surgery le2 1

. . lNU COLLEGE OF MEDICINE DEPARTMENT OF SURGERY.

. . SHOCK. • The failure to meet the metabolic needs of the cell and the consequences that ensue..

. . Core principles in the management of patients in hemorrhagic shock.

. . Core principles in the management of patients in septic shock.

. . CURRENT DEFINITIONS AND CHALLENGES. • A modern definition and approach to shock acknowledges that.

. . CURRENT DEFINITIONS AND CHALLENGES. • Current challenges include moving beyond fluid resuscitation based.

. . PATHOPHYSIOLOGY OF SHOCK. • Regardless of etiology. the initial physiologic responses in shock are driven by.

. . • Many of the organ-specific responses are aimed at maintaining perfusion in the cerebral and.

. . HYPO VO LEM IC/HEMORRHAGIC. • The most common cause of shock in the surgical or trauma patient is.

. . HYPOVOLEMIC/'HEMORRHAGIC. • DIAGNOSIS. • The clinical signs: agitation, cool clammy extremities. tachycardia. weak or absent peripheral pulses. and hypocension.

. . HYPO VO LEM I C/'H EMO RR HAG IC. • DIAGNOSIS.

. . ble 5-5 lassification of hemorrhage. CLASS. ARAMETER l II Ill IV.

. . TABLE 3·1 SIGNS ANO SYMPTOMS OF HEMORRHAGE BY CLASS.

. . TREATMENT. • Control of ongoing hemorrhage is an essential component of the resuscitation of the patient in.

. . • In trauma. identifying the body cavity harboring active hemorrhage will help focus.

. . DAMAGE CONTROL RESUSCITATION. , This strategy begins in the emergency department. continues into the operating room. and into the intensive.

. . Reasonable conclusions in the setting of uncontrolled hemorrhage include.

. . • Data also support the use of antifibrinolytic agents in bleeding trauma patients, specifically tranexamic acid..

. . . . . . . , (..__A_c_id_o_s_is _ _.). Improved perfusion Reversal of hypothermia Reversal of coagulopathy Continued (gentle) resuscitation.

. . TRAUMATIC SHOCK. • soft tissue injury. long bone injury, and blood loss.

. . TRAUMATIC SHOCK. • Examples of traumatic shock include small volume hemorrhage accompanied.

. . TRAUMATIC SHOCK. • Treatment of traumatic shock is focused on correction of the individual elements to diminish the cascade of proinflammatory activation, and includes prompt.

. . SEPTIC SHOCK (Y ASODILATORY SHOCK). • The re.suit of dysfunction of the endothelium and vasculature secondary to.

. . Table 5-6. Causes of septic and vasodilatory shock Systemic response to infection Noninfectious systemic inflammation Pancreatitis Bums Anaphylaxis Acute adrenal insufficiency . Prolonged, severe hypotension · Hemorrl1agic shock Cardiogenic shock Cardiopulmonary bypass Metabolic Hypoxic lactic acidosis Carbon monoxide poisoning.

. . Table 5-6. Causes of septic and vasodilatory shock Systemic response to infection Noninfectious systemjc inflammation Pancreatitis Bums Anaphylaxis Acute adrenal insufficiency . Prolonged, severe hypotension · Hemorrhagic shock Cardiogenic shock Cardiopulmonary bypass Metabolic Hypoxic lactic acidosis Carbon monoxide poisoning.

. . Septic shocl<. • By-product of the body's response to disruption of the host-microbe equilibrium,.

. . • DIAGNOSIS. • Patients with sepsis have evidence of an infection, as well as systemic signs of inflammation (e.g., fever, leukocytosis, and tachycardia)..

. . . . Sequentiil or;an F.rilu,e A.ss:eurnent =.

. . . . . ALTERED f.1ENTAL. STATUS. THREE CRITERIA.

. . • Recognizing septic shock begins with. • defining the patient at risk..

. . • The.se should prompt an aggressive search for infection. including a.

. . TREATMENT. Table 5-7. Surviving Sepsis Campaign bundles of care to be initiated within the first hour after presentation in the patient with sepsis93•94.

. . CARDIOGENIC SHOCK. • Defined clinically as circulatory pump failure leading to diminished forward flow and subsequent tissue hypoxia, in the setting of adequate intravascular volume..

. . . Causes of cardiogenic shock '- Acute myocardial infarction Pump failure Mechanical complications.

. . . . . . PATHOPHYSIOLOGY. -- ...... ... __. _.- _., ... __ - -- . .. -· . - ~~ . • ~ -- - ....::-...:-11.-.-. r ...._::-.....,_;~--,1.:.::;. - • -.

. . DIAGNOSIS. • Signs of circulatory shock include.

. . DIAGNOSIS. • Signs of circulatory shock include.

. . OBSTRUCTIVE SHOCK. • Can be caused by a number of different etiologies that result in.

. . Table 5-9. Causes of obstructive shock Pericardia} tamponade Pulmonary embolus Tension pneumothorax IVC obstruction Deep venous thrombosis Gravid uterus on IVC Neoplasm Increased intrathoracic pressure Excess positive end-expiratory pressure Neoplasm.

. . . . Caltapset Pneumothorax Doa• Vena Heart. Scanned with CamScanner.

. . DIAGNOSIS AND TREATMENT. • The diagnosis of tension pneumothorax should be made on clinical examination..

. . . • In most instances. empiric treatment with pleural.

. . . . • In most instances, empiric treatment with pleural.

. . • The manifestations of cardiac tamponade, such as.

. . . • Patients who present with. circulatory arrest from cardiac.

. . NEUROGENIC SHOCK. • Refers to diminished tissue perfusion as a result of loss of vasomotor tone to.

. . Table 5-10. Causes ,of neurogenic shock. Spinal cord trjun1a Spinal cord neoplasm Spinal/epidural anesthetic.

. . • Acute spinal cord injury results in activation of multiple secondary injury mechanisms:.

. . ENDPOINTS IN RESUSCITATION. • With prolonged anaerobic metabolism, tissue acidosis and Odebt.

. . • The easily obtainable parameters of arterial blood pressure, heart rate, urine.