HTN -shock.docx

Shock Definition: The rate of arterial blood flow is inadequate to meet tissue metabolic demands. Classification & types of shock Hypovolemic shock External blood loss (Trauma ,GIT bleeding) Internal blood loss (Haematoma) Loss of plasma (Burns ,Sever dermatitis) Loss of fluids and electr...

Shock Definition: The rate of arterial blood flow is inadequate to meet tissue metabolic demands. Classification & types of shock Hypovolemic shock External blood loss (Trauma ,GIT bleeding) Internal blood loss (Haematoma) Loss of plasma (Burns ,Sever dermatitis) Loss of fluids and electrolytes (Vomiting,Diarrhoea) Cardiogenic shock: Arrhythmia Cardiac failure 2 ry to myocardial infarction or Obstructive shock cardiac tamponade, Obstructive valvular disease, Massive pulmonary emobilization Distributive shock Septic shock The most common cause of distributive shock Mortality rate is very high 40-80% Neurogenic shock Traumatic spinal cord injury Epidural or spinal anaesthesia Reflex Vagal stimulation Pain Diagnosis of shock Systolic hypotension, systolic blood pressure < 90 mmHg End organ hypo perfusion: Rapid pulse, decreased urine output, cold bluish extremities, altered mental status, ischemic bowel disease, ischemic hepatitis Altered mental status, agitation, lethargy confusion, coma Treatment of shock: General measures: Basic life support Airway maintenance Cardiopulmonary resuscitation Fluid resuscitation Laboratory testing: Blood counts Electrolytes Glucose levels Arterial blood gases Coagulation parameters Blood group and cross matching Volume replacement: Blood products transfusion for haemorrhagic shock Isotonic saline Lactated ringer solution Plasma expanders: eg. Albumin, dextran Medications Vasopressor agents: Eg. Dopamine, Dobutamine, Nor-epinephrine, vasopressin. Sodium bicarbonate: for acidosis Broad spectrum antibiotics in sepsis Corticosteroids: in adrenal insufficiency Treatment of the underlying cause Eg. Revascularization for myocardial infarction Intra arterial balloon dilation for acute heart failure Causes and management of shock in dental office Septic shock Infections can develop anywhere in your mouth – in the gums (periodontal), lips, palate, cheeks, and tongue, or within and below teeth (endodontic). Paying attention to dental health is essential in preventing dental infections. A dental infection within or below a tooth can be caused by tooth decay or a broken tooth that causes the pulp to become infected. The pulp is the part of the tooth that contains blood vessels, connective tissue, and large nerves. When an infection occurs, bacteria can move out of the tooth to the bone or tissue below, forming a dental abscess. A dental infection can lead to sepsis. This is common in Old age and in Immuno-compromised patients Vasovagal shock Syncope is the most common emergency in dental practice it may be presented due to Psychogenic factor as fear , pain Excessive manipulation orPostural hypotension Anaphylactic shock Life threatening hypersensitivity reaction occurs after Exposure to provoking agent (local anesthetic agent ) ,Peak severity occurs within 5 – 30 min there has to be Resuscitative drugs (antihistamine ,adrenaline , corticosteroid ) in the clinic .it is Systemic hypertension Systemic arterial Hypertension is present when the blood pressure ≥ 140/90 mmHg, it is more common with advance of age and in blacks more than whites Cardiovascular morbidities and mortalities increase when both systolic and diastolic blood pressures increase. Complications of hypertension: Cerebrovascular strokes : cerebrovascular infraction and intracranial haemorrhage Coronary artery diseases Congestive heart failure Renal failure Peripheral vascular diseases Definitions: Isolated systolic hypertension: If the systolic blood pressure is elevated (≥140) with a normal (<90) diastolic blood pressure (DBP) Primary / idiopathic/ essential hypertension: systemic hypertension of unknown cause, it constitutes 95 % of all cases of hypertension Secondary hypertension: systemic hypertension secondary to a known cause, it constitutes 5 % of all cases of hypertension White coat hypertension: Is a phenomenon where the blood pressure level is above the normal range, when measured by a physician or in a health care setting, though it is normal outside the clinical setting.  It is believed that the phenomenon is due to anxiety. Malignant hypertension: It is a hypertensive emergency, where there is markedly elevated blood pressure, when the diastolic > 120 mmHg, associated with papillodema (edema of the optic disc in the eye) Etiology and pathogenesis of Systemic hypertension: Primary hypertension: 90 % of hypertension is primary Pathogenic mechanisms: Sympathetic over activity Over activity of the Renin Angiotensin system (RAS): Renin is proteolytic released from the juxtaglomerular apparatus of the kidney surrounding the afferent arterioles, it will act on angiotensinogen converting it to angiotensin I, angiotensin converting enzyme will act on angiotensin I to convert it to angiotensin II a potent vasopressor, angiotensin II will stimulate the release of aldosterone from the adrenal cortex, a major vasoconstrictor risk factors of primary systemic hypertension: Obesity Increased salt intake Cigarette smoking Excessive use of Non Steroidal Anti-Inflammatory Drugs (NSAID) Lack of exercise Secondary hypertension: Renal causes Renal parenchyma diseases: Acute glomerulonephritis Chronic nephritis Collagenic vascular diseases Diabetic nephropathy Renal artery stenosis Renin secreting tumors Endocrine causes: Cushing syndrome Diabetes mellitus Acromegaly Hyperthyroidism Pheochromocytoma Hyperparathyroisism Drug induced Glucocorticoides oral contraceptive pills NSAID Cyclosporins Nasal decongestants Antidepressants Management of systemic hypertension: Treatment: Non pharmacological treatment: A healthy DASH diet has recommended reducing blood pressure A diet rich in fruits, vegetables, low in fat dairy product, low saturated fat diet Reduce salt intake Encourage aerobic exercise Cessation of smoking Pharmacological treatment: Diuretics: eg.Hydrochlrothiazides, Frusemide Beta adrenergic blocking agents: eg. Carvedilol, Atenolol Alpha adrenoreceptor blockers: eg. Doxazosin, Prozosin Central sympatholytics: eg. Clonidine, Methydopa Angiotensin converting enzyme inhibitors (ACEI): eg. Ramipril, Captopril. Enalapril Angiotensin II receptor blocking Drugs (ARBs): eg. Losartan, Cadesartan, Valsartan Calcium channel blockers: eg. Verapamil, Amlodipine Vasodilators: eg. Hydralazine, Minoxidil Hypertension in dental clinic elevated blood pressure can lead to excessive intraoperative bleeding during surgical procedures knowing the history of the patient plays a role in deciding when to perform certain procedures, and precautions should be taken when performing surgeries. There are a number of drug interactions associated with the use of vasoconstrictors. Epinephrine has been shown to react with some antihypertensive agents as well as other drugs. Before proving care to hypertensive patients, the practitioner should be able to assess patient blood pressure and if the blood pressure is high referred the patient to medical counsel. Rheumatic fever • Rheumatic fever is a acute immunologically mediated multisystem disease of childhood, often recurrent that follows group A beta hemolytic streptococcal infection • It is a delayed consequence to pharyngitis secondary to GABH streptococci. • It is a diffuse inflammatory disease of connective tissue, primarily involving heart, blood vessels, joints, subcutaneous tissue and Central nervous system. Epidemiology - Ages 5-15 yrs are most susceptible - 20 % in adults - Girls are more affected than boys - Common in developing countries - Environmental factors: overcrowding, poor sanitation, poverty Clinical features Arthritis Fleeting migratory polyarthritis, involving major joints • Commonly involved joints: knee, ankle, elbow & wrist • doesn’t lead to permanent damage of the affected joints Carditis Manifest as pancarditis (endocarditis, myocarditis and pericarditis), occur in 60-80% of affected children • Carditis is the only manifestation of rheumatic fever that leaves a sequelae & permanent damage to the organ • Chronic phase- fibrosis, calcification & stenosis of heart valves Sydenham Chorea • Occur in 5-10% of cases • Mainly in girls of 1-15 yrs age • Clinically manifest as-clumsiness, deterioration of handwriting, emotional liability or grimacing of face Subcutaneous nodules Painless, pea-sized, palpable nodules • Mainly over extensor surfaces of joints, spine, scapulae & scalp Erythema marginatum The annular erythema (exudative lesions) : • Appear on the extremities and the trunk skin. 1-2 days. Diagnostic criteria of Rheumatic fever: - Rheumatic fever is mainly a clinical diagnosis - No single diagnostic sign or specific laboratory test available for diagnosis - Diagnosis based on MODIFIED JONES CRITERIA