HEMORRHAGE AND

SHOCK
Muhammad Haseeb Ur Rehman

SHOCK DEFINITION


A profound hemodynamic and metabolic
disturbance due to failure of the circulatory
system to maintain adequate perfusion of vital
organs.



SHOCK DESCRIPTION

INADEQUATE TISSUE PERFUSION
Generalized decreased blood flow that leads to the too
little oxygen and other nutrients to the tissue cells

Damages the body tissues including heart, musculature,
walls of the blood vessels

Condition progressively gets worse

SHOCK CAUSES
PHYSIOLOGICAL CAUSES INCLUDE:

Circulatory shock caused by decreased cardiac
output

Circulatory shock without diminished cardiac
output
SHOCK DECREASED CO
Decreased cardiac output results in decreased tissue
perfusion
Factors that decrease Cardiac Output:
1- Cardiac Abnormalities
Decreased pumping ability of the heart e.g.
MI, valvular dysfunctions, and arrhythmias
2- Decreased Venous returns:
Diminished blood volume, decreased
vascular tone and blood obstruction at any point


WITHOUT DIMINSHED CO


Usually cardiac output is normal but the person is
in circulatory shock e.g. excessive metabolism of
the body.

SHOCK END RESULT

Tissue deterioration is the end result of the shock,
whatever the cause is.
Shock itself breeds more shock
Low tissue perfusion involves heart and circulatory
system itself which causes more shock
Vicious cycle of shock until death
SHOCK STAGES
Non- Progressive (Compensated shock):
Without outside therapy normal compensatory
mechanisms cause full recovery
Progressive Stage:
Without therapy shock becomes steadily worse
until death
Irreversible Stage:
All forms of therapy are inadequate
SHOCK TYPES
Hypovolemic Shock (Hemorrhagic shock)

Neurogenic Shock

Anaphylactic Shock

Septic Shock
NEUROGENIC SHOCK
Vascular capacity increased so much that even the
normal amount of blood becomes incapable of
filling the circulatory system adequately
One of the major causes is sudden loss of
vasomotor tone
That decreases the venous return also called venous
pooling of blood
Decreased CO and diminished tissue perfusion

NEUROGENIC SHOCK- CAUSES

Deep General Anesthesia:
Depresses the vasomotor center causing
vasomotor paralysis resulting neurogenic shock
Spinal Anesthesia:
Blocks the sympathetic nervous outflow that is
involved in increasing vasomotor tone, resulting in
NS
Brain Damage:
Trauma, infection; It causes vasomotor paralysis.
ANAPHYLACTIC SHCOK
Allergic condition results from antigen antibody
reaction
Antigen enters the circulation
Antigen-antibody reaction
Basophils in blood and mast cells in peri-capillary
tissues release histamine or histamine like
substance
ANAPHYLACTIC SHCOK
Histamine Causes:
Venous Dilation:
Increases vascular capacity leads to marked
decrease in venous return
Arterioler Dilation:
Decreased arterial pressure, low tissue
perfusion
Increased Capillary Permeability:
Rapid loss of fluid and protein into the tissue spaces
leading to reduced venous return



SEPTIC SHOCK

Previously termed as blood Poisoning

Septic shock refers to bacterial infection widely
spread to many areas of the body, with the infection
being borne through the blood from one tissue to
another and causing damage.


SEPTIC SHOCK CAUSES
Peritonitis caused by spread of infection from the
uterus and fallopian tubes due to unhygienic
instrumental abortion
Peritonitis caused by rupture of GI system
wounds or intestinal disease
Generalized bodily infection Streptococcal or
Staphylococcal Skin infection
Generalized gangrenous Infection Gas gangrene
Bacilli (Clostridium) peripheral tissue to internal
organs (Liver)

SEPTIC SHOCK FEATURES
High fever
Marked vasodilation especially in the infected
tissue
Sludging of the blood RBCs agglutination due to
damaging tissue
Micro-blood clots are developed in the widespread
areas of the body a condition called disseminated
intravascular coagulation this causes the blood
clotting factors to be used up, so that hemorrhage
occurs in many tissues, especially in GIT


SEPTIC SHOCK FEATURES
Early stages of septic shock there is no sign of
circulatory collapse but only signs of bacterial
infection
Progressively infection becomes more severe
involving the circulatory system either by direct
of infection or toxins produced by bacteria with
resultant loss of plasma into the infected tissues
through deteriorating blood capillary walls
Then deterioration of circulation follows same way
of other shocks
HEMORRHAGIC SHOCK
Also called hypovolemic shock or shock caused by
hypovolemia
Hypovolemia means diminished blood volume in the
body
Hypovolemic shock may be caused by plasma loss or
trauma
Hemorrhage is the most common cause of
hypovolemic shock
Hemorrhage decreases the filling pressure of the
circulation decreased venous return low cardiac
output shock ensues
BLEEDING VOLUME
Fall in CO and arterial pressure is directly related to
lost bleeding volume

10% loss of blood volume : Almost no effect on
CO and arterial pressure

35 45 % loss of blood volume : CO and arterial
pressure falls to zero
SYMPATHETIC REFLEX COMPENSATION
Hemorrhage decreases the arterial pressure and
pressures in the pulmonary arteries and veins
This decrease cause powerful sympathetic reflexes
initiated by baroreceptor and stretch muscle
reflexes
These reflexes stimulate the sympathetic
vasoconstrictor system, throughout the body,
resulting three important physiologic effects

SYMPATHETIC REFLEX COMPENSATION
1- Arterioles constricts in most parts of systemic
circulation increasing total peripheral resistance

2- The veins constrict and maintain adequate
venous return despite diminished blood volume

3- Heart rate increases markedly upto 160 -180
beats / minute

PROTECTION OF CORONARY
AND CEREBRAL CIRCULATION
1- Sympathetic stimulation does not cause
significant constriction of either cerebral or
coronary stimulation
2- In both these, vascular beds, local blood flow
autoregulation is excellent, that prevents moderate
decreases in arterial pressures
Therefore, blood flow through the heart and brain
is maintained essentially at normal levels until the
arterial pressure is upto 70 mm Hg
COMPENSATED HEMORRHAGIC SHOCK
Factors that play a crucial role in this are:
1- Baroreceptor reflexes
2- Central Nervous System Ischemic response
3- Reverse stress-relaxation
4- Formation of angiotensin
5- Formation of vasopressin
6- Other compensatory mechanisms
PROGRESSIVE H. SHOCK
Cardiac output is diminished and factors that are
involved in the progression of shock are :

1- Cardiac depression
2- Vasomotor failure
3- Blockage of small vessels
4- Increased capillary permeability

PROGRESSIVE H. SHOCK

5- Release of toxins by Ischemic Tissue
6- Generalized Cellular deterioration
7- Tissue Necrosis
8- Blood Acidosis

IRREVERSIBLE PHASE

All the above mentioned deteriorative changes in
the cells depress hearts ability to pump

Person will die, eventually

PHYSIOLOGY OF TREATMENT IN SHOCK
Replacement Therapy
1- Blood and Plasma Transfusions:
-Hemorrhage Whole blood
-Plasma Loss Plasma or plasma substitute
-Dehydration Appropriate electrolyte solution
2- Drugs
-Sympathomimetics drugs (NS / AS)


PHYSIOLOGY OF TREATMENT IN SHOCK

3- Other Therapies
- Head down position
- Oxygen Therapy
- Glucocorticoids