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
cardiogenic
hypovolemic

CO
decreased decreased increased decreased

PCWP
increased decreased decreased Increased

SVR
increased increased decreased increased

distributive obstructive

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 Dopamine Indication Renal perfusion hypotension MOA Dopaminergic 1 & dopaminergic Hypotension >10 mcg/kg/min 1 Cardiogenic shock 2.5-25 mcg/kg/min Selective 1 Hypotension 2-4 mcg/min 1 & 1 Hypotension 40-180 mcg/min Selective 1 Dose 2-5 mcg/kg/min 5-10 mcg/kg/min Principal actions Renal a. dilation + inotrope vasoconstriction + inotrope Vasoconstriction Vasoconstriction

Dobutamine Norepinephrine Phenylephrine

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 IVs or central line. Pressors are last line, but commonly required.

Addisons Disease
Deficiency of cortisol and aldosterone production in the adrenal glands This is suspected when patient is nonresponsive to fluids and antibiotics. Electrolytes may reveal hyponatremia and hyperkalemia Hydrocortisone 100 mg IV immediately then taper appropriately