SHOCK *Shock can be classified into :

1. 2. 3. a. b. c.

Hypovolemic shock Cardiogenic shock Distributive shock neurogenic anaphylactic septic

can be classified into:

Causes of hypovolemic shock

I. II. III. IV.

Loss of abundant amounts of fluid for example hemorrhage Severe diarrhea Severe vomiting Bleeding

Cardiogenic shock Here we are talking about:

cardiac output blood pressure

*When does the cardiac output decrease to a level that can't meet the metabolic demands ? in massive myocardial infarction and that will lead to ischemia and later on leads to lactic acid accumulation(due to anaerobic respiration) thus acidosis and death *Why is acidosis fatal?

because the enzymes that are important in ATP production can't work in acidic medium it affects the function of central nervous system

Anaphylactic shock Anaphylactic shock means hypersensitivity reaction due to either food,drugs or insect bites *Why is anaphylactic shock dangerous ? Because it leads to releasing abundant amount of histamine Histamine is a local mediator --> vasodilation --> reduces venous return and blood pressure --> anaphylactic shock

Septic shock Septic shock is related to the presence of an infection diabetic mellitus patients that have peripheral neuropathy and microangiopathy, might develop diabetic foot and later on if it is not treated it will lead to migraine and general septicemia **The symptoms of infection:

 pain hotness swelling redness Swelling is due to increasing in permeability of blood vesseles -->accumulation of fluid or filtration from circulation to interstitial fluid Neurogenic shock Neurogenic shock is due to a sudden trauma for example in spinal cord -What does shock mean? Shock is disruption of homeostasis(state of equilibrium) which is maintained by cardiopulmonary system *(Cardio) how ? by maintenance of stable balance between cardiac output and total peripheral resistance, means balance between preload(volume) and after load(resistance) *(respiratory system) by tidal volume (the amount of air exhaled or inhaled by each breath ,or respiratory rate) Cardiogenic shock * (important)* when does a patient develop cardiogenic shock? before he enters a shock he passes through stages Intial: we know that blood pressure is maintained moment to moment (short term regulation) by baroreceptors is due to changing the position. if there is loss of blood volume which leads to decreases in the blood pressure over minutes or hours there will be interference of another mechanism which is long term regulation(renin angiotensin aldosterone system) these mechanisms are called compensatory mechanisms.

**if these mechanisms do not success to prevent deterioration, what will happen? renin angiotensin aldosterone and antiduratic hormone (which is secreted from pituitary gland) and enhances reabsorption of fluids from terminal ducts and collecting ducts--> increasing of blood volume if all these mechanisms and atrio natriuretic hormones failed to maintain the state of homeostasis--> this leads to shock **For example you are sitting in emergency room as a visitor, and see a male who is 24 years old, he was brought to emergency department after a car accident. At the beginning he was , concious, orriented, you can feel his pulse even if it might be weak,not confused,his pupils are reactive to light. But after 2 minutes he starts to look pale with thready pulse(weak),he becomes confused ,not alert and starts to lose his consciousness which means he is deteriorating .. By this you can know the signs and symptoms of the shock..

We talked last time about the mechanism by which the body responses to hypotension due to hypovolemia- by reflex tachycardia ..for example you measure the patients radial pulse and it was 120, this patient who is pale, sweaty, confused, his blood pressure is almost not measurable, has a thready pulse, and the patient enters the stage of shock..hypovolemic shock or cardiogenic shock. but its mostly hypovolemic due to severe internal bleeding,,this internal bleeding occurs in the chest or abdomen but mostly in the abdomen, so these signs reflex the case of hemorrhage in the abdomen.. **what will be the best way to manage with this patient who is deteriorating ,having severe bleeding and hypovolemic shock which is leading to an irreversible situation??

the best treatment is to do whats called laparotomy which is opening the abdominal cavity and clamping the damaged artery to stop bleeding. ( clamping means securing or closing the bleeding artery)..this is the best way to save this patients life, then he might be sent to the operative department and they might do anastomosis for him.. ( anastomosis is the reconnection of two streams that previously branched out, such as blood vessels or leaf veins)

So, in general what you need to understand from the shock subject, that the body tries to deal with the data given,for example a Cardiogenic shock is due to decreased cardiac output, this decreased output could be for any reason, maybe hypovolemia, or mainly due to ischemic heart disease (Massive myocardial infarction)..Massive myocardial infarction leads to cardiogenic shock, in the case of cardiogenic shock when we measure the patients blood pressure its less than 90 systolic, so in this case we cant increase the blood pressure of these patients by giving them blood supply or fluids,we cant resuscitate these patients sometimes.(resuscitate means to revive, especially from apparent death or from unconsciousness.) because the condition became irreversible, so we have to deal in a proper way with them. They should be given : 1)dobutamine 2)IV infusion **Whats the function of dobutamine?? Dobutamine is a catecholamine, like dopamine but theres a difference between them,,Go and read about the difference between them and when do we give Dobutamine to patients. **Here are some information that I collected from internet that might help..there may be additional information in them.. *Functions of Dobutamine: -Dobutamine is a drug that acts on the sympathetic nervous system. Physicians use it to treat heart failure and cardiogenic shock. -Dopamine is a neurotransmitter that our bodies produce in order to send signals between brain cells.

-Dobutamine is used to treat acute but potentially reversible heart failure, such as which occurs during cardiac surgery or in cases of septic or cardiogenic shock, on the basis of its positive inotropic action. -Dobutamine can be used in cases of congestive heart failure to increase cardiac output. It is indicated when parenteral (intravenous) therapy is necessary for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility, which could be the result of either organic heart disease or cardiac surgical procedures. It is not useful in ischemic heart disease because it increases heart rate and thus increases myocardial oxygen demand. -The drug is also commonly used in the hospital setting as a pharmacologic stress testing agent to identify coronary artery disease.

 Norepinephrine (NE) is a catecholamine with multiple roles, including as a hormone and a neurotransmitter. Areas of the body that produce or are affected by norepinephrine are described as noradrenergic. An inotrope is an agent that alters the force or energy of muscular contractions. Negatively inotropic agents weaken the force of muscular contractions. Positively inotropic agents increase the strength of muscular contraction.

All the previous information written in italic and the table are external, the doctor said you should read about them..and didnt say anything else..

So, the shock happens when the body fails to deal with the situation, and there is abundant loss of blood, or massive myocardial infarction that leads to decrease in cardiac output and blood pressure.Then leads to death if not treated. There are another important mechanisms that are involved and may lead to death ,one of them is DIC (Disseminated Intravascular Coagulation) which is involved in the acceleration of deterioration..when someone bleeds severely he may enter in this stage.DIC is simply involved in forming blood clots all over the body.

The Objectives of the lecture: You need to know: 1- whats shock 2- types of it 3-causes of it 4- how to deal with it 5-stages of it 6-you need to know about the effect of acidosis, alkalosis and Dobutamine..thats all what you have to know from this lecture

** Excuse us if theres any mistake, and please share it to benefit the rest of our colleagues..

This Lecture was Done By: Khansaa AL Shaibany AND Nagham Rabi

GOOD LUCK ALL.. ;)