Download Hypovolemic Shock

shock
)‫(شوک‬
1
2
‫نام‬
‫و نام خانوادگی ‪:‬‬
‫مرجان میرقائد‬
‫موضوع‪:‬‬
‫‪shock‬‬
‫(شوک)‬
‫پست سازمانی‪:‬‬
‫سوپر وایزر بالینی‬
‫بیمارستان ‪ 22‬بهمن‬
‫بهمن ‪1931‬‬
‫عنوان ‪ ....................................‬شماره‬
‫مقدمه ‪4........................................ ................................ ................................ ................................‬‬
‫علت های شوک ‪5............................ ................................ ................................ ................................‬‬
‫انواع شوک ‪6................................. ................................ ................................ ................................‬‬
‫شوک عفونی‪7............................... ................................ ................................ ................................ :‬‬
‫شوک قلبی ‪8.................................. ................................ ................................ ................................‬‬
‫‪3‬‬
‫شوک آنافالکتیک ‪8........................... ................................ ................................ ................................‬‬
‫شوک عصب زا ‪9............................ ................................ ................................ ................................‬‬
‫شوک هیپو ِولمیک ‪9.......................... ................................ ................................ ................................‬‬
‫پوولِمیک‪10 ....................... ................................ ................................ ................................ :‬‬
‫شوک هی ُ‬
‫شوک خون رویشی ‪11 ....................... ................................ ................................ ................................‬‬
‫شوک گردشی ‪13 ............................. ................................ ................................ ................................‬‬
‫عالئم و نشانه ها‪14 ......................... ................................ ................................ ................................ :‬‬
‫عالئم شوک قلبی‪15 ........................ ................................ ................................ ................................ :‬‬
‫تشخیص‪15 .................................. ................................ ................................ ................................ :‬‬
‫مقدمه‬
‫ً باا میا پ شکشاو‬
‫واژه ی شوک متفاوتا‬
‫هیگان‬
‫استفاده شده است‪ .‬توارد ذهن‬
‫واکنش ماطف‬
‫و میاوم‬
‫توسپ میوم یک‬
‫شدید با وضع ت شردغدغه یا اخباار باد‬
‫‪4‬‬
‫است‪ .‬تعریف شکشو‬
‫شوک بس ار متفاوت اسات‪ .‬ا‬
‫شکشو ‪ ،‬شوک به منوان وضع ت‬
‫نی‬
‫نرار‬
‫که بافات هاا در بادن‬
‫توانند اکس ژن و مواد مغایی کااف‬
‫را دریافات‬
‫کنند تا اینوه سلول ها را قادر به فعال ت ساا ند‪،‬‬
‫ً به مرگ سلول ‪ ،‬ش شارفت‬
‫تعریف شده است‪ .‬این نهایتا‬
‫اان‬
‫ادم درما‬
‫اورت ما‬
‫ً در دا‬
‫اا‬
‫اان و نهایتا‬
‫ااتوان ارنا‬
‫نا‬
‫ناتوان‬
‫کل بدن و مرگ منجر م‬
‫شود‬
‫در ادطالحات شکشو ‪ ،‬یک شوک وضع ت‬
‫سلول های متنوع بدن اکس ژن کااف‬
‫کنند هنگام‬
‫است که در آن‬
‫را دریافات نیا‬
‫که مرضه ی ناکاف ِ خون به کل بخش هاای‬
‫بدن وجود دارد‪.‬‬
‫ااک و تهدیاد برانگ اک‬
‫ً خطرنا‬
‫شوک یک وضع ت شدیدا‬
‫ندن‬
‫است‪ ،‬هنگام‬
‫که مادم اکسا ژن در بافات هاای‬
‫تواند سبب فلج و میلوارد‬
‫ارنان های متفاوت بدن م‬
‫بد سلول های مغک و در اکثر موارد ایست قلب‬
‫یک درمان فوری بنابراین بایسات‬
‫باا ب یاار داورت‬
‫ن رد به میض اینوه بدنش دستخوش یک شوک م‬
‫شوک رخ م‬
‫شاود‪.‬‬
‫شود‪ .‬یک‬
‫دهد هنگام وه بادن دساتخوش یاک رویاداد‬
‫غ رمنترره م‬
‫شود‪ ،‬کاه ما‬
‫تواناد هرنوناه جراحات‬
‫ف کیو ‪ ،‬ب یاری شدید یا یک ضربه ی ماطف‬
‫علت های شوک‬
‫‪5‬‬
‫باشد‪.‬‬
‫دالیل بس اری ا‬
‫اتفاق م‬
‫شوک‬
‫شکشو‬
‫افتد ایان اسات کاه ن رناده هاییاان یاک‬
‫س گنال غ رمعیول‬
‫دریافت م‬
‫شود‪ .‬آن معیوالً مان‬
‫م‬
‫وجود دارد‪ .‬چ کی که‬
‫کند و دستخوش یک شاوک‬
‫اتفاق م‬
‫ب یاری غ رمعیول‪ ،‬یک آس ب خارج‬
‫افتد که بدن یاک‬
‫یاا یاک‬
‫یا داخل‬
‫واقعه ی غم انگ ک برای ارائه ی س گنال برای جریان‬
‫ُرناان هاای بادن یاک مرضاه ی‬
‫خون متییل م شود و ا‬
‫ناکاف‬
‫اکس ژن به دست م‬
‫ا‬
‫آورند‪.‬‬
‫شوک موجب شده توسپ یک آس ب یا یک ب یااری بسا ار‬
‫خطرناک تر است و یک کی‬
‫شوک موجاب شاده‬
‫متفاوت ا‬
‫با یک رخداد غم انگ ک یا یاک رخاداد وحشات انگ اک‬
‫است‪ ،‬ا‬
‫آسان‬
‫طوالن‬
‫که در مورد دوم‬
‫آنجای‬
‫تواند باه‬
‫بدن م‬
‫در اکثر موارد بهبود یابد و تأث ر باه مادت‬
‫طول نی‬
‫کشد‪.‬‬
‫انواع شوک‬
‫شوک های ماطف‬
‫غ رمنترره م‬
‫م‬
‫و روان‬
‫شود که به جریان غ ر دی ح خون منجار‬
‫شود که در موض سبب رساندن ناکااف‬
‫شود که به فلج موقت‬
‫ا‬
‫به سادن‬
‫سبب یک رویداد‬
‫یا طوالن‬
‫اکسا ژن ما‬
‫حواس منجر م‬
‫شاود‪.‬‬
‫سوی دیگر‪ ،‬شوک های موجب شده توسپ یک آسا ب یاا‬
‫یک ب یاری شدید بس ار ش چ ده تر هساتند و متفااوت‬
‫ا‬
‫هیدیگر هستند‪ .‬آنها به شنج نوع مهم‬
‫ِ‬
‫بندی شده اند‪:‬‬
‫‪6‬‬
‫یار دساته‬
‫شوک عفونی‪:‬‬
‫یک نوع متعارف و معیول ا‬
‫شوک مفون‬
‫شاوک اسات‬
‫که با ب یاری های شدید مانند ذات الریاه‪ ،‬مننژیات‬
‫ً ایان‬
‫یا چند مفونت درون شوی هیراه م شود‪ .‬اساسا‬
‫یک مفونت باکتریای‬
‫شوک بعد ا‬
‫موجب شده است‪ .‬انر‬
‫ب یاری تشخ ص داده شود و درمان آنتا‬
‫ب یار داده شود‪ ،‬سلول های باکتریای‬
‫رشدشان م‬
‫شوک رنج نی‬
‫شود و بدن ا‬
‫اما انر ب یاری طوالن‬
‫درون بدن توث ر م‬
‫باکتریای‬
‫سیوم با خون ترک ب م‬
‫برد‪.‬‬
‫شود‪ ،‬سلول های باکتریای‬
‫را در بدن آ اد م‬
‫کند‪ .‬آنها اکس ژن را مصرف م‬
‫م‬
‫شوک مفون‬
‫کند‪ .‬ایان‬
‫شوند‪ .‬و کل شبوه ی نردش خون‬
‫بدن دستخوش یک شوک شدید م‬
‫مغک منته‬
‫درون مانع ا‬
‫شوند‪ .‬توث ار ساریع سالول هاای‬
‫سیوم خاد‬
‫را منهدم م‬
‫ب وت اک باه‬
‫کنناد و‬
‫شود که به فلاج دائیا‬
‫شود‪.‬‬
‫خطرناک ا‬
‫یک نوع خ ل‬
‫شوک موجب شده‬
‫است که کاامالً متعاارف و‬
‫توسپ مفونت های باکتریای‬
‫معیول هستند‪ .‬شخص باید یک درمان دی ح بارای چناان‬
‫ب یااری هاای‬
‫باکتریای‬
‫داشاته باشاد هیچنانواه سالول هاای‬
‫در بدن سالم باق‬
‫حالت شوک منجر م‬
‫شوند‪.‬‬
‫‪7‬‬
‫م‬
‫مانند که آنها باه‬
‫شوک قلبی‬
‫شوک قلب‬
‫نارسای‬
‫ً باا‬
‫شوک است که مستق یا‬
‫نوع دیگری ا‬
‫قلب برای تول د مقدار ناکااف ِ خاون بارای‬
‫بدن موجب شده است‪.‬‬
‫هنگام وه دریچه های قلب مسدود نرفته م‬
‫آنها شروع باه تول اد مقادار کیا‬
‫موردن ا‬
‫منته‬
‫م‬
‫م‬
‫ا‬
‫شاوند‪،‬‬
‫خاون ا‬
‫حاد‬
‫کنند که به کیبود شدید اکس ژن در بدن‬
‫شود‪.‬‬
‫مان وه قلب کامالً در تول د خون ناکاام ما‬
‫ماناد‪،‬‬
‫این به یک شوک شدید باه دنباال یاک حیلاه ی قلبا‬
‫منته‬
‫قلب‬
‫م‬
‫انسدادی منجر م‬
‫هیچن ن م‬
‫قلب‬
‫شود‪ .‬در اکثر موارد میون است به نارسای‬
‫شاود‪ .‬بناابراین شاوک قلبا‬
‫تواند به منوان یک شوک با شا ش حیلاه ی‬
‫نام ده شود‪.‬‬
‫شوک آنافالکتیک‬
‫شوک آنافالکت ک با یک واکنش آلرژیک شدید در بدن‬
‫تواناد هار ناوع ا‬
‫موجب شده اسات‪ .‬آن ما‬
‫ً این شوک با یک واکانش آلرژیاک‬
‫آلرژیک باشد‪ .‬اکثرا‬
‫در بدن هیراه م‬
‫واکانش‬
‫شود که با ن ش حشرات‪ ،‬داروها یاا‬
‫هر نوع غیا موجب م‬
‫شود‪.‬‬
‫ملت آلرژی میون است در افاراد مختلاف‪ ،‬متفااوت‬
‫ً به حساس ت بادن فارد‬
‫باشد ا آنجای که آن منیصرا‬
‫‪8‬‬
‫دارد‪ .‬در هر دورت‪ ،‬آلرژی که‬
‫در جهت یک مامل بستگ‬
‫سبب مامل در آ ادسا ی سیوم در بدنیان م‬
‫کنترل نشود‪ ،‬این سُیوم یک بخش ا‬
‫شود و سبب یک ددمه ی شدید م‬
‫منته‬
‫م‬
‫شود‪ ،‬انر‬
‫نردن بادنیان ما‬
‫شود که باه یاک شاوک‬
‫شود‪.‬‬
‫شوک عصب زا‬
‫شوک مصب‬
‫ا احتیاالً خطرناک ترین نوع شوک است که‬
‫به یک فلج آن‬
‫منته‬
‫م‬
‫شود که برای هی شه طول م‬
‫کشد‪.‬‬
‫این شوک با ددمه ی شدید نخاع موجب شده است‪ .‬ا‬
‫آنجای‬
‫فعال ات هاا در‬
‫کاه نخااع‪ ،‬ر س بسا اری ا‬
‫بدنیان است‪ ،‬هرنونه ددمه با نخاع م‬
‫آس ب دائی‬
‫تواند سبب یک‬
‫شود‪.‬‬
‫ِلمیک‬
‫شوک هیپوو‬
‫شوک ه پوولی ک نوع متعارف دیگری ا‬
‫یا داخل‬
‫شوک است که‬
‫با هرنونه ددمه ی خارج‬
‫ً این شوک به ملت کاهش شادید خاون موجاب شاده‬
‫اساسا‬
‫توسپ جراحت موجب شده است‪.‬‬
‫‪9‬‬
‫هیراه ما‬
‫شاود‪.‬‬
‫شوک(انواع خاص)‪:‬‬
‫ِی ک و شوک خون روش ‪:‬‬
‫ُل‬
‫شوک ه پوو‬
‫ِمیک‪:‬‬
‫ُل‬
‫شوک هیپوو‬
‫ن ا‬
‫در خاون‬
‫به آب نلبول هاای قرمکخاون کااف‬
‫وجود دارد برای اینوه قلاب سا االت را درون مجارای‬
‫خون حرکت دهد‪ .‬هنگام وه بدن آب ا‬
‫دسات ما‬
‫میون است نلبول های قرمک خاون کااف‬
‫دهاد‪،‬‬
‫وجاود داشاته‬
‫باشد‪ ،‬اما حجم کامل س ال کاهش یافته اسات و فشاار‬
‫درون س ستم کاهش م‬
‫یابد‪ .‬فرآورده ی قلب ‪ ،‬مقادار‬
‫است که قلب م‬
‫تواند در یک دق قه شیپاژ کند‪.‬‬
‫خون‬
‫آن به منوان حجم حرکت در نرر نرفتاه شاده اسات(چه‬
‫مقدار خون در هر تپش و‬
‫نش قلب ما‬
‫شود) که با سرمت قلب توث ر م‬
‫قلب چقدر سریع م‬
‫تواناد شیپااژ‬
‫شاود(در هار دق قاه‬
‫تپد)‪ .‬انار خاون کیا‬
‫در س ساتم‬
‫برای شیپاژ وجود داشته باشد‪ ،‬قلب سریع کار م‬
‫کند‬
‫برای اینوه تالش کند تا فرآوری ثابتش را حفظ کناد‪.‬‬
‫آب ‪ 09‬دردد ا‬
‫خون را تشو ل م‬
‫شود به خاطر این است که آب ا‬
‫جیب س ال(مایع) ناکاف‬
‫فرآورده ی قلب‬
‫کند‪ .‬اما هنگام‬
‫دهد‪ .‬انر بدن خشاک‬
‫دست رفتاه اسات یاا‬
‫است‪ ،‬بدن تالش ما‬
‫را با ایجاد‬
‫کناد تاا‬
‫نش سریعتر قلاب حفاظ‬
‫که مقدار سا ال کااهش ما‬
‫موان کم های هیبستگ‬
‫بدن مختل م‬
‫شوک روی دهد‪.‬‬
‫‪10‬‬
‫یاباد‪،‬‬
‫شوند و میون است‬
‫ِی ک مربوط باه اتاالف آب ما‬
‫ُل‬
‫شوک ه پو و‬
‫نقطه ی شایان بس اری ا‬
‫تواناد‬
‫ب یاری ها باشد‪ ،‬اما منصر‬
‫ِ‬
‫معیول‪ ،‬مدم س ال درون بدن است‪.‬‬
‫ِی ک‪ ،‬ب یاار نیا‬
‫ُل‬
‫ً در شوک ه پو و‬
‫نهایتا‬
‫مقدار س ال‬
‫که با نوش دن آب کااف‬
‫است را جایگکین کند‪ ،‬و بدن نی‬
‫فرآورده ی قلب‬
‫ا‬
‫تواناد‬
‫دسات رفتاه‬
‫تواند فشار خاون و‬
‫را حفظ کناد‪ .‬در تیاام حالات هاای‬
‫شوک‪ ،‬هنگام وه سلول ها شروع به بد میال کاردن ما‬
‫کنند میصوالت‬
‫ائد تشو ل ما‬
‫شای ن سلول شروع م‬
‫شاوند و مارگ ماارش‬
‫شود‪ ،‬افکایش اس دو‬
‫رخ م‬
‫دهد‬
‫و وخ م تر شدن می پ بدن باه مارگ ب شاتر سالول‪ -‬و‬
‫ً ناتوان ارنان منجر م شود‪.‬‬
‫نهایتا‬
‫شوک خون رویشی‬
‫یک‬
‫یر مجیومه ا‬
‫شوک خون روش‬
‫اتفاق م‬
‫افتاد‬
‫ً ساریع‬
‫مان وه خون ریکی مهم وجود دارد کاه نسابتا‬
‫اتفاق م‬
‫افتد‪.‬‬
‫خم معیول ترین و شایع ترین نیونه‬
‫ی خونریکی یا خون روش‬
‫ا‬
‫شرایپ شکشو‬
‫‪ ‬خون ریاکی ا‬
‫مانند‬
‫است‪ ،‬اما خونریکی م‬
‫تواند‬
‫یر رخ دهد‪:‬‬
‫دساتگاه م عدی و روده ای معیاول‬
‫است؛ مثال ها شامل‬
‫خام معاده یاا‬
‫خم اثنا‬
‫مشری‪ ،‬سرطان های روده ی بکرگ یا دیورت وول ها‬
‫باشند‪.‬‬
‫‪11‬‬
‫‪ ‬در‬
‫نان‪ ،‬خونریکی مفرط و با ش ا‬
‫تواند ا‬
‫انادا ه ما‬
‫رحم اتفاق ب افتد‪.‬‬
‫‪ ‬افراد مبتال باه سارطان یاا سارطان خاون بارای‬
‫خونریکی خود به خود ا‬
‫مناابع متناوع باالقوه‬
‫هستند در دورت وه مغک استخوانشان موامل لختاه‬
‫کاف‬
‫شدن‬
‫‪ ‬ب یاران‬
‫تول د نی‬
‫که ا‬
‫کند‪.‬‬
‫رق ق کننده هاای خون(داروهاای‬
‫ضد انعقاد خون) استفاده م‬
‫ً خونریکی کنند‪.‬‬
‫توانند شدیدا‬
‫کنند‪ ،‬هیچنا ن ما‬
‫کاهش خون دو تأث ر بر روی بدن دارد‪ .‬اوالً‪ ،‬کاهش‬
‫حجم درون مجراهای خون برای شیپاژ وجاود دارد(شاوک‬
‫ً کااهش اکسا ژن باه‬
‫ِی ک را بب ن د) و دوماا‬
‫ُل‬
‫ه پو و‬
‫خاطر ددمه ی نلبول های قرمک خاون رخ ما‬
‫غ ر این دورت افراد سالم م‬
‫دهاد‪ .‬در‬
‫توانند تا ‪ 09‬دردد ا‬
‫حجم خونشان را بدون داشتن نشانه هاای ب یااری باا‬
‫ضعف‪ ،‬ن ج‬
‫یا کوتاه‬
‫تنفس ا‬
‫درمان شوک خون روشا‬
‫دست دهند‪.‬‬
‫باه ملات آن بساتگ‬
‫دارد‪.‬‬
‫یافتن و کنترل منبع خاونریکی حاائک اهی ات واالیا‬
‫است‪ .‬مایعات داخل وریدی بارای کیاک در بهاوش آوری‬
‫استفاده شده اند برای اینوه حجم ماایع درون فااای‬
‫مجرای خون افکایش یاباد‪ ،‬اماا تکریاق خاون هی شاه‬
‫الکام‬
‫ن ست‪ .‬انار خاونریکی کنتارل شاود و ب یاار‬
‫استوارتر شود‪ ،‬مغک استخوان میون است اجا ه دهد که‬
‫ً‬
‫نلبول های قرمکخون کاه ا دسات رفتاه اناد مجاددا‬
‫توی ل شوند‪.‬‬
‫‪12‬‬
‫شوک گردشی‬
‫معیوالً به منوان یک شوک شاناخته شاده‬
‫شوک نردش‬
‫است‪ ،‬که یک وضع ت شکشو‬
‫که به ملت‬
‫تهدید برانگ ک‬
‫یر الیاه ی ناکااف‬
‫ندن‬
‫اسات‬
‫بارای تانفس سالول‬
‫دهد‪ .‬در مراحل اول ه‪ ،‬این معیاوالً یاک‬
‫هوا ی رخ م‬
‫سطح بافت ناکاف‬
‫مالئم معیول‬
‫ا‬
‫اکس ژن است‪.‬‬
‫شوک‪ ،‬فشار خون شای ن‪ ،‬ضاربان قلاب‬
‫سریع و مالوم تکریق وریدی ضع ف ارناان یاا حیلاه ی‬
‫قلب‬
‫مان های‬
‫است‪.‬‬
‫وجود دارد که فشاار خاون یاک‬
‫شخص میون است ثابت باق‬
‫در شوک نردش‬
‫بیاند‪ ،‬اما میون است هنو‬
‫باشد‪ ،‬بنابراین آن هی شاه یاک مالمات‬
‫ن ست‪.‬‬
‫شوک نردش‬
‫ا‬
‫آنجای‬
‫نباید با حالت ماطف‬
‫شوک مغشوش شود‪،‬‬
‫که این دو مرتبپ ن ستند‪ ،‬شوک نردش‬
‫یاک‬
‫امر فاوق العااده و غ ار منتراره ی شکشاو ِ تهدیاد‬
‫برانگ ک‬
‫ندن‬
‫است و یو‬
‫معیول ترین ملات هاای‬
‫ا‬
‫مرگ برای افرادی که به طور وخ م ب یار هستند‪ ،‬ما‬
‫باشد‪ .‬شوک م‬
‫تواند تناوم‬
‫ا‬
‫تاأث رات‪ ،‬هیاه باا‬
‫ش امدهای مشابه داشته باشد‪ ،‬اما هیه به یک مسالله‬
‫با س ستم نردش خون مرتبپ هستند‪ ،‬برای مثاال‪ ،‬شاوک‬
‫میوان اسات باه کام اکسا ژن (مدم اکسا ژن در خاون‬
‫شریان ) یا ایست قلب‬
‫قلب‬
‫‪13‬‬
‫منجر شود‪.‬‬
‫یو‬
‫ا‬
‫خطرات اساس‬
‫موان کم انعواس‬
‫شروع م‬
‫شوک این است که آن توسپ یک‬
‫مثبت ش ش ما‬
‫رود‪.‬‬
‫مان واه شاوک‬
‫شود‪ ،‬تیایل دارد که خودش را بادتر ساا د‪.‬‬
‫این است که دل ل اینوه چرا درمان فاوری شاوک مهام‬
‫است‪.‬‬
‫عالئم و نشانه ها‪:‬‬
‫شوک ه پوولی ک‬
‫واکااااااااااانش‬
‫درماااااااااااان‬
‫رده‬
‫کاهش خون‬
‫حداقل‪،‬‬
‫کی ته ای‬
‫(‪>07 %)9/57‬‬
‫‪I‬‬
‫مایعات داخل وریدی‬
‫(‪07-09 % )9/57 -0/7‬‬
‫نش سریع قلب‪ ،‬فشار خون طب ع‬
‫نش سریع قلب‪ ،‬حداقل‪ ،‬فشار خاون شاای ن‬
‫‪II‬‬
‫مایعات و ‪ RBC‬های بسته ای‬
‫(‪09-09 % )0/7-2‬‬
‫نش خ ل‬
‫‪III‬‬
‫مااداخالت فعاالنااه‬
‫(‪<09 % )< 2‬‬
‫شدت شوک خون روش‬
‫روی مالئم ف کیو‬
‫سریع قلب‪ ،‬فشار خون شاای ن‪ ،‬ن جا‬
‫فشااار خااون و‬
‫نااش قلااب وخاا م‬
‫‪IV‬‬
‫م‬
‫تواند در یاک مق ااس ‪ 0-0‬بار‬
‫درجه بندی شود‪ .‬این به کاهش موثر‬
‫حجم خون نکدیک است‪.‬‬
‫‪14‬‬
‫عالئم شوک قلبی‪:‬‬
‫‪ ‬س اهرگ متورم‬
‫س اهرن‬
‫یر نلوئ‬
‫به ملت افاکایش فشاار‬
‫یر نلوئ‬
‫‪ ‬تپش ضع ف یا غ رموجود‬
‫‪ ‬ب‬
‫نری‬
‫در ضربان قلب‪ ،‬اغلب ضربان شدید قلب‬
‫‪ ‬تپش های متناقض در مورد ‪tamponade‬‬
‫تشخیص‪:‬‬
‫اول ن تغ‬
‫داد قلب‬
‫رات دیده شده در شاوک افاکایش بارون‬
‫به دنبال کاهش در ترک اب اشاباع اکسا ژن‬
‫س اهرن (‪)Smvo2‬است‪ ،‬هیانگونه که در شریان ریوی ا‬
‫ِر(سوند) شریان ریوی اندا ه ن ری شاد‪.‬‬
‫ِت‬
‫طریق یک کات‬
‫اشباع اکس ژن س اهرن‬
‫مرککی(‪ )Scvo2‬هیانگونه که ا‬
‫طریق یک خپ مرککی اندا ه ن اری شاد باه خاوب‬
‫‪ Smvo2‬مرتبپ م‬
‫باا‬
‫باشد و برای به دست آوردن آساانتر‬
‫است‪ .‬انر شوک متابول سم غ رهوا ی را به ش ش ببرد‪،‬‬
‫شروع خواهد کرد که با افکایش اس د الکت ک خاون باه‬
‫م نوان یک ش امد رخ دهد‪ .‬در حال وه بس اری ا‬
‫های آ مایشگاه‬
‫تست‬
‫تسات‬
‫معیوالً انجام نرفته شده است و ها‬
‫وجود ندارد که مستنث‬
‫ا‬
‫تشخ ص باشد‪ .‬اشعه ی‬
‫‪ X‬س نه یا اولتراسوند درشارتیان اورژانس میون است‬
‫برای تع‬
‫ن حجم حالت مف د باشد‪.‬‬
‫‪15‬‬
Pade.................................................................................................. number
Types Of Shock .......................................................................................................................17
Causes Of Shock .....................................................................................................................17
Types Of Shocks .....................................................................................................................18
Septic Shock...........................................................................................................................18
Cardiogenic Shock ..................................................................................................................18
Anaphylactic Shock .................................................................................................................19
Neurogenic Shock ...................................................................................................................19
Hypovolemic Shock.................................................................................................................19
Shock - Specific Types .............................................................................................................19
Hemorrhagic Shock.................................................................................................................21
Shock (circulatory) ..................................................................................................................22
Signs and symptoms ...............................................................................................................23
Hypovolemic ..........................................................................................................................23
Cardiogenic............................................................................................................................24
Distributive ............................................................................................................................24
Pathophysiology .....................................................................................................................25
Initial ....................................................................................................................................25
Compensatory .......................................................................................................................26
Progressive ............................................................................................................................26
Refractory .............................................................................................................................27
Septic shock ...........................................................................................................................27
Diagnosis ...............................................................................................................................27
Differential diagnosis ..............................................................................................................27
Hypovolemic ..........................................................................................................................28
Distributive ............................................................................................................................28
Endocrine ..............................................................................................................................29
Management .........................................................................................................................30
16
Fluids ....................................................................................................................................30
Medications ...........................................................................................................................30
Treatment goals .....................................................................................................................31
Epidemiology .........................................................................................................................31
History ..................................................................................................................................31
References ............................................................................................................................32
introduction
The word shock is used differently by the medical community and the
general public. The connotation by the public is an intense emotional
reaction to a stressful situation or bad news. The medical definition of
shock is much different.
Medically, shock is defined as a condition where the tissues in the body
don't receive enough oxygen and nutrients to allow the cells to function.
This ultimately leads to cellular death, progressing to organ failure, and
finally, if untreated, whole body failure and death.
Types Of Shock
In medical terms a shock is a condition in which various cells of the body
fail to receive enough oxygen as there is an insufficient supply of blood to
the entire body parts.
Shock is an extremely dangerous and a life threatening situation as the
lack of oxygen in the tissues of various organs of the body can cause a
paralysis and malfunctioning of brain cells and in most cases a cardiac
arrest.
An immediate treatment must be, therefore, given to the patient as soon as
his body undergoes a shock. A shock occurs when a body undergoes an
unexpected event. It can be any physical injury, severe illness or an
emotional blow.
Causes Of Shock
There are many causes of a medical shock. What happens is that when our
receptors receive an unusual signal and it undergoes goes a shock. It
happens usually when the body goes through an unusual illness, an
external or an internal injury or a tragic event our brain cells seize to give
17
the signals for the blood to flow and the body organs get an insufficient
supply of oxygen.
The shock caused by an injury or an illness is far more dangerous and a bit
different from the shock caused by a tragic or a frightening event as in the
latter case the body can easily recover on its own in most cases and the
effect is not long lasting.
Types Of Shocks
Emotional and psychological shocks are simply caused by an unexpected
event which leads to an improper flow of blood which in return causes an
insufficient supply of oxygen which leads to either a temporary or a
prolonged paralysis of senses.
On the other hand the shocks caused by an injury or severe illnesses are far
more complex and are different from each other.
They are classified into following five major types:
Septic Shock
Septic shock is a common type of shock which accompanies severe
diseases such as pneumonia, meningitis or some intra abdominal
infections. Basically this shock is caused after a bacterial infection. If the
disease is diagnosed and the antibiotic treatment is given to the patient the
bacterial cells inside inhibit their growth and the body does not suffer from
the shock.
But if the disease is prolonged the bacterial cells inside the body keep on
multiplying. The rapidly multiplying bacterial cells release certain toxins
in the body. These toxins mix with the blood and damage the entire
network of blood circulation. They take up the oxygen and the body
undergoes a severe shock which results in the permanent paralysis of the
brain.
Septic shock is a very dangerous kind of shock caused by bacterial
infections that are quite common. One must have a proper treatment for
such diseases as if the bacterial cells remain intact in the body they lead to
a shocked state.
Cardiogenic Shock
18
Cardiogenic shock is another kind of shock which is directly caused by the
failure of heart to produce sufficient amount of blood for the body.
When the valves of heart get clogged up and congested they start
producing less amount of blood than required which results in a severe
shortage of oxygen in the body.
There comes a time when the heart completely fails to produce blood this
results in a severe shock followed by a heart attack. In most cases it may
result in congestive heart failure. Hence cardiogenic shock can also be
called as a pre heart attack shock.
Anaphylactic Shock
Anaphylactic shock is caused by a severe allergic reaction in the body. It
can be any kind of allergic reaction. Mostly this shock accompanies an
allergic reaction in the body caused insect bites, medicines or any food.
The cause of allergy may vary in different people as it solely depends on
the sensitivity of one’s body towards an agent. Any way the allergy
causing agent in the releases toxins in our, if not controlled early these
toxins become a part of our circulation and cause a severe damage which
results in a shock.
Neurogenic Shock
Neurogenic shock is probably the most dangerous kind of shock as it
results in an instant paralysis which lasts forever.
This shock is caused by a severe injury of the spinal cord. Since spinal
cord is the head of many activities in our body, any damage to the spinal
cord can cause a permanent damage.
Hypovolemic Shock
Hypovolemic shock is another common type of shock which accompanies
any internal or external injury. Basically this shock is caused due to severe
loss of blood caused by the injury.
Shock - Specific Types
Hypovolemic and Hemorrhagic Shock
19
Hypovolemic Shock
There needs to be enough red blood cells and water in the blood for the
heart to push the fluids around within the blood vessels. When the body
becomes dehydrated, there may be enough red blood cells, but the total
volume of fluid is decreased, and pressure within the system decreases.
Cardiac output is the amount of blood that the heart can pump out in one
minute. It is calculated as the stroke volume (how much blood each heart
beat can push out) multiplied by the heart rate (how fast the heart beats
each minute). If there is less blood in the system to be pumped, the heart
speeds up to try to keep its output steady.
Water makes up 90% of blood. If the body becomes dehydrated because
water is lost or fluid intake is inadequate, the body tries to maintain
cardiac output by making the heart beat faster. But as the fluid losses
mount, the body's compensation mechanisms fail, and shock may ensue.
Hypovolemic (hypo=low + volemic=volume) shock due to water loss can
be the endpoint of many illnesses, but the common element is the lack of
fluid within the body.
Gastroenteritis can cause significant water loss from vomiting and
diarrhea, and is a common cause of death in third world countries. Heat
exhaustion and heat stroke is caused by excessive water loss through
sweating as the body tries to cool itself. Patients with infections can lose
significant amounts of water from sweating. People with diabetes who
have diabetic ketoacidosis lose significant water because of because of
elevated blood sugar that cause excess water to be excreted in the urine.
Ultimately in hypovolemic shock, the patient cannot replace the amount of
fluid that was lost by drinking enough water, and the body is unable to
maintain blood pressure and cardiac output. In all shock states, when cells
start to malfunction waste products build up, a downward spiral of cell
20
death begins, increased acidosis occurs, and a worsening body
environment leads to further cell death - and ultimately organ failure.
Hemorrhagic Shock
A subset of hypovolemic shock occurs when there is significant bleeding
that occurs relatively quickly. Trauma is the most common example of
bleeding or hemorrhage, but bleeding can occur from medical conditions
such as:
•Bleeding from the gastrointestinal tract is common; examples include
stomach or duodenal ulcers, colon cancers or diverticulitis.
•In women, excessive bleeding can occur from the uterus.
•People with cancers or leukemia have the potential to bleed
spontaneously from a variety of sources if their bone marrow does not
make enough clotting factors.
•Patients who are taking blood thinners (anticoagulant medications) can
bleed excessively as well.
Blood loss has two effects on the body. First, there is a loss of volume
within blood vessels to be pumped (see hypovolemic shock) and second, a
reduced oxygen carrying capacity occurs because of the loss of red blood
cells. Otherwise healthy people can lose up to 10% of their blood volume
(about the amount that a person donates at a blood drive) without
becoming symptomatic with weakness, lightheadedness, or shortness of
breath.
The treatment of hemorrhagic shock depends on the cause. Finding and
controlling the source of bleeding is of paramount importance. Intravenous
fluids are used to help with resuscitation to increase the fluid volume
within the blood vessel space, but blood transfusion is not always
mandatory. If the bleeding is controlled and the patient becomes more
21
stable, the bone marrow may be allowed to replenish the red blood cells
that were lost.
If the red blood cell count in the blood decreases gradually over time,
either because of bleeding or the inability of the body to make enough new
red cells, the body can adjust to the lower levels to maintain adequate cell
perfusion, but the individual's exercise tolerance may decrease. This means
that they may do well in normal daily activities but find that routine
exercise or household activities bring on weakness or shortness of breath.
The treatment depends on the underlying diagnosis, since it isn't a total
fluid problem as in hypovolemic shock
Shock (circulatory)
From Wikipedia, the free encyclopedia
Jump to: navigation, search
"Acute shock" redirects here. For the psychological condition, see Acute
stress reaction.
Circulatory shock, commonly known simply as shock, is a lifethreatening medical condition that occurs due to inadequate substrate for
aerobic cellular respiration. In the early stages this is generally an
inadequate tissue level of oxygen.
The typical signs of shock are low blood pressure, a rapid heartbeat and
signs of poor end-organ perfusion or "decompensation/peripheral shut
down" (such as low urine output, confusion or loss of consciousness).
There are times that a person's blood pressure may remain stable, but may
still be in circulatory shock, so it is not always a sign.
Circulatory shock should not be confused with the emotional state of
shock, as the two are not related. Circulatory shock is a life-threatening
medical emergency and one of the most common causes of death for
critically ill people. Shock can have a variety of effects, all with similar
outcomes, but all relate to a problem with the body's circulatory system.
For example, shock may lead to hypoxemia (a lack of oxygen in arterial
blood) or cardiac arrest.
22
One of the key dangers of shock is that it progresses by a positive
feedback mechanism. Once shock begins, it tends to make itself worse.
This is why immediate treatment of shock is critical.[3]
Signs and symptoms
The presentation of shock is variable with some people having only
minimal symptoms such as confusion and weakness. While the general
signs for all types of shock are low blood pressure, decreased urine output,
and confusion these may not always be present. While a fast heart rate is
common, those on β-blockers, those who are athletic and in 30% of cases
those with shock due to intra abdominal bleeding may have a normal or
slow heart rate. Specific subtypes of shock may have additional symptoms.
Hypovolemic
Hemorrhage classes
Class Blood loss
Response
Treatment
I
<15 %(0.75 l)
min. fast heart rate, normal
minimal
blood pressure
II
15-30 %(0.751.5 l)
fast heart rate, min. low blood
intravenous fluids
pressure
III
30-40 %(1.5-2 l)
very fast heart rate, low blood fluids and packed
pressure, confusion
RBCs
IV
>40 %(>2 l)
critical blood pressure and aggressive
heart rate
interventions
Direct loss of effective circulating blood volume leading to:
23






A rapid, weak, thready pulse due to decreased blood flow combined
with tachycardia
Cool, clammy skin due to vasoconstriction and stimulation of
vasoconstriction
Rapid and shallow breathing due to sympathetic nervous system
stimulation and acidosis
Hypothermia due to decreased perfusion and evaporation of sweat
Thirst and dry mouth, due to fluid depletion and
Cold and mottled skin (Livedo reticularis), especially extremities,
due to insufficient perfusion of the skin
The severity of hemorrhagic shock can be graded on a 1-4 scale on the
physical signs. This approximates to the effective loss of blood volume.
Cardiogenic




Distended jugular veins due to increased jugular venous pressure
Weak or absent pulse
Arrhythmia, often tachycardic
Pulsus paradoxus in case of tamponade
Distributive
Systemic inflammatory response syndrome[7]
Finding
Value
Temperature
<36 °C (96.8 °F) or >38 °C (100.4 °F)
Heart rate
>90/min
Respiratory
rate
>20/min or PaCO2<32 mmHg (4.3 kPa)
WBC
<4x109/L (<4000/mm³), >12x109/L (>12,000/mm³), or
10% bands
Distributive shock includes infectious, anaphylactic, and neurogenic
causes. The SIRS features typically occur in early septic shock.
24
Anaphylaxis




Hives may present on the skin
Localised edema, especially around the face
Weak and rapid pulse
Breathlessness and cough due to narrowing of airways and swelling
of the throat
Pathophysiology
Effects of inadequate perfusion on cell function.
There are four stages of shock. As it is a complex and continuous
condition there is no sudden transition from one stage to the next. At a
cellular level shock is oxygen demand greater than oxygen supply.
Initial
During this stage, the state of hypoperfusion causes hypoxia. Due to the
lack of oxygen, the cells perform lactic acid fermentation. Since oxygen,
25
the terminal electron acceptor in the electron transport chain is not
abundant, this slows down entry of pyruvate into the Krebs cycle, resulting
in its accumulation. Accumulating pyruvate is converted to lactate by
lactate dehydrogenase and hence lactate accumulates (causing lactic
acidosis).
Compensatory
This stage is characterised by the body employing physiological
mechanisms, including neural, hormonal and bio-chemical mechanisms in
an attempt to reverse the condition. As a result of the acidosis, the person
will begin to hyperventilate in order to rid the body of carbon dioxide
(CO2). CO2 indirectly acts to acidify the blood and by removing it the body
is attempting to raise the pH of the blood. The baroreceptors in the arteries
detect the resulting hypotension, and cause the release of epinephrine and
norepinephrine. Norepinephrine causes predominately vasoconstriction
with a mild increase in heart rate, whereas epinephrine predominately
causes an increase in heart rate with a small effect on the vascular tone; the
combined effect results in an increase in blood pressure. Renin-angiotensin
axis is activated and arginine vasopressin (Anti-diuretic hormone; ADH) is
released to conserve fluid via the kidneys. These hormones cause the
vasoconstriction of the kidneys, gastrointestinal tract, and other organs to
divert blood to the heart, lungs and brain. The lack of blood to the renal
system causes the characteristic low urine production. However the effects
of the Renin-angiotensin axis take time and are of little importance to the
immediate homeostatic mediation of shock.
Progressive
Should the cause of the crisis not be successfully treated, the shock will
proceed to the progressive stage and the compensatory mechanisms begin
to fail. Due to the decreased perfusion of the cells, sodium ions build up
within while potassium ions leak out. As anaerobic metabolism continues,
increasing the body's metabolic acidosis, the arteriolar smooth muscle and
precapillary sphincters relax such that blood remains in the capillaries.[9]
Due to this, the hydrostatic pressure will increase and, combined with
histamine release, this will lead to leakage of fluid and protein into the
surrounding tissues. As this fluid is lost, the blood concentration and
viscosity increase, causing sludging of the micro-circulation. The
prolonged vasoconstriction will also cause the vital organs to be
compromised due to reduced perfusion. If the bowel becomes sufficiently
26
ischemic, bacteria may enter the blood stream, resulting in the increased
complication of endotoxic shock.
Refractory
At this stage, the vital organs have failed and the shock can no longer be
reversed. Brain damage and cell death are occurring, and death will occur
imminently. One of the primary reasons that shock is irreversible at this
point is that much cellular ATP has been degraded into adenosine in the
absence of oxygen as an electron receptor in the mitochondrial matrix.
Adenosine easily perfuses out of cellular membranes into extracellular
fluid, furthering capillary vasodilation, and then is transformed into uric
acid. Because cells can only produce adenosine at a rate of about 2% of the
cell's total need per hour, even restoring oxygen is futile at this point
because there is no adenosine to phosphorylate into ATP.
Septic shock




Systemic leukocyte adhesion to endothelial tissue
Reduced contractility of the heart
Activation of the coagulation pathways, resulting in disseminated
intravascular coagulation
Increased levels of neutrophils
Main manifestations are produced due to massive release of histamine
which causes intense vasodilatation
Diagnosis
The first changes seen in shock is an increased cardiac output followed by
a decrease in mixed venous oxygen saturation (SmvO2) as measured in the
pulmonary artery via a pulmonary artery catheter. Central venous oxygen
saturation (ScvO2) as measured via a central line correlates well with
SmvO2 and are easier to acquire. If shock progresses anaerobic
metabolism will begin to occur with an increased blood lactic acid as the
result. While many laboratory tests are typically performed there is no test
that either makes or excludes the diagnosis. A chest X-ray or emergency
department ultrasound may be useful to determine volume state.
Differential diagnosis
27
Shock is a common end point of many medical conditions. It has been
divided into four main types based on the underlying cause: hypovolemic,
distributive, cardiogenic and obstructive. A few additional classifications
are occasionally used including: endocrinologic shock.
Hypovolemic
This is the most common type of shock and is caused by insufficient
circulating volume.[2] Its primary cause is hemorrhage (internal and/or
external), or loss of fluid from the circulation. Vomiting and diarrhea are
the most common cause in children.[1] With other causes including burns,
environmental exposure and excess urine loss due to diabetic ketoacidosis
and diabetes insipidus.
Cardiogenic
This type of shock is caused by the failure of the heart to pump effectively.
This can be due to damage to the heart muscle, most often from a large
myocardial infarction. Other causes of cardiogenic shock include
dysrhythmias, cardiomyopathy/myocarditis, congestive heart failure
(CHF), contusio cordis, or cardiac valve problems.
Obstructive
Obstructive shock is due to obstruction of blood flow outside of the heart.
Several conditions can result in this form of shock.




Cardiac tamponade in which fluid in the pericardium prevents inflow
of blood into the heart (venous return). Constrictive pericarditis, in
which the pericardium shrinks and hardens, is similar in
presentation.
Tension pneumothorax Through increased intrathoracic pressure,
bloodflow to the heart is prevented (venous return).
Pulmonary embolism is the result of a thromboembolic incident in
the blood vessels of the lungs and hinders the return of blood to the
heart.
Aortic stenosis hinders circulation by obstructing the ventricular
outflow tract
Distributive
28
Distributive shock is due to impaired utilization of oxygen and thus
production of energy by the cell.[2] Examples of this form of shock are:



Septic shock is the most common cause of distributive shock.
Caused by an overwhelming systemic infection resulting in
vasodilation leading to hypotension. Septic shock can be caused by
Gram negative bacteria such as (among others) Escherichia coli,
Proteus species, Klebsiella pneumoniae which release an endotoxin
which produces adverse biochemical, immunological and
occasionally neurological effects which are harmful to the body, and
other Gram-positive cocci, such as pneumococci and streptococci,
and certain fungi as well as Gram-positive bacterial toxins. Septic
shock also includes some elements of cardiogenic shock. In 1992,
the ACCP/SCCM Consensus Conference Committee defined septic
shock: ". . .sepsis-induced hypotension (systolic blood pressure <90
mm Hg or a reduction of 40 mm Hg from baseline) despite adequate
fluid resuscitation along with the presence of perfusion
abnormalities that may include, but are not limited to, lactic acidosis,
oliguria, or an acute alteration in mental status. Patients who are
receiving inotropic or vasopressor agents may have a normalized
blood pressure at the time that perfusion abnormalities are
identified."
Anaphylactic shock Caused by a severe anaphylactic reaction to an
allergen, antigen, drug or foreign protein causing the release of
histamine which causes widespread vasodilation, leading to
hypotension and increased capillary permeability.
High spinal injuries may cause neurogenic shock. The classic
symptoms include a slow heartrate due to loss of cardiac
sympathetic tone and warm skin due to dilation of the peripheral
blood vessels. (This term can be confused with spinal shock which is
a recoverable loss of function of the spinal cord after injury and does
not refer to the haemodynamic instability per se.)
Endocrine
Based on endocrine disturbances such as:


Hypothyroidism (Can be considered a form of Cardiogenic shock) in
critically ill patients, reduces cardiac output and can lead to
hypotension and respiratory insufficiency.
Thyrotoxicosis (Cardiogenic shock)
29
may induce a reversible cardiomyopathy.
Acute adrenal insufficiency (Distributive shock) is frequently the
result of discontinuing corticosteroid treatment without tapering the
dosage. However, surgery and intercurrent disease in patients on
corticosteroid therapy without adjusting the dosage to accommodate
for increased requirements may also result in this condition.
Relative adrenal insufficiency (Distributive shock) in critically ill
patients where present hormone levels are insufficient to meet the
higher demands
o


Management
The best evidence exists for the treatment of septic shock in adults and as
the pathophysiology appears similar in children and other types of shock
treatment this has been extrapolated to these areas. Management may
include securing the airway via intubation to decrease the work of
breathing, oxygen supplementation, intravenous fluids and a passive leg
raise (not Trendelenburg position), and blood transfusions. It is important
to keep the person warm as well as adequately manage pain and anxiety as
these can increase oxygen consumption.
Fluids
Aggressive intravenous fluids are recommended in most types of shock
(e.g. 1-2 liter normal saline bolus over 10 minutes or 20ml/kg in a child)
which is usually instituted as the person is being further evaluated. Which
intravenous fluid is superior, colloids or crystalloids, remains
undetermined.
Thus as crystalloids are less expensive they are
recommended. If the person remains in shock after initial resuscitation
packed red blood cells should be administered to keep the hemoglobin
greater than 100 gms/l.
For those with hemorrhagic shock the current evidence supports limiting
the use of fluids for penetrating thorax and abdominal injuries allowing
mild hypotension to persist (known as permissive hypotension). Targets
include a mean arterial pressure of 60 mmHg, a systolic blood pressure of
70-90 mmHg, or until their adequate mentation and peripheral pulses
People can't go into shock by waking up too suddenly.
Medications
30
Vasopressors may be used if blood pressure does not improve with fluids.
There is no evidence of superiority of one vasopressor over another.
Vasopressors have not been found to improve outcomes when used for
hemorrhagic shock from trauma but may be of use in neurogenic shock.
Activated protein C (Xigris) while once aggressively promoted for the
management of septic shock has been found to improve survival and is
associated with a number of complications, thus recommended. The use of
sodium bicarbonate is controversial as it has not been shown to improve
outcomes. If used at all it should only be considered if the pH is less than
7.0.
Treatment goals
The goal of treatment is to achieve a urine output of greater than
0.5 cc/kg/hr, a central venous pressure of 8-12 mmHg and a mean arterial
pressure of 65-95 mmHg. In trauma the goal is to stop the bleeding which
in many cases requires surgical interventions.
Epidemiology
Hemorrhagic shock occurs in about 1-2% of trauma cases.
Prognosis
The prognosis of shock depends on the underlying cause and the nature
and extent of concurrent problems. Hypovolemic, anaphylactic and
neurogenic shock are readily treatable and respond well to medical
therapy. Septic shock however, is a grave condition with a mortality rate
between 30% and 50%. The prognosis of cardiogenic shock is even worse.
History
In 1972 Hinshaw and Cox suggested the classification system for shock
which is still used today.
31
References
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Pathway For Life-Threatening Pediatric Illnesses And Injuries".
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www.wikipedia.com‫پدیا ویکی‬
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