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Shock

Shock. Tad Kim, M.D. Connie Lee, M.D. Shock: Definitions. Shock = inadequate tissue perfusion Tissue perfusion is determined by: Cardiac output (CO) = HR x SV SV = function of preload, afterload, contractility Systemic vascular resistance (SVR). Shock: Types. Hypovolemic

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Shock

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  1. Shock Tad Kim, M.D. Connie Lee, M.D.

  2. Shock: Definitions Shock = inadequate tissue perfusion Tissue perfusion is determined by: Cardiac output (CO) = HR x SV SV = function of preload, afterload, contractility Systemic vascular resistance (SVR)

  3. Shock: Types • Hypovolemic • Septic (high CO, low SVRI) • Cardiogenic (high CVP) • Neurogenic • Anaphylactic • Adrenal insufficiency

  4. Shock Types & Physiology

  5. Hypovolemic Shock • CNS response to hypovolemia • Rapid: peripheral vasoconstriction, increased cardiac activity • Sustained: arterial vasoconstriction, Na/water retention, increased cortisol • 2/2 hemorrhage or fluid loss • Classes of hemorrhage: I: 15% II: 15-30% = tachycardia III: 30-40% = decreased SBP, confusion IV: >40% = lethargy, no UOP Tx: stop source / fluids / blood

  6. Septic Shock • SIRS = T >38C or <36C, HR >90, RR >20, PaCO2 <32mmHg, WBC >12 or <4 • Sepsis = SIRS + focus of infection • Severe sepsis = sepsis + MSOF • Septic shock = sepsis + refractory hypotension • Capillary leak/impaired oxygen utilization/peripheral vasodilation • Remember: septic shock is high CO • Tx: fluids, antibiotics, pressors

  7. Cardiogenic Shock • Cardiogenic shock 2/2 cardiac disease or cardiac compression • Cardiac disease: MI, arrhythmia, valve dysfunction, increased PVR or SVR, increased ventricular resistance • Cardiac compression: tension PTX, cardiac tamponade, positive pressure ventilation • Look for Beck’s triad in tamponade (hypotension, JVD, muffled heart sounds) • Tx: fluids, tx underlying cause (relieve PTX, pericardiocentesis, change ventilator settings), may need pressor (ie: dobutamine)

  8. Neurogenic Shock • Shock 2/2 spinal cord injury, regional anesthesia, autonomic blockade • Mechanism: loss of vasomotor control, expansion of venous capacitance bed • Signs: warm skin, normal or low HR, normal CO, low SVR • Tx: Fluids / pressors / +- steroids

  9. Hypoadrenal • Unresponsive to fluids or pressors • Tx: steroids

  10. Shock: Signs • Pale, cool skin • Change in MS, lethargy • Decreased UOP • Hypotension, tachycardia, tachypnea

  11. Shock: Evaluation Airway: includes brief evaluation of mental status Breathing Circulation: includes placement of adequate IV access Disability: identification of gross neurologic injury Exposure: ensures complete exam History: review PMHx, PSHx, ALL, SHx PE: complete Labs: include ABG (pH, base deficit, lactate)

  12. Case 1 55y M post-op day 0 s/p colectomy Called for tachycardia, hypotension, altered mental status, abdominal distension, decreased UOP PE: pale, disoriented, abdomen tense, TTP, UOP 15mL/hr What is your diagnosis? What additional information should you obtain? What is the plan?

  13. Case 1: Continued Dx: hemorrhagic shock Additional information: CBC, coags, T&C Management ABC (intubate, IV access) Resuscitate (isotonic IVF) Order blood products Prepare for take-back

  14. Case 2 75y M h/o CAD, PVD, DM, POD 1 s/p AAA repair c/o nausea What do you need to think about? What is the plan?

  15. Case 2: Continued Dx: MI Plan: ABC MONA, beta-blockade Cardiology consult for catheterization Labs/x-rays: cardiac enzymes Q8H x3 sets w/EKG, chemstick, BMP, CXR/KUB

  16. Case 2: Continued Cath w/critical stenosis of left main s/p balloon angioplasty PE: intubated, 80/50, UOP 10mL/hr Echo: severe LV dysfunction What is the diagnosis? What is the plan?

  17. Case 2: Continued Dx: Post-myocardial infarction (cardiogenic) shock Plan: ABC Pressor support as needed Placement of Swan-Ganz catheter +/- Intra-aortic balloon pump, cardiac assist device Heparin (maintain coronary patency)

  18. Case 3 60y M h/o chronic ETOH use presents to ED w/ N/V and epigastric pain radiating to the back PE: tachycardic, hypotensive, confused What is the working diagnosis? What is the plan?

  19. Case 3: Continued Dx: Hypovolemic shock 2/2 acute pancreatitis Plan: ABC (intubate, IV acess, NGT, Foley, DHT) Resuscitate Labs: chemstick, ABG, BMP, LFT, amylase/lipase, CBC, coags Studies: CXR, CT A/P

  20. Case 4 55y M POD 0 s/p colectomy, w/epidural placed for post-op pain control Called by nurse for hypotension and bradycardia PE: AAOx3, abdomen ND, NT Recent post-op labs: HCT 35 What is your working diagnosis?

  21. Case 4: Continued DX: Neurogenic shock 2/2 epidural Treatment is: IVF Turn down or turn off epidural If BP does not respond to IVF, initiate pressor support w/alpha-agonist such as phenylephrine

  22. Case 5 25y M p/w diffuse abdominal pain. PMHx PUD. PE: febrile, tachycardic, hypotensive, lethargic, rigid abdomen w/ involuntary guarding What is your working diagnosis? What is your plan?

  23. Case 5 Dx: septic shock 2/2 duodenal perforation Plan: ABC Broad-spectrum IV antibiotics Emergent OR for ex-lap, washout & repair

  24. Shock: Take Home Points Shock = inadequate tissue perfusion Types of shock: hypovolemic, septic, cardiogenic, neurogenic, anaphylactic Signs of shock: altered MS, tachycardia, hypotension, tachypnea, low UOP Always start with ABCs Resuscitation begins with fluid (exception - cardiogenic shock)

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