Shock with special refrence to COVID-19
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Shock is defined as a physiologic state characterized by systemic reduction in tissue perfusion. The main types of shock discussed are hypovolemic, cardiogenic, septic, neurogenic, traumatic, and obstructive. Signs and symptoms of shock range from mild features like cold skin to severe features like unconsciousness. Management of shock involves treating the underlying cause, improving cardiac function, and improving tissue perfusion through monitoring, fluid resuscitation, vasopressors, and inotropes as needed. End points of resuscitation include normalization of vital signs and markers of tissue perfusion like lactate and base deficit.
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Similaire à Shock with special refrence to COVID-19
Similaire à Shock with special refrence to COVID-19 (20)
Plus de LPS Institute of Cardiology Kanpur UP India
Plus de LPS Institute of Cardiology Kanpur UP India (20)
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Dernier (20)
Shock with special refrence to COVID-19
- 1. SHOCK Dr Awadhesh Sharma LPS Institute of Cardiology
- 2. Definition Shock is a physiologic state characterized by systemic reduction in tissue perfusion, resulting in decreased tissue oxygen delivery. 3
- 4. Shock – Effects on Organ Heart – ↓ CO / hypotension / myocardial depressants Lung - ↓gas exchange / tachypnoea / pulmonary edema Endocrine – ADH → ↑ reabsorption of water CNS – perfusion ↓ – drowsy Blood - Coagulation abnormalities – DIC Renal - ↓ GFR - ↓ urine output GIT – mucosal ischaemia – bleeding & hepatic - ↑ enzyme levels
- 5. Types 5 • Hypovolemic • Cardiogenic • Septic (vasogenic) • Neurogenic • Traumatic • Obstructive
- 6. Hypovolemic shock 6 • Hemorrhagic • Trauma • Bleeding disorders • GI/ GU bleed • Non- hemorrhagic • Dehydration • “Inter compartmental fluid mal-adjustments” • Third spacing
- 7. Cardiogenic Shock 8 • Pump failure • Adequate but ineffective intravascular volume. • Cardiac causes • Pulmonary embolism • High mortality rates
- 8. Cardiogenic shock 9 • Hemodynamic criteria: 1.Sustained Hypotension (i.e. SBP <90 mm Hg for at least 30 minutes) 2.Reduced Cardiac Index (<2.2 L/min per square meter) & 3.Elevated Pulmonary Artery Wedge Pressure (>15 mm Hg)
- 9. SEPTIC SHOCK 11 • Four sepsis-related clinical syndromes = Four steps of increasingly exaggerated systemic inflammatory responses SIRS Sepsis Severe Sepsis (Sepsis Syndrome) Septic Shock
- 10. Clinical Features Features of shock depend on the degree of loss of volume & on duration of shock. Types Mild shock. Moderate shock. Severe shock.
- 11. Mild Shock Features Collapse of subcutaneous veins of extremities esp. the feet, which become pale and cool Sweat on forehead, hand and feet Urine output normal. Pulse rate normal. Blood pressure normal. Patient feels thirsty and cold.
- 12. Moderate Shock Features Mild shock features + drowsy & confused Oliguria Pulse rate increased usually less then 100/min. Blood pressure normal initially then falls in later stage.
- 13. Severe Shock Features Unconscious. Gasping respiration. Anuria. Rapid pulse. Profound hypotension.
- 15. Monitoring Blood pressure Heart rate Respiratory rate Urine output Blood CBC Pulse- oximetry ECG U/S , CT , X-ray
- 16. Special Monitoring CARDIO – VASCULAR - Central venous pressure Normal ; 5-10cmH2O, If CVP<5cmH2O Inadequacy of blood volume CVP>12cmH2O Cardiac dysfunction - Cardiac output Pulmonary catheter Doppler ultrasound Pulse waveform analysis
- 17. Special Monitoring SYSTEMIC & ORGAN PERFUSION Clinical : urine output & Level Of Conciousness Sr. Lactate estimation & Base defecit Blood gas analysis PO2 / PCO2 / ph Mixed venous O2 saturation – N – 50-70% Newer methods Muscle tissue O2 probes Near –infrared spectroscopy Sublingual capnometry
- 18. Management principles Treat the cause Improve Cardiac function Improve Tissue perfusion
- 22. International Experts – 34 Countries - 14 20th March,2020 08-04- 2020 SGPGIMS, Lucknow. 22
- 24. Hemodynamic Monitoring Skin Temperature Capillary refill testing ± Serum lactate 08-04- 2020 SGPGIMS, Lucknow. 24
- 25. HemodynamicFailure Vascular Tone Myocardial Depression Hypovolemia Asses each component & apply appropriate therapeutic component Fluids Vasopressors Inotropes Associated Lung Injury 08-04- 2020 SGPGIMS, Lucknow. 25
- 26. Fluids • Conservation fluid strategies • 10 mL/Kg is better than 20 mL/Kg • Use crystalloids • Prefer balanced / buffered fluids, if available DO NOT USE synthetic colloids • like HES, Gelatins Avoid Albumin use 08-04- 2020 SGPGIMS, Lucknow. 26
- 27. Fluid Related Documentation Daily Fluid Balance: Daily sum of all intakes and outputs (i.e. over 24 hours) Cumulative Fluid Balance: This is the sum total of fluid accumulation over a set period of time (like over 3 days, 5 days, 7 days, or during hospital stay etc.) • Fluid Accumulation: Cumulative fluid balance (in litres) per kg of body weight multiplied by 100 is the percentage of fluid accumulation. • Fluid Overload: Fluid accumulation of more than 10% is called fluid overload. 08-04- 2020 SGPGIMS, Lucknow. 27
- 30. VasoactiveAgent Norepinephrine is the first line of vasoactive agent Target Mean Arterial Pressure (MAP) 60-65 mmHg If Norepinephrine is not available, then can consider Epinephrine Refractory shock: low-dose corticosteroid could be considered Intravenous hydrocortisone 200 mg per day administered either as an infusion or intermittent doses. 08-04- 2020 SGPGIMS, Lucknow. 30
- 32. End Points of Resuscitation Classic / Traditional Restoration of blood pressure Normalization of heart rate and urine output Appropriate mental status Improved / Global All of the above plus Normalization of serum lactate levels Resolution of base deficit Goal directed approach Urine output > 0.5 mL/kg/hr CVP 5 -10 cm H2o MAP 65 to 90 mmHg Central venous oxygen concentration >70%