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SHOCK
- GARGYA
SHOCK....syndrome resulting from inadequate perfusion of tissues. Aim of management.restoration of perfusion of the tissues. Restoration would be complete only after knowing the cause for shock Etiology is established by taking history, clinical features, lab investigations, radiographic studies and other tests. Once the cause is known, the approach of treatment varies based on the type of shock.
HYPOVOLEMIC
The most fundamental emergency management of any case would be the ABCs.i.e.
Airway.maintaining a patent airway, may be with endotracheal intubation Breathingproper ventilation of lungs, may be with assistance Circulationmaintaining the blood circulation, which in this context mainly means maintenance of blood volume and also prevention of pooling of blood.
HYPOVOLEMIC ......!!!
Diagnosis
Hemodynamic instability. Obvious source of volume loss.(u/s scan for abd.aneurysm, endoscopy for GI bleed, X-Ray, pregnancy test for ectopic pregnancy, etc.) Lab investigations CBC, electrolytes, PT, aPTT, ABGs, urine analysis, blood grouping and cross matching.
Treatment
At a prehospital level
prevent further loss, immobilize, ensure ventilation, and immediate transport to a hospital
maintained ( elevating the legs alone is the optimal position..transient effectdelays recovery if prolonged.) This is mainly useful to regain consciousness after a syncopal episode.
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Cardiogenic shock......!!!
Two types are the
Intrinsic Compressive
INOTROPES
The most important drugs in cardiogenic shock are the Inotropes i.e.
Dopamine, Dobutamine, Nor epinephrine, Vasopressin. vasoconstrictors and inotropes inotrope but a vasodilator.
Dopamine, nor epinephrine and vasopressin act by both Dobutamnie is used only when arterial pressure is restored as it is a
OTHER DRUGS
Septic shock......!!!
There are two types
Hyperdynamic Hypodynamic
Clinical features
Hyperdynamic tachycardia, norm. or increased CO, decreased systmc vascular resistance and increased pulm. Resistance (oxygen delivery is good but extraction is bad) Hypodynamic vasoconstriction and decreased CO, inc. PR, febrile, cold n mottled cyanotic extremities, oliguria, renal failure, inc. Sr.lactate.
Diagnosis
By the C/F, leucocytosis or leucopoenia, thrombocytopenia. Definitive diag. by the isolation and identification of microbes and detection of endotoxin in blood
Treatment
antibiotics and later based on the culture reports specific drug is to be given.
Rule out other causes of sep[sis using X-ray, CT, U/S. Hemodynamic support
- IV fluids 1-2 lit of NS over 2hrs - Urine output maintained at >0.5 ml/kg/hr - Diuretic is used when needed. - If fluid resuscitation fails, inotropics and vasopressors are used.
Metabolic support by bicarbonate admn (during acidosis) and fresh frozen plasma or platelets (in case of DIC)
STEROIDS inhibit the inflammatory rn. and their use is still limited
Management
The prehospital care as mentioned earlier The ABCs Control the hemorrhage by identifying the bleeding points. Early debridement of devitalized and injured tissues to reduce the inflammatory response Evacuation of any hematomas. Supplementing natural antioxidants to prevent further organ damage
Treatment
For hemodynamic instability IV dexamethasone sod. Phosphate..4mg Once insufficiency is confirmed hydrocortisone 100mg for 6-8 hrs. Volume resuscitation is needed
Tourniquet may be applied if the site of antigen inj. was on an extremity If intractable hypotension is present, Ns and vasopressors may be used. Initial nasal catheter or intermittent positive pressure breathing of
oxygenif progressive hypoxia develops then endotracheal intubation or tracheotomy