantage of colloids is that since they do not rapidly
diffuse across the capillary membrane, they act to hold
water in the
intravascular space and maintain intravascular volume
expansion for longer periods of time than crystalloids

29. Water and Glucose
 These solutions are Hypotonic
 Most common concentrations:
 D5W – Fluid replacement and caloric
supplementation
 D50W – treats hypoglycemic (low blood sugar) in
adults

30. Water and Glucose
 Contraindications:
 DO NOT use in HEAD INJURIES
 Will cause cellular swelling
 Precautions:
 Volume overload
 Electrolyte imbalance

31. Whole Blood
 Ideal replacement fluid if blood is being lost
 Indications
 Acute massive blood loss
 Will resolve symptoms of hypovolemic shock and
anemia

32. VASSOPRESSOR AND IONOTROPICS
 NOT AS FIRST LINE THERAPY
 Administration of this agents in absence of
adequqte preload lead to decrease coronary
perfusion and depletion of myocardial oxygen
reserve
 Noradrenaline – distributive shock
 Ionotrops in - cardiogenic shock

33. SEPTIC SHOCK
 Severe sepsis with cardiovascular organ dysfunction,
i.e. hypotension (systolic blood pressure [SBP] < 5th
centile
 non-specific systemic inflammatory response to
infection,trauma, burns, surgery etc.
 Characterized by abnormalities in 2 or more of the
following • body temperature• heart rate• respiratory
function
• peripheral leucocyte count

34. SEPTIC SHOCK --management
 RESUSCITATION– ABC
 FLUID THERAPY-- aggressive fluid resuscitation with
crystalloids or colloids at 20 mls/kg as rapid IVpush
over 5-10 mins. Can be repeated up to 60 mls/kg or
more.
 - correct hypoglycaemia and hypocalcaemia
 IONOTROPES -- IV Dopamine 5 - 15 μg/kg min
 IV Dobutamine 5 - 15 μg/kg/min
 - for fluid refractory and dopamine/dobutamine
refractory shock Adrenaline is given

35.  ANTIMICROBIAL-- IV antibiotics should be
administered immediately after appropriate cultures
are taken.
 Start empirical, broad spectrum to cover all likely
pathogens
 antibiotic regime to be modified accordingly once C&S
results

36.  RESPIRATORY SUPPORT- use PEEP and FIO2 to keep
SaO2 > 90%, PaO2 > 80 mmHg
 SUPPORTIVE THERAPY-
 packed cells transfusion if Hb <10g%
 - platelet concentrate transfusion if platelet count < 20
000
 - if overt clinical bleeding, correct coagulopathy or
DIVC

37.  - bicarbonate therapy: give bicarbonate only in
refractory metabolic acidosis,
 - maintain normal electrolytes and blood sugar

38. THANK YOU