Diagnosis and Management of Shock

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Objectives
Identify the major types of shock and principles of management
Review fluid resuscitation and use of vasopressor and inotropic agents Understand concepts of O2 supply and demand Discuss the differential diagnosis of oliguria

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Shock
Always a symptom of primary cause
Inadequate blood flow to meet tissue oxygen demand

May be associated with hypotension

Associated with signs of hypoperfusion: mental status change, oliguria, acidosis
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Shock Categories
Cardiogenic Hypovolemic Distributive Obstructive

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Cardiogenic Shock
Decreased contractility

Increased filling pressures, decreased LV stroke work, decreased cardiac output

Increased systemic vascular resistance compensatory
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Hypovolemic Shock
Decreased cardiac output Decreased filling pressures

Compensatory increase in systemic vascular resistance

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Distributive Shock
Normal or increased cardiac output Low systemic vascular resistance

Low to normal filling pressures

Sepsis, anaphylaxis, neurogenic, and acute adrenal insufficiency

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Obstructive Shock
Decreased cardiac output Increased systemic vascular resistance Variable filling pressures dependent on etiology Cardiac tamponade, tension pneumothorax, massive pulmonary embolus
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Cardiogenic Shock Management

Treat arrhythmias
Diastolic dysfunction may require increased filling pressures Vasodilators if not hypotensive Inotrope administration

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Cardiogenic Shock Management

Vasopressor agent needed if hypotension present to raise aortic diastolic pressure Consultation for mechanical assist device Preload and afterload reduction to improve hypoxemia if blood pressure adequate
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Hypovolemic Shock Management

Volume resuscitation crystalloid, colloid Initial crystalloid choices Lactated Ringers solution Normal saline (high chloride may produce hyperchloremic acidosis) Match fluid given to fluid lost Blood, crystalloid, colloid
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Distributive Shock Therapy

Restore intravascular volume
Hypotension despite volume therapy Inotropes and/or vasopressors Vasopressors for MAP < 60 mm Hg Adjunctive interventions dependent on etiology
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Obstructive Shock Treatment

Relieve obstruction Pericardiocentesis Tube thoracostomy

Treat pulmonary embolus

Temporary benefit from fluid or inotrope administration

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Fluid Therapy
Crystalloids Lactated Ringers solution Normal saline Colloids Hetastarch Albumin Gelatins Packed red blood cells Infuse to physiologic endpoints
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Fluid Therapy
Correct hypotension first
Decrease heart rate Correct hypoperfusion abnormalities

Monitor for deterioration of oxygenation

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Inotropic / Vasopressor Agents

Dopamine

Low dose (2-3 g/kg/min) mild inotrope plus renal effect

Intermediate dose (4-10 g/kg/min) inotropic effect High dose ( >10 g/kg/min) vasoconstriction Chronotropic effect
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Inotropic Agents
Dobutamine
5-20 g/kg/min Inotropic and variable chronotropic effects Decrease in systemic vascular resistance

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Inotropic / Vasopressor Agents

Norepinephrine 0.05 g/kg/min and titrate to effect

Inotropic and vasopressor effects

Potent vasopressor at high doses

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Inotropic / Vasopressor Agents

Epinephrine Both and actions for inotropic and vasopressor effects 0.1 g/kg/min and titrate Increases myocardial O2 consumption

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Therapeutic Goals in Shock

Increase O2 delivery Optimize O2 content of blood Improve cardiac output and blood pressure Match systemic O2 needs with O2 delivery Reverse/prevent organ hypoperfusion

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Oliguria
Marker of hypoperfusion Urine output in adults <0.5 mL/kg/hr for >2 hrs Etiologies Prerenal Renal Postrenal
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Evaluation of Oliguria
History and physical examination Laboratory evaluation Urine sodium Urine osmolality or specific gravity BUN, creatinine

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Evaluation of Oliguria
Laboratory Test Blood Urea Nitrogen/ Creatinine Ratio Urine Specific Gravity Urine Osmolality (mOsm/L) Urinary Sodium (mEq/L) Fractional Excretion of Sodium (%) Prerenal >20 >1.020 >500 <20 <1 ATN 1020 <1.010 <350 >40 >2

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Therapy in Acute Renal Insufficiency

Correct underlying cause Monitor urine output Assure euvolemia Diuretics not therapeutic

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Low-dose dopamine may urine flow Adjust dosages of other drugs Monitor electrolytes, BUN, creatinine Consider dialysis or hemofiltration

Pediatric Considerations
BP not good indication of hypoperfusion

Capillary refill, extremity temperature better signs of poor systemic perfusion

Epinephrine preferable to norepinephrine due to more chronotropic benefit Fluid boluses of 20 mL/kg titrated to BP or total 60 mL/kg, before inotropes or vasopressors

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Pediatric Considerations
Neonates consider congenital obstructive left heart syndrome as cause of obstructive shock Oliguria <2 yrs old, urine volume <2 mL/kg/hr Older children, urine volume <1 mL/kg/hr
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Key Points

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