Beruflich Dokumente
Kultur Dokumente
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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
Hypovolemic Shock
Decreased cardiac output Decreased filling pressures
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Distributive Shock
Normal or increased cardiac output Low systemic vascular resistance
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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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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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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
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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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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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Low-dose dopamine? Adjust dosages of other drugs Monitor electrolytes, BUN, creatinine Consider dialysis
Pediatric Considerations
BP not good indication of hypoperfusion
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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