Dentistry L5 SHOCK

GENERAL SURGERY
Shock
ASSIST. PROF. Dr. LUTFI GHULAM AWAZLI
Consultant General Surgery and Cosmetic Laser Surgery
University of Baghdad
College of Dentistry
20123 - 2024
 Shock:
 Definition:
 Shock is inadequate tissue perfusion, (i.e. Inadequate oxygen delivery to meet
cellular metabolic activity and oxygen consumption requirements, producing
cellular and tissue hypoxia).
 Shock is a life threatening emergency as a result of problems within the

circulatory system that may be reversible if early recognized and treated.
Circulatory system : Heart, Blood vessels, and Blood

 Classification (Types) of shock:
There are numerous ways to classify shock but the most common and clinically
applicable way is that based on the initiating Cause.
The main types of shock include:
1. Hypovolaemic shock (caused by too little blood volume)

2. Septic shock (due to infections)
3. Cardiogenic shock (due to heart problems)
4. Anaphylactic shock (caused by allergic reaction)
5. Neurogenic shock (caused by damage to the nervous system
1) Hypovolemic shock:
 Hypovolemia is probably the most common form of shock.
 It is caused by a reduced circulating blood volume.
 It may be due to hemorrhagic or non-hemorrhagic causes.
A. Hemorrhagic/Bleeding causes :either:

• External hemorrhagic (e.g. Traumatic deep wound)
• Internal hemorrhagic (e.g. Ruptured internal artery or Bleeding peptic ulcer).
B. Non Hemorrhagic/Bleeding causes: These conditions can also reduce

circulatory volume and lead to a dangerous drop in blood pressure.
include :
• Poor fluid intake for long time (Dehydration).
• Excessive fluid loss because of severe vomiting, diarrhoea, urinary loss (e.g.
diabetes), or severe burns.
2) Septic shock:
 Septic shock is a serious condition that
occurs when sever infection in the body
leads to sever low blood pressure.
 Any type of microorganism can cause sever
sepsis (bacteria, virus, fungus) but
bacterial infections are the most common
cause of septic shock.
 Septic shock is related to the release of
bacterial products (endotoxins) which cause
generalized vasodilation and maldistribution
of blood flow to the organs and dysfunction
of the cellular utilization of oxygen.
 In the later phases of septic shock there is
intravascular Hypovolemia from fluid
loss into the interstitial spaces and there
may be associated myocardial depression.
3) Cardiogenic shock:
 Cardiogenic shock is due to primary failure of the heart to pump blood to
the tissues.
 Causes include:
 Myocardial infarction
 Cardiac dysrhythmias
 Valvular heart disease
 Cardiomyopathy.
4) Neurogenic shock:
 High spinal cord injury at the level of the cervical spine or above may lead
to a form of vasogenic shock.
 There is failure of sympathetic outflow and adequate vascular tone with
Inappropriate generalized vasodilation, and resultant hypotension.
5) Anaphylaxis shock:
 Severe anaphylaxis (allergic) reaction causes massive
generalized vasodilation with sever hypotension and
cardiovascular collapse (shock).
 Vasodilation is caused by activation of mast cells and
release of histamine through immunoglobulin E (Ig-E)
reaction to an allergen.
 Common causes include:
• Allergies to insect bites and stings
• Allergies to foods – including nuts, milk, fish,
shellfish, eggs and some fresh fruits or dried fruits.
• Allergies to some antibiotics (Penicillin) and non-
steroidal anti-inflammatory drugs (NSAIDs) like
aspirin.
 Features: Facial, tongue, throat swelling and
bronchospasm leading to airway obstruction.
 Stages of Shock:
First Stages Second Stages Third Stages
Initial Compensated, Non compensated,

Irreversible stage
Reversible stage progressive stage
Reflex Compensatory If not treated early and Shock not respond to

mechanism appropriately the treatment.
HR Reflex Compensatory
COP mechanism begin to fail
RR Multiple organ dysfunction
Vascular constrictions
Multiple organ failure

Increase blood pressure There will be persistent
and maintain acid base hypotension, increase
balance and maintain acidosis with persistent
tissue perfusion to vital Hypoperfusion to vital Death
organs. organs (Brain, Heart, Lung).
 General clinical features of shock : Signs and symptoms:
Depending on the Cause and Severity of shock, Signs and symptoms may
include:
 Pale, cold, cyanotic skin, (Note: in Septic and Neurogenic shock there is
warm skin due to peripheral vasodilatation and fever).
 Shallow, rapid difficult breathing (Tachypnea, Dyspnea)
 Rapid heart beat (Tachcardia), Heart beat irregularities or palpitations
 Excessive thirst or a dry mouth
 Low urine output or deep yellow urine (Oliguria, anuria)
 Nausea, Vomiting
 Anxiety, Dizziness, Confusion, Disorientation, Unconsciousness/Coma.
 Investigations of shocked patient:
 Blood grouping(ABO/Rh) and cross match
 Complete Blood Count and Picture:
 Hb,PCV,ESR
 WBC : Leukocytosis (>10,000 cells/ mm3)
Leukopenia (<4,000cells/ mm3)
 Thrombocytopenia (low platelet count is common in sepsis)
 Random blood sugar
 Acid/ Base: Pyruvate, HCO3, anion gap/base excess
 Renal function test:
 B. Urea, S. Creatinine, K. clearance
 Electrolyte assessment (Na, K, CL, Ca, Mg)
 GUE
 Liver function tests (LFTS) may help guide evaluation of the function of the liver
SGOT, SGOP, ALK. Phosphates, TSP( Albumin, Globulin), TSB, Lipase/Amylase,
 Coagulation studies (PT, PTT, INR; fibrinogen, fibrin related markers): Identifies DIC
and other coagulation disturbances.
 Lactate level : Anaerobic metabolism leads to the production of lactate.
 Oxygen saturation : SPO2: Mixed venous oxygen saturation. Often elevated in sepsis
due to impaired oxygen utilization in the tissue
 Arterial Blood Gas (ABG): Evaluates acidosis, and ventilation parameter end points
 (Blood, Sputum, Urine, Stool, Wound) cultures: to identify infective sources
 Cardiac enzymes as creatine kinase (CK) -Lactate dehydrogenase (LDH) and troponins
T which are the best markers for acute MI.
 ECG, Echocardiography
 Imaging:
 Chest XR : Evidence of pulmonary edema and cardiac enlargement, tension
pneumothorax.
 US/CT/MRI to exclude intra-abdominal abscesses
 Management of shock:
 Shock is a life threatening condition, So Resuscitation should not be delayed.
 The goal of treatment is to restore cellular and organ perfusion (blood/oxygen).
 In any patient with shock, we should follow the general guidelines:
 ABCDEF: Airway, Breathing, Circulation, Disability, Exposure, Follow up.

 Respiratory resuscitation:
Immediate resuscitation to ensure a patent airway and adequate oxygenation
and ventilation. Once ‘airway’ and ‘breathing’ are assessed and controlled,
attention is directed to cardiovascular resuscitation.
 Cardiovascular resuscitation :
Established two wide bore IV cannula to allow rapid fluid infusion as
necessary, we may need insertion of central line ( Internal jagular or subclavian
vein ), Urinary catheterization for monitoring and follow up and to assess the
renal function.
 Diagnosis:
Rapid History and Clinical examination to established the cause of shock.
Arrange for definitive and specific treatment according to the cause.
Specific treatment of shock according to the (type) cause::
1) Treatment of Hypovolaemic shock:
 General guidelines of shock:
+
 Specific treatment of Hypovolaemic shock:
 In case of hemorrhagic shock:
 Stop bleeding :
Measures to stop bleeding such as direct pressure, packing, tourniquets may be
applied to help with immediate hemorrhage control until definitive
management can stop the bleeding.
 IV fluid therapy (Crystalloid solutions)
 Blood replacement.
 In case of non hemorrhagic shock:

 IV fluid therapy (Crystalloid solutions: Normal saline or Ringer lactate,
Hartmann’s solution ).
2) Treatment of Septic shock:
+
 Specific treatment of Septic shock:
 Administration of appropriate antibiotics
 IV Vasopressor agents ( Adrenaline)
3) Treatment of Cardiogenic shock:
+
 Specific treatment of Cardiogenic shock:
 The patient should transfer to CCU ( Coronary care unit)

 Administer high flow oxygen
 Assess ventilation
 Inotropic therapy (Dobutamine) may be required to increase cardiac
output and, therefore, oxygen delivery.
4) Treatment of Anaphylactic shock :
+
 Specific treatment of Anaphylactic shock:
 Antihistamine agents ( Anti-allergy)
 IV steroids therapy
5) Treatment of Neurogenic shock :
 General guidelines of shock in general:
+
 Specific treatment of Neurogenic shock:
 Monitoring of shocked patient:
The standards for monitoring of the patient in shock are:
 Continuous oxygen saturation monitoring/O2
 Continuous heart rate (ECG) monitoring/HR
 Respiratory rate monitoring/RR
 Frequent blood pressure monitoring/BP
 Hourly urine output measurements/UOP
 Endpoints of resuscitation:
Traditionally patients have been resuscitated until they have a :
 Normal oxygen saturation
 Normal heart rate ( pulse oxymeter)
 Normal respiratory rate
 Normal blood pressure
 Normal urine output.
THE END

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GENERAL SURGERY

 Shock is a life threatening emergency as a result of problems within the

Circulatory system : Heart, Blood vessels, and Blood

The main types of shock include:

1. Hypovolaemic shock (caused by too little blood volume)

A. Hemorrhagic/Bleeding causes :either:

B. Non Hemorrhagic/Bleeding causes: These conditions can also reduce

First Stages Second Stages Third Stages

Initial Compensated, Non compensated,

Reflex Compensatory If not treated early and Shock not respond to

Multiple organ failure

 ABCDEF: Airway, Breathing, Circulation, Disability, Exposure, Follow up.

1) Treatment of Hypovolaemic shock:

 General guidelines of shock:

 In case of non hemorrhagic shock:

 General guidelines of shock:

 General guidelines of shock:

 The patient should transfer to CCU ( Coronary care unit)

 General guidelines of shock:

 General guidelines of shock in general:

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