Hypotension & Shock

M. Sikander Akbar
August 7
th
, 2003
Case Scenario
It is 4:57 PM and for the first time since starting
internship, you have finished all your notes and are
preparing to sign out. You are excited because you
have a hot date later that evening. Just as you are
about to sign out, you are paged to 3300 and as
usual, you answer your page promptly. A frantic
sounding nurse answers the phone and says that your
patient Mr. Smith has a blood pressure of 70/40.
What are the most appropriate next step in
the management of this patient?

(A) Sign out to the covering intern on call
(B) Go to any empty room, close the door,
then shout out S---! as loud as you can.
(C) Ask the nurse to recheck the blood
pressure manually.
(D) Go and evaluate the patient.
Definition of Hypotension and Shock
Hypotension:
MBP <60 or acute reduction >40 mmHg (Harrison)
Shock:
Acute circulatory failure; inadequate organ perfusion results in
tissue ischemia & organ dysfunction
Irreversible Shock:
Cell death eventually leads to irreversible dysfunction of vital
organ
Shock
A physiologic state characterized by a significant,
systemic reduction in tissue perfusion, thereby
resulting in decreased tissue oxygen delivery
Prolonged oxygen deprivation leads to generalized
cellular hypoxia and the derangement of critical
biochemical processes.
These abnormalities rapidly become irreversible and
result sequentially in cell death, end-organ damage,
failure of multiple organ systems, and death.
Organ perfusion
Stroke Volume
Preload
Afterload
Contractivity
Cardiac factors
C.O. =
Stroke volume
x Heart rate
Intrinsic
Myogenic rp.
Meta.-E.T.
autoregulation
Extrinsic
Neural
Hormonal
Arterioles
Smooth-Muscle
Tone
Vascular factors
Resistance =
Length x Visco
/ R4
Renin
Vasopression
PGs, Kinin
ANP, Catecho.
CNS
Ischemia
Toxins
Immunologic
Humoral factors
Capillary flow
Osmotic P
Hydrostatic P
Shunting, Firbrin
Deformed RBCs
Adhesion of
WBC, PLt
Micro-
circulatory
factors
Stages of Shock
Early compensated shock
(Constriction of A. bed; HR;RAA)
Progressive decompensated shock
(Decrease C.O. & hypotension; tachypnea; oliguria;
Metabolic lactic acidosis)
Irreversible shock
Pathogenesis and Stages of
Shock
Prognosis of Shock
Mortality rate
<10%
Hypovolemic
Neurogenic
Shock
Mortality rate
30-60%
Cardiogenic
Shock
Mortality rate
40-50%
Septic
Shock
Clinical Manifestations of Shock
Hypotension
Cool, clammy skin
Altered mental status
Oliguria
Metabolic Acidosis

Clinical Manifestations of Shock
Encephalopathy
Tachy/Bradycardia
Ventricular Ectopy
Myocardial ischemia and
depression
Acute Respiratory Failure
ARDS
ARF (pre-renal, ATN)
Gut Barrier Function
Depression
Cellular/Humoral Immune
Depression


Illeus
Erosive Gastritis
Pancreatitis
Acalculous Cholecystitis
Colonic Submucosal
Hemorrhage
Shock Liver
Intrahepatic Cholestasis
DIC
Thrombocytopenia
Hyper/hypoglycemia
Hypertryglyceridemia
Clinical Correlations of Shock
Pulmonary changes
Cerebral and Cardiac
Changes
Initial Threats
Fluid overload
Hyperkalemia
Acidosis, Uremia
(2nd to 6th days)
Oliguria 50-70%
Secondary Phase
Volunerability to
Infection
20% death in
3rd phase
Increase in
urine volume 3 L/d
Third
(Diuretic) Phase
Clinical Manifestations of Shock
Hypotension
MAP < 60 mm Hg or
SBP < 90 mm Hg
Hypotension is RELATIVE
BP of 100/50 is abnormal in a hypertensive patient
whose BP is usually 160/80
BP of 80/40 may be physiologic for a patient with
CHF or cirrhosis
Measurement of Blood pressure
Correlate with clinical symptoms & signs
Document it at another limb
Cuff pressure
Inaccurate in the face of low flow status & elevated
peripheral resistance
Intra-arterial pressure
Mismatch of aortic & radial pressure may be up to
40 mmHg
Calculation of Blood Pressure
Blood pressure = Cardiac Output x Resistance
Cardiac output = Stroke Volume x Heart rate
Stroke volume: Positive relation to Preload,
Myocardial contractility &
Negative relation to Afterload
Poiseuille equation:
Resistance = 8

4
= viscosity
= length
= radius of the tube

Hemodynamic Mechanism of Shock

Reduction of intravascular volume
Pump failure
Increased arterial resistance
Impaired capillary exchange
Excessive resistance in post-capillary
venules & small veins
Arteriovenous shunting
Pooling in the venous capacitance circuit
Obstruction to blood flow
Physiologic Determinants of Shock
Arterial Pressure
Cardiac Performance
Cardiac function
Preload
Afterload
Contractility
Heart rate
Venous return
Vascular Performance
Extrinsic regulatory systems
Sympathetic nervous system
Adrenal hormone release
Intrinsic regulatory systems
Anatomic vascular disease
Exogenous vasoactive agents
Microvascular Function
Microvascular obstruction
Cellular Function
Oxygen unloading and diffusion
Blood pH
Temperature
Cellular energy generation/substrate utilization
Other energy metabolism pathways
Classification of Shock
Hypovolemic Shock
Cardiogenic Shock
Obstructive Shock
Distributive Shock
Mixed Shock
Physiologic Classification
Physiologic Determinants of Shock


BP = CO x SVR
Hypovolemic Shock
Result of blood or fluid loss
Leads to decreased circulating blood volume
and reduced diastolic filling pressures and
volume

BP = CO x SVR
BP = (HR x SV) x SVR
Etiologies of Hypovolemic Shock
Hemorrhage
Dehydration
Vomiting
Diarrhea
Polyurea
Thermal injury

Specific Treatment of Hypovolemic
Shock
Volume, Volume, Volume!!!
Hemorrhagic Shock
Transfusion of PRBC and aggressive evaluation of
source of bleeding
Other forms of hypovolemic shock
Crystalloids
Normal Saline or Lactate Ringer
Colloids
Albumin, Hetastarch
Cardiogenic Shock
Severe reduction in cardiac function due to
direct myocardial damage or a mechanical
abnormality of the heart

BP = CO x SVR
BP = (HR x SV) x SVR
Hemodynamics of Cardiogenic
Shock
SBP < 80 mmHg

C.I. (C.O./BSA) < 1.8 (L/min)/m
2

LV filling pressure > 18 mmHg

Usual Pulmonary edema
Etiologies of Cardiogenic Shock
Myocardial Infarction
Myocardial contusion
Cardiomyopathy
Post-ischemic
myocardial stunning
Septic myocardial
depression
Anthracycline
Cardiotoxicity
Calcium Channel
Blockers
Valvular failure
(stenosis or
regurgitation)
Hypertrophic
Cardiomyopathy
Ventricular Septal
Defect
Bradyarrhythmias
Tachyarrhthmias


Specific Treatment of Cardiogenic
Shock
Vasopressor and Inotropes
Goal MAP > 60 mm Hg and CI > 2.2 L/min/m
2
IABP
Ventricular Assist Device
Emergent Coronary Revascularization
Surgical repair of valvular abnormalities or
septal defects
Obstructive Shock
Obstruction to flow in the cardiovascular
circuit
Leads to inadequate diastolic filling or
decreased systolic function due to increased
afterload

BP = CO x SVR
BP = (HR x SV) x SVR
Etiologies of Obstructive Shock
Obstructive
Intrathoracic Tumors
Tension Pneumothorax
Mechanical Ventilation
Asthma
Constrictive Pericarditis
Cardiac Tamponade

Massive Pulmonary
Embolism
Acute Pulmonary
Hypertension
Aortic Dissection
Specific Treatment of Obstructive
Shock
Tension Pneumothorax
Needle Thoracostomy
Cardiac Tamponade
Fluids and Vasopressors
Pericardiocentesis or Pericardotomy
Massive Pulmonary Embolism
Thrombolytic Therapy
Embolectomy
Distributive Shock
Characterized by peripheral vasodilation

BP = CO x SVR
Etiologies of Distributive Shock
Sepsis
Toxic Shock Syndrome
Drugs or Toxins
Anaphylaxis
Neurogenic or Spinal Shock
Adrenal Crisis
Myxedema Coma
Specific Treatment of Distributive
Shock
Septic Shock
Remove nidus of infection with drainage and
antibiotics
Fluid
Vasopressors
Drotrecogin Alfa (Xigris)
Supportive Care
Specific Treatment of Distributive
Shock
Medications
Stop offending drug (e.g. anti-hypertensive, opioid
analgesic, etc.)
Anaphylaxis
Epinephrine 0.1mg (1 cc of 1:10,000) IVP
Epinephrine 0.3mg (3 cc of 1:1,000) SQ
Adrenal Insufficiency
Hydrocortisone
Mixed States of Shock

Hemorrhagic shock precipitates to myocardial
infarction in pt with CAD.
Sepsis leads to adrenal crisis
Treatment of one may unmask the presence of
the other
Frequent evaluation & close monitoring is the
key to correct management
Differentiation of different types
by Pulmonary artery catheterization
Type of
Shock
Cardiac
Output
SVR RA P PCWP
Hypovolemic Down Up Down Down
Cardiogenic Down Up Up Up
Obstructive Down Up
Normal
Up Normal
Down
Distributive Up Down Down
Normal
Down
Normal

Clinical Approach to Shock
Shock is a life threatening emergency
Time is important
Diagnosis, evaluation, and management must
occur simultaneously
Rapid initial evaluation with directed history
and physical exam
Initiate diagnostic tests to determine the cause
Restore blood pressure and tissue perfusion
Therapy of Shock

Prevention
Block the pathogenic process before actual shock occurs
Medical emergency
Correct etiologic diagnosis is most importance
Maintenance of airway & ventilation
ICU care with appropriate cardiac & hemodynamic
monitoring
Prevention and early identification of complication
Close monitoring of the response to therapy
Therapy of Shock
Monitoring

Vital signs, symptoms, physical examination
Urine output
EKG
Arterial blood gas (PH, PaO2, PaCO2, AaDO2)
Cardiac filling pressures (CVP, PCWP)
Cardiac output & systemic vascular resistance
Biochemistry
Therapy of Shock
Volume resuscitation

Must be undertaken promptly in all cases
except for cardiogenic shock
Trendelenburg position
Fluid resuscitation
No clear advantage of colloid over crystalloid
Swan-Ganz
C.V.P
Management of Shock
Background
Mr. Smith is a 65 year old male with a history of
CAD, DM, and recently diagnosed colon cancer who
presented with a colonic obstruction. He is post-
operative day number 11 status post diverting
colostomy. His post-op course has been complicated
by the inability to tolerate oral feedings. He has been
receiving total parenteral nutrition through a right
ante-cubital PICC line. You are called by his nurse
when his BP is noted to be 70/40.
Differential Diagnosis
Hypovolemic Shock
Hemorrhage, Vomiting, Diarrhea
Cardiogenic
Myocardial Infarction, Tachy/bradyarrhythmia
Obstructive
Pulmonary Embolism
Distributive
Sepsis, Anaphylaxis

Focused History
Is the patient symptomatic from hypotension?
Assess mental status
Lightheadedness
Consider the differential diagnosis when formulating
your history.
Fever or localizing symptoms
Chest pain, palpitations, shortness of breath
Abdominal Pain
Vomitting, Diarrhea
Hematemesis, melena, bleeding
Mr. Smiths History
No dizziness or lightheadedness.
Slight fevers, but no cough or dysurea.
Right arm slightly swollen and red.
No chest pain, palpitations, or shortness of
breath.
No abdominal pain
No vomiting or diarrhea
No hematemesis, no melena.
Focused Physical Exam
Vital Signs
Use manual cuff to confirm blood pressure.
If not audible, try palpating.
SBP is >= 60 if carotid pulse palpable.
SBP is >= 80 if radial pulse palpable.
Focused Physical Exam
Hypovolemia: Volume status
Hemorrhage: Guaic Stool
Tamponade: Pulsus paradoxus, Elevated JVP,
Distant heart sounds
Pneumothorax: Tracheal deviation, Unequal breath
sounds, Hyperresonance
PE/DVT: Loud P2, Swollen Calf
Sepsis: Fever, AMS, Diaphoresis, Cool skin
Anaphylaxis: Wheezing, Urticaria
Mr. Smiths Physical Exam
T 38.0 BP 70/40 HR 105 RR 26
I=3000 cc, O=1200 cc
GEN: Alert and in no apparent distress.
HEENT: Moist mucous membranes
Heart: Regular, Tachy, Normal S1S2. No murmurs.
JVP 7cm H
2
O
Lungs: Mild bilateral basilar crackles.
Abdomen: Colostomy in LLQ with brown guaic
negative stool, Otherwise benign.
Ext: Erythema and tenderness around PICC line
insertion site in right antecubital fossa.
Review of Medications
Look for anti-hypertensives.
Look for diuretics.
Look for narcotics.
Look for intravenous fluids.
Mr. Smiths Medication List.
Pipercillin-tazobactam 4.5 mg IV Q8
Morphine 2 mg IV Q4 PRN Pain
Total parenteral nutrition
Initial Evaluation
CBC with differential
Lytes, BUN, Creatinine
CK, MB, Troponin I
Blood and Urine Cultures
12-Lead EKG
CXR
Initial Laboratories and Studies
WBC: 11K (88% N)
Hgb/Hct: 10.4/33
Plts: 112K
Electrolytes within normal limits
CK, MB: normal; Troponin intermediate
EKG: NSR with non-specific T wave changes in
anterior and lateral leads
CXR: Low Lung Volumes with basilar atelectasis
Initial Management
Intravenous Access
One or Two Large Bore catheters
Consider Central Venous and Arterial Catheter
Consider Pulmonary Artery Catheter
Electrocardiographic monitor and continuous
pulse oximetry
Fluid Challenge
NS Bolus of 500cc to 1000cc
Vasopressors


Vasopressors
Drug Alpha
Vasoconstriction
Beta-1
Inotropy
Chronotropy
Beta-2
Vasodilation
Dobutamine + ++++ ++
Epinephrine +++ ++++ ++
Dopamine ++++ +++ ++
Norepinephrine ++++ +++ 0
Phenylephrine ++++ 0 0
Isoproterenol 0 ++++ ++++
Milrinone 0 ++++ +++
Vasopressors
Patients in shock who fail to response to volume
administration
No studies have directly demonstrated a survival
benefit of one particular strategy for choosing
combinations of pressors
Such choices remain in the realm of theoretical
considerations by empiric trials in an individual
patient.
Vasopressors
Dopamine
Commonly used for septic or cardiogenic shock.
Dobutamine
Used in patient with cardiogenic shock.
Norepinephrine
Usually added to dopamine for septic shock.
Epinephrine
Used for anaphylaxis, cardiogenic, and septic shock.
Usually last line.
Specific Treatment
Direct further diagnostic tests based on initial
assessment
E.g. ECHO if suspect cardiac tamponade
Treat underlying cause
Mr. Smiths Management
Fluid resuscitation
Pulled PICC line
Pan cultured
Changed antibiotics to Vancomycin and
Gentamicin (Bactericidal)
Rescheduled hot date
Outcome
The patients blood pressure responded to fluid
resuscitation
After pulling the infected PICC line, and
changing of antibiotic regimen, the patients
blood pressure stabilized.
The patients blood culture grew out
Enterococcus faecium one day later.
You had a lousy time on your hot date the
next evening.
Thank You!