Diagnosis and Management of Shock

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Objectives
Define the major types of shock and principles of management
Review fluid resuscitation, vasopressors and inotropes Address the balance of O2 supply and demand Discuss the differential diagnosis of oliguria

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Shock
Always a symptom of its cause
Abnormally low organ perfusion usually associated with decreased blood pressure Signs of organ 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 etiology dependent 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

Vasopressors if hypotensive to raise aortic diastolic pressure Mechanical assistance Consultation

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Hypovolemic Shock
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

Expand intravascular volume
Hypotension despite volume therapy
Inotropes

Vasopressors for MAP < 60 mm Hg Adjunctive antibiotics in sepsis

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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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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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Fluid Therapy
Crystalloids Lactated Ringers solution Normal saline Colloids Hetastarch Albumin 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 Agent

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 Agent
Dobutamine
5-20 g/kg/min Inotropic and variable chronotropic effect Decrease in systemic vascular resistance

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Inotropic / Vasopressor Agent

Norepinephrine 0.05 g/kg/min and titrate Inotropic and vasopressor effects

Potent vasopressor at high doses

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

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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? Adjust dosages of other drugs Monitor electrolytes, BUN, creatinine Consider dialysis

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 from epinephrine Fluid boluses of 20 mL/kg titrated to BP or total 60 mL/kg, before inotropes or vasopressors

Pediatric dosages in text

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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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