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Radius fracture with
ulna dislocation
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Elbow dislocation.
Distal humerus fracture
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Dislocation
of shoulder joint
Shock
Shock is a multifactorial clinical state, that occurs when cardiac output
is inadequate to permit arterial perfusion of blood under sufficient
pressure to provide organs and tissues with adequate blood flow. It is
also an inadequate blood flow to vital organs and inability of body cell
mass to metabolize nutrients normally, and accompanied by hypotension,
oliguria and cutaneous vasoconstriction. Prominent in early shock are
a number of compensatory mechanisms which maintain blood flow to
vital areas such as the heart and brain. When shock is prolonged,
tissue injury occurs and is manifested in the surviving patient as the
various complications of shock.
Classification of shock.
I. Hypovolemic shock.
A. Blood loss (massive haemorrhage and actual reduction of blood volume).
B. Plasma loss (massive burns lead to exudation of plasma).
C. Loss of fluid and electrolytes (excessive dehydration due to severe
vomiting or diarrhea).
II. Cardiogenic shock.
a. Myocardial infarction.
b. Myocardial contusion.
c. Arrhythmias.
d. Cardiac tamponade.
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e. Pulmonary embolism.
f. Respiratory failure.
III. Septic shock.
It is endotoxin shock in severe toxemia, as in peritonitis, septicemia
(gram negative organism) or pancreatitis.
The septic shock is a result of fluid loss into the extravascular space,
pain and the effect of chemical or bacterial toxins on the heart.
IV. Neurogenic shock. vasovagal syndrome produced by severe pain
or emotional disturbance due to reflex vasodilatation in muscle
together with vagal cardiac slowing.
V. Anaphylactic shock.
Also known as anaphylaxis , is an allergic condition that can be
severe and potentially fatal. It is a widespread and very serious
allergic reaction. Symptoms include dizziness, loss of consciousness,
labored breathing, swelling of the tongue and breathing tubes,
blueness of the skin, heart failure, low blood pressure and death.
Immediate emergency treatment is required for this shock. The whole
body can be affected, usually within minutes of contact with an
allergen, though sometimes the reaction can happen hours later. The
reaction is unpredictable and varies from mild itchiness and swelling
to severe and life-threatening symptoms.
Anaphylaxis can be triggered by a wide range of foods and other
substances. The most common food triggers include nuts, sesame
seeds, shellfish and eggs. Sometimes a person can be so sensitive to a
particular food that they can develop anaphylaxis just by breathing in
particles from it, such as dust from nuts.
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Anaphylaxis can also be caused by an allergic reaction to wasp or bee
stings, natural latex (rubber) and certain drugs, such as the antibiotic
penicillin.
VI. Shock due to adrenal cortical failure following adrenalectomy,
Addison s disease or lack of cortico-steroid replacement after long
term corticoids therapy.
If the shock condition continues (unstopped bleeding), it produces a
series of irreversible changes to vital organs, so that patient may die in
spite of blood replacement (irreversible shock).
= Specific changes in vital organs in shock state.
1- Kidneys: acute tubular necrosis.
2- Lungs: adult respiratory distress syndrome (ARDS), shock lung.
3- Heart: cardiac failure.
4- Adrenals: no normal reaction to stress.
5- Brain: cerebral ischemia.
6- Gut: non occlusive infarction.
= Changes in cell metabolism in shock.
1- Elevated arterial blood lactate (lactic acidosis).
2- Hypoglycemia.
3- High blood alanine.
4- Low fatty acid concentration.
5- Decrease in ATP production.
6- Membrane function:
a. Sodium leaks into the cell and potassium leaks out of the cell.
b. Lysosomes fragment causes autodigestion.
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= High risk patients in shock state.
1- Traumatic shock (haemorrhagic shock).
a. Fractures e.g. pelvis and polytrauma cases.
b. Gastro-intestinal bleeding.
c. Post-operative bleeding.
2- Septic shock.
a. After urinary tract and bowel surgery.
b. Burns.
c. Immune suppressive therapy.
d. Steroids.
e. Diabetes mellitus.
3- Cardiac shock.
a. Elderly people.
b. Previous myocardial infarction.
= Clinical features of shock.
1- Pallor.
2- Cold and clammy skin with sweating.
3- Empty veins.
4- Increased pulse rate, thread and irregular pulse.
5- Low blood pressure.
6- Nausea and vomiting.
7- Patient may be confused, restless or semi-conscious.
8- Respiratory distress.
= Treatment of haemorrhagic shock.
1- The principle is, removal of the cause and replacement of the
blood volume.
2- Arrest of further haemorrhage.
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3- Blood transfusion.
4- Relief of pain.
5- Elevation of foot end of the bed.
6- Avoid excessive warmth which produces vasodilatation of the skin
vessels.
= Shock treatment due to other causes.
1. Appropriate fluid replacement e.g. plasma substitute in the case of
burns and saline in severe vomiting or diarrhea.
2. In cases of adreno-cortical depletion, intravenous administration
of hydrocortisone etc.
3. In septic shock (toxemic patient) e.g. severe peritonitis appropriate
antibiotics are given in heavy dosage
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Blood Transfusion
Blood Is the organ which provides O2 and nutrients to all tissues and
removes CO2, waste products and toxic material. Its cellular elements,
White blood cells (WBCs), red blood cells (RBCs) and platelets are
suspended in the plasma.
Total circulating blood volume is about 8% of the body weight that is
about 5600ml in 70kg man (65 -75 ml/kg in adults).
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