Shock.ppt

SHOCK

DEFINITION

• Profound hemodyamic and metabolic disturbance characterized by failure of the circulatory system to maintain adequate perfusion of vital organs

Types of Shock

• Cardiogenic (intracardiac vs extracardiac)

• Hypovolemic

• Distributive– sepsis****– neurogenic (spinal shock)– adrenal insufficiency– anaphylaxis

Cardiogenic Shock, intracardiac

• Myocardial Injury or Obstruction to Flow– Arrythymias– valvular lesions– AMI– Severe CHF– VSD– Hypertrophic Cardiomyopathy

Presentation of Cardiogenic Shock

• Pulmonary Edema

• JVD

• hypotensive

• weak pulses

• oliguria

Cardiogenic Shock, extracardiac(Obstructive)

• Pulmonary Embolism

• Cardiac Tamponade

• Tension Pneumothorax

• Presentation will be according to underlying disease process.

Hypovolemic Shock

• Reduced circulating blood volume with secondary decreased cardiac output– Acute hemorrhage– Vomiting/Diarrhea– Dehydration– Burns– Peritonitis/Pancreatitis

Presentation of Hypovolemic Shock

• Hypotensive

• flat neck veins

• clear lungs

• cool, cyanotic extremities

• evidence of bleeding?– Anticoagulant use– trauma, bruising

• oliguria

Distributive Shock

• Peripheral Vasodilation secondary to disruption of cellular metabolism by the effects of inflammatory mediators.

• Gram negative or other overwhelming infection.

• Results in decreased Peripheral Vascular Resistance.

Distributive Shock: Presentation

• Febrile

• Tachycardic

• clear lungs, evidence of pneumonia

• warm extremities

• flat neck veins

• oliguria

Diagnosing Shock

• Response to fluids

• Echo/EKG

• CXR

• Evidence of infection

• Swan-Ganz Catheter?

Swan-Ganz Catheter

• Utilized to differentiate types of shock and assist in treatment response.

• Probably overused by physicians. Studies documenting increased mortality in patients with catheters versus no catheters, although somewhat swayed by selection bias.

Swan-Ganz Catheter

Swan-Ganz Interpretation

Etiology CO PCWP SVR

cardiogenic decreased increased increased

hypovolemic decreased decreased increased

distributive increased decreased decreased

obstructive decreased Increased increased

Management

• Correct underlying disorder if possible and then direct efforts at increasing the blood pressure to increase oxygen delivery to the tissues.

• Maintain a mean arterial pressure of 60 (1/3 systolic + 2/3 diastolic)

• Keep O2 sats >92%, intubate if neccesary

Correction of hypotension

• Normal Saline should be administered anytime a patient is hypotensive. If hypotension exists give more NS. ***

• If possible give blood as it replaces colloid.

• Vasopressors

• Inotropic agents for cardiogenic shock

• Intra-aortic Balloon Pump for cardiogenic

Autonomic Drugs in Shock

Drug Indication Dose MOA Principal actionsDopamine Renal perfusion 2-5 mcg/kg/min Dopaminergic Renal a. dilation

hypotension 5-10 mcg/kg/min 1 &dopaminergic

+ inotrope

Hypotension >10 mcg/kg/min 1 vasoconstrictionDobutamine Cardiogenic shock 2.5-25 mcg/kg/min Selective 1 + inotropeNorepinephrine Hypotension 2-4 mcg/min 1 & 1 VasoconstrictionPhenylephrine Hypotension 40-180 mcg/min Selective 1 Vasoconstriction

Management of Cardiogenic Shock

• Attempt to correct problem and increase cardiac output by diuresing and providing inotropic support. IABP is utilized if medical therapy is ineffective. Catheterization if ongoing ischemia

• Cardiogenic shock is the exception to the rule that NS is always given for hypotension NS will exacerbate cardiac shock.

Intra-Aortic Balloon Pump

Management of Septic Shock

• Early goal directed therapy• Identification of source of infection• Broad Spectrum Antibiotics• IV fluids • Vasopressors• Steroids ??• Recombinant human activated protein C ( Xygris)• Bicarbonate if pH < 7.1

Management of Hypovolemic Shock

• Correct bleeding abnormality

• If PT or PTT elevated then FFP

• Aggressive Fluid replacement with 2 large bore IV’s or central line.

• Pressors are last line, but commonly required.

Addison’s Disease

• Deficiency of cortisol and aldosterone production in the adrenal glands

• This is suspected when patient is non-responsive to fluids and antibiotics.

• Electrolytes may reveal hyponatremia and hyperkalemia

• Hydrocortisone 100 mg IV immediately then taper appropriately