Shock Management

Dr.Jason Waechter
Jan/04
But first!
A little refresher from a previous
presentation
What is the Ddx of an anion
gap metabolic acidosis?
KUSMAL breathing is a memory helper
K ketones
U uremia
S salycilates
M methanol
A alcohol
L lactate
What is Shock?
Is a condition where the perfusion of organs is
too low to meet the metabolic demands and
leads to anaerobic metabolism.

In other words, blood flow (pressure) and
oxygen delivery to the body is too low
An Approach to Shock
BP = CO x SVR

BP = blood pressure
CO = cardiac output
SVR = systemic vascular resistance
An Approach to Shock
If the blood pressure is low, then either the:
CO is low
or
the SVR is low
Low SVR
There are only a few causes of low SVR.
They ALL cause vasodilation:
sepsis
acute spinal cord injury (spinal, epidural)
vasodilators (NTG, anesthetics)
anaphylaxis

How do you assess SVR?
Look at and feel the patient!

Low SVR has the features:
warm !!!
pink (maybe also a rash)
hyperdynamic heart (fast and
pounding)
What if the SVR is high?
patient will have cool or cold arms/legs
patient will NOT look pink

Cause of shock or low BP is then:
low CO
What are factors of CO?
CO = HR x SV

CO = cardiac output
HR = heart rate
SV = stroke volume
HR Problems
HR problems are easy to diagnose

bradycardia and tachycardia will be covered
in my arrhythmia talk later
Low SV (stroke volume)
Most common cause of shock
but
Most difficult to diagnose and manage
Factors of SV
Preload: is the ventricle full?
Contractility: how well does the ventricle contract
Valve function: normal?
regurgitation?
stenosis?
Stroke Volume
Which factors can we influence?
Preload and contractility

We cannot change valve function
Summary
BP = CO x SVR

CO = HR x SV
SV = preload
contractility
valves
Perfusion (blood pressure) depends on:
Your patient has BP of 60/20
BP 60/20
What do you think of?

CO and SVR
HR and SV
preload, contractility, valves
Case 1: BP 60/20
25 yr old healthy man
after induction, HR to 180 over 2 minutes
JVP flat
arms and hands flushed and warm
Diagnosis?


Case 1
Possibilities:
anaphylaxis
anesthetic overdose
severe volume depletion
Case 2: BP 60/20
(real case at Jichi)
Emergency case of abdominal sepsis
dx. of perf. intestine
4 days post axillo-fem bypass, on warfarin
HR 130, JVP flat, extremities very cold
subacute course of < 12hours
no previous cardiac disease

What are your thoughts?
Case 2: BP 60/20
What is the SVR in this patient?
High (cold arms and legs)
What is the SVR in early sepsis?
Low (warm, flushed)
This patient did not have a fever.
Is this septic shock?
Case 2: BP 60/20
If SVR is high, then CO is low!
Next, we have to think about:
Preload contractility valves
JVP is flat therefore this is NOT:
PE, tension pneumothorax, tamponade
acute heart failure
Case 2: BP 60/20
Why is the JVP flat?
Volume depletion
Why is the patient volume depleted?
Had an IV for maintenance
Why did the patient crash over 12 hours?
Case 2: BP 60/20
15 minutes into the laparotomy, the blood
results became available
the Hb was 50
the pre-op CT scan showed a retroperitoneal
hematoma
The laparotomy was completely unnecessary
The patient was in shock because of acute
bleeding and not because of sepsis
Case 3: BP 60/20
trauma car accident
HR 130, JVP full, extremities cold

Thoughts?
Case 3: BP 60/20
Does a full JVP mean that preload is adequate?
no
What are 4 causes of decreased preload with a full
JVP?
pulmonary embolism
tension pneumothorax
pericardial tamponade
RV infarction
Case 3: BP 60/20
In a trauma setting, think about:
tension pneumothorax
pericardial tamponade

as causes of inadequate preload
Summary
Managing shock is THE SAME as managing
low blood pressure

Requires analysis of all factors of BP:
SVR, CO, HR, preload, contrqctility, valves