Shock

As usual, after I clocked in at the department, I go to level 1 and saw my colleagues lepak2 bersenang lenang at the tables provided in the hallway, ate nasi lemak ayam or nasi minyak in the morning dua ringgit setengah. The group which will be presenting was setting up their seminar on the day, Shock, supervised my Mr. Khadri. It sounds like a simple seminar indeed, revising things which was taught in each year since our first year in medical school. But still, there were lots of knowledge we are lacking.

In any medical or surgical textbooks, shock is among the earliest topic the author or editor would put into their books. It should be in the second or third chapter, like that. In any posting, be it in O&G, medical, ortho, paed, surgical, shock is a very important topic which is mandatory to be covered. It can happen everywhere and anywhere even if one day one of you happen to be a clinical pathologist, looking at specimens day and night sampai juling, if your title is doctor, shock is still a thing you should not throw it away from your cerebrum, lock it deep inside. Unless, you want to start to do other business, then you may go and throw it away.


Basically, the presenters were presenting the same thing back in our BMS, refreshing our mind on what we have learnt. The definition, in a simple way in my language

"Profound haemodynamic and metabolic disturbance characterized by failure of the circulatory system to maintain an appropriate blood supply to the microcirculation with the consequence of inadequate perfusion of vital organs."

In a simple way, systemic hypoperfusion of tissue of organs, so they shut down la...dah tak ada modal, nak jalan pun tak boleh. Like a factory.

So, they classified shock pertaining to its etiology which lead to inadequate perfusion

• cardiogenic
• hypovolemic
• distributive
• anaphylactic
• neurogenic
• septic

The pathophysiology from inadequte perfusion in each etiology which will eventually lead to organs failure.

http://upload.wikimedia.org/wikipedia/commons/thumb/0/0e/Shock-cell2.svg/500px-Shock-cell2.svg.png

The stages of shock together with the clinical features in each stage. They are almost the same, but might be different in the distributive type wherein there will be pooling of blood to the periphery.

Complication of shock was included as well, spesific for each organ. Commonly, in the ward, kidney is the first to be affected.

And a lot more. I was yawning throughout the seminar, I couldn't sleep last night as usual. My eyes was like satu suku lagi boleh tutup dah, but I tried to keep it open and yes, my eyes wide opened when the last presenter mentioned " Any question?" Heh.

So, they were bombarded with questions. Honestly I was waiting for the presenters to discuss on the management and complication in clinical point of view, yes they did but not as complete as I thought. I was expecting more, ended up, I put it as my learning need and will do more reading on that later. Biyane... :P But, it was a great seminar though, Come on, we are still new whaaaatt. *Excuses* 

Few questions was asked and more questions came as the discussion went on.

1. What if localized inflammation with no systemic manifestation but presented with shock? 
2. At what stage resuscitation should be done? 
3. What is PCWP (pulmonary wedge pressure)? how is the procedure done? Is it commonly used in our local setting? 
4. management of shock especially in case of hypovolumic shock and the importance of clinical judgement in managing and recogniczing shock. Is blood transfusion is more superior than isotonic solution?

Discussion 

1. We know that shock is set in motion when there is failure to deliver towards and to excrete substances away in short. But how does that occur in a person would be depending on two factors 

• insults which was presented well by the presenters pertaining to the etiology.
• body response is different between persons. A patient may come with small amount of insult like a simple cat-scratch but may develop severe shock. A patient may presented with many cat-scratch or bites ( huh?) but still nothing happen.

For example, in case of bleeding or trauma

Case 1 : A 65 year old gentleman with several co-morbidities namely ischemic heart disease, kidney disease, etc. lost blood about 500 ml but may presented with late stage of shock.

Case 2 : A young, medium built gentleman with no known medical illness, lost 1 500 ml ( sebotol air mineral besar) may come with just dizziness, or showing early stage of shock.

http://www.dcavm.org/10oct2.gif

Even if we were provided with several guidelines of the clinical features of shock, the doctors will decide if this is shock or not. Early recognition is very crucial and should not be missed as it may affect if the treatment will be successful.

Cardinal signs of acutely ill or shocked patient

• substantially increased or decreased respiratory rate
• bradycardia or tachycardia
• low BP
• hypo or hyperthermia
• decreased level of consciousness

REFER MEWS

2. At what stage resuscitation should be done? Once shock is recognized, resuscitation need to be done, stabilizing every components ABCDE.

Early management should be within 24 hours  of acute deterioration

• clinical assessment of the volume
• treat the cause of shock or infection if any
• support vital organs
• optimise the cardiovascular and haemodynamic system, aiming for 
• central venous pressure 8-12mmHg
• mean arterial pressure over 65mmHg
• UO >0.5ml/kg/hour
• monitor and assess the response
• urine output
• stroke volume

3.Blood is not the best for resuscitation. The best is by using isotonic such as D5%, NS, HM, etc \ but need to remember, HM solution contain lactate which might worsen acidosis in shock.

May Allah ease.