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SHOCK C omplications & Approach to Patient. Dr.Mohammed Sharique Ahmed Quadri Assistant Prof.Physiology Almaarefa College. Complications of Shock. Acute respiratory distress syndrome Acute renal failure Gastrointestinal complications Disseminated intravascular coagulation

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shock c omplications approach to patient

SHOCKComplications &Approach to Patient

Dr.MohammedSharique Ahmed Quadri

Assistant Prof.Physiology

Almaarefa College

complications of shock
Complications of Shock
  • Acute respiratory distress syndrome
  • Acute renal failure
  • Gastrointestinal complications
  • Disseminated intravascular coagulation
  • Multiple organ dysfunction syndrome
acute respiratory distress syndrome ards
Acute Respiratory Distress Syndrome (ARDS)
  • Potentially life threatening form of lung injury
  • Characterized by
    • Severe dyspnea of rapid onset
    • Respiratory rate increases
    • Profound hypoxemia (cyanosis) refractory to supplemental oxygen
      • Results from greatly reduced diffusion of gases across the thickened alveolar membranes.
    • Pulmonary infiltration ( x-ray chest)
    • Exact cause is unknown
pathophysiology of ards
Pathophysiology of (ARDS)

Activation of

neutrophils

Accumulates in pulmonary vasculature

cytokines

Leakage of fluid and plasma proteins in alveolar spaces

Injury to endothelial cells

  • Atelectasis
  • Impaired gas exchange
  • Decrease compliance (stiffness)
  • Decrease surfactant
clinical features of ards
Clinical features OF ARDS
  • Tachypnea, tachycardia, hypoxia, and respiratory alkalosis are typical early clinical manifestations
  • Usually followed by the appearance of diffuse pulmonary infiltrates and respiratory failure within 48 hours.
acute renal failure arf
Acute Renal Failure (ARF)
  • Renal vasoconstriction cuts off urine production
    • Results in Acute renal failure
  • Continued vasoconstriction cuts off renal oxygen supply
    • Renal tubular cells die leading to
      • Acute tubular necrosis
acute renal failure arf1
Acute Renal Failure (ARF)
  • Frequent monitoring of urine out put provided a means of assesing renal blood flow.(urine out put of 20 ml/hr or less indicate impaired renal perfusion)
  • Serum creatinineand blood urea nitrogen levels provided valuable information regarding renal status
g i complication
G.I Complication
  • Constriction of vessels supplying GIT for redistribution of blood flow
      • Severe Decrease mucosal perfusion
        • GIT ulceration
        • Bleeding
disseminated intravascular coagulation dic
Disseminated IntravascularCoagulation (DIC)

coagulation

pathways

activated

clots in

platelets

many

and

small

clotting

blood

proteins

vessels

used up

ORAGAN FAILURE

microinfarcts,

bleeding

ischemia

problems

multiple organ dysfunction syndrome mods
Multiple Organ Dysfunction Syndrome (MODS)
  • The most frequent cause of death in the noncoronary intensive care unit
  • Affects multiple organ system (kidney, heart lungs, liver & brain.
  • Mortality rates vary from 30% to 100%
  • Pathogenesis not clearly understood
major risk factor for development of mods are
Major risk factor for development of MODS are
  • Severe trauma
  • Sepsis
  • Prolonged periods of hypotension
  • Hepatic dysfunction
  • Infarcted bowel
  • Advanced age
  • Alcohol abuse
avoid over reliance on invasive haemodynamic monitoring

Assess

Intervene

RE-assess

Seek help

Avoid over reliance on invasive haemodynamic monitoring

Pulse rate

Capillary fill time

temperature

Blood pressure

Level of consciousness

Blood-gas estimation

practically speaking
Practically Speaking….
  • Keep eye on these patients
  • Frequent vitals signs:
    • Monitor success of therapies
    • Watch for decompensated shock
  • Let your nurses know that these patients are sick!
approach to the patient in shock1
Approach to the Patient in Shock
  • ABCs
    • Cardiorespiratory monitor
    • Pulse oximetry
    • Supplemental oxygen
    • IV access
    • ABG, labs
    • Foley catheter
    • Vital signs
diagnosis
Diagnosis
  • Physical exam (Vital Signs, mental status, skin color, temperature, pulses, etc.)
  • Surveillance for Infectious source
  • Labs:
    • CBC
    • Chemistries ( urea, creatinin ,etc)
    • Lactate
    • Coagulation studies
    • Cultures
    • ABG ( arterial blood gas analysis)
further evaluation
Further Evaluation
  • CVP( central venous pressure)and PCWP(pulmonary capillary wedge pressure)
  • CT of head/sinuses
  • Lumbar puncture
  • Wound cultures
  • Abdominal/pelvic CT or USG
  • Cortisol level
  • Fibrinogen, FDPs(fibrin degradation product), D-dimer
approach to the patient in shock2
History

Recent illness

Fever

Chest pain, SOB

Abdominal pain

Comorbidities

Medications

Toxins/Ingestions

Recent hospitalization or surgery

Baseline mental status

Physical examination

Vital Signs

CNS – mental status

Skin – color, temp, rashes, sores

CV – JVP, heart sounds

Resp – lung sounds, RR, oxygen sat, ABG

GI – tenderness , rigidity, guarding, rebound

Renal – urine output

Approach to the Patient in Shock
is this patient in shock
Is This Patient in Shock?
  • Patient looks ill
  • Altered mental status
  • Skin cool and mottled or hot and flushed
  • Weak or absent peripheral pulses
  • SBP <110
  • Tachycardia

Yes!

These are all signs and symptoms of shock

shock
Shock
  • Do you remember how to quickly estimate blood pressure by pulse?

60

  • by palpating a pulse,
  • you know SBP is at
  • least this number

70

80

90

goals of treatment
Goals of Treatment
  • ABCDE
    • Airway
    • control work of Breathing
    • optimize Circulation
    • assure adequate oxygen Delivery
    • achieve End points of resuscitation
a irway
Airway
  • Determine need for intubation but remember: intubation can worsen hypotension
    • Sedatives can lower blood pressure
    • Positive pressure ventilation decreases preload
  • May need volume resuscitation prior to intubation to avoid hemodynamic collapse
control work of b reathing
Control Work of Breathing
  • Respiratory muscles consume a significant amount of oxygen
  • Mechanical ventilation and sedation decrease WOB and improves survival
optimizing c irculation
Optimizing Circulation
  • Isotonic crystalloids
  • Titrated to:(aims to achieve)
    • CVP 8-12 mm Hg
    • Urine output 0.5 ml/kg/hr (30 ml/hr)
    • Improving heart rate
  • May require 4-6 L of fluids
maintaining oxygen d elivery
Maintaining Oxygen Delivery
  • Decrease oxygen demands
    • Provide analgesia and anxiolytics to relax muscles and avoid shivering
  • Maintain arterial oxygen saturation/content
    • Give supplemental oxygen
    • Maintain Hemoglobin > 10 g/dL
  • Serial lactate levels or central venous oxygen saturations to assess tissue oxygen extraction
e nd points of resuscitation
End Points of Resuscitation
  • Goal of resuscitation is to maximize survival and minimize morbidity
  • Use objective hemodynamic and physiologic values to guide therapy
  • Goal directed approach
    • Urine output > 0.5 mL/kg/hr
    • CVP 8-12 mmHg
    • MAP 65 to 90 mmHg
    • Central venous oxygen concentration > 70%
treatment objectives
Treatment objectives
  • Specific treatment will depend on the underlying cause
      • ABC approach
      • Volume replacement: Hypovolemic or septic
      • Inotropes: Cardiogenic
      • Vasopressors: Septic
      • Adrenaline: Anaphylactic
what type of shock is this
68 yo M with hx of HTN and DM presents to the ER with abrupt onset of diffuse abdominal pain with radiation to his low back. The pt is hypotensive, tachycardic, afebrile, with cool but dry skin

Types of Shock

Hypovolemic

Septic

Cardiogenic

Anaphylactic

Neurogenic

Obstructive

What Type of Shock is This?

Hypovolemic Shock

hypovolemic shock
Hypovolemic Shock
  • ABCs
  • Establish 2 large bore IVs or a central line
  • Crystalloids
    • Normal Saline or Lactate Ringers
    • Up to 3 liters
  • PRBCs
    • O negative or cross matched
  • Control, if any bleeding
  • Arrange definitive treatment
what type of shock is this1
An 81 yo F resident of a nursing home presents to the ED with altered mental status. She is febrile to 39.40C, hypotensive with a widened pulse pressure, tachycardia, with warm extremities

Types of Shock

Hypovolemic

Septic

Cardiogenic

Anaphylactic

Neurogenic

Obstructive

What Type of Shock is This?

Septic

sepsis
Sepsis
  • Two or more of SIRS criteria
    • Temp > 380C or < 360C
    • HR > 90 beats /min
    • RR > 20 /min
    • WBC > 12,000 or < 4,000 / mm3
  • Plus the presumed existence of infection
  • Blood pressure can be normal!
treatment of septic shock
Treatment of Septic Shock
  • 2 large bore IVs
    • NS IVF bolus- 1-2 L wide open (if no contraindications)
  • Supplemental oxygen
  • Empiric antibiotics, based on suspected source, as soon as possible
persistent hypotension
Persistent Hypotension
  • If no response after 2-3 L IVF, start a vasopressor (norepinephrine, dopamine, etc) and titrate to effect
  • Goal: MAP > 60
  • Consider adrenal insufficiency: hydrocortisone 100 mg IV
what type of shock is this2
A 55 yo M with hx of HTN, DM presents with “crushing” sub sternal Chest Pain, diaphoresis, hypotension, tachycardia and cool, clammy extremities

Types of Shock

Hypovolemic

Septic

Cardiogenic

Anaphylactic

Neurogenic

Obstructive

What Type of Shock is This?

Cardiogenic

cardiogenic shock
Signs:

Cool, mottled skin

Tachypnea

Hypotension

Altered mental status

Narrowed pulse pressure

Rales, murmur

Defined as:

SBP < 90 mmHg

CI < 2.2 L/m/m2

PCWP > 18 mmHg

Cardiogenic Shock
ancillary tests
Ancillary Tests
  • ECG
  • Chest X-Ray
  • CBC, Chemistry , cardiac enzymes, coagulation studies
  • Echocardiogram
treatment of cardiogenic shock
Treatment of Cardiogenic Shock
  • Goals- Airway stability and improving myocardial pump function
  • Cardiac monitor, pulse oximetry
  • Supplemental oxygen, IV access
  • Intubation may decrease preload and result in hypotension
    • Be prepared to give fluid bolus
what type of shock is this3
A 34 yo F presents to the ER after dining at a restaurant where shortly after eating the first few bites of her meal, became anxious, diaphoretic, began wheezing, noted diffuse pruritic rash, nausea, and a sensation of her “throat closing off”. She is currently hypotensive, tachycardic and ill appearing.

Types of Shock

Hypovolemic

Septic

Cardiogenic

Anaphylactic

Neurogenic

Obstructive

What Type of Shock is This?

Anaphylactic

anaphylactic shock diagnosis
Anaphylactic Shock- Diagnosis
  • Clinical diagnosis
    • Defined by airway compromise, hypotension, or involvement of cutaneous, respiratory, or GI systems
  • Look for exposure to drug, food, or insect
  • Labs have no role
anaphylactic shock treatment
Anaphylactic Shock- Treatment
  • ABC’s
    • Angioedema and respiratory compromise require immediate intubation
  • IV line , cardiac monitor, pulse oximetry
  • IVFs, oxygen
  • Epinephrine
  • Second line
    • Corticosteriods
    • H1 and H2 blockers
what type of shock is this4
A 41 yo M presents to the ER after an RTA complaining of decreased sensation below his waist and is now hypotensive, bradycardic, with warm extremities

Types of Shock

Hypovolemic

Septic

Cardiogenic

Anaphylactic

Neurogenic

Obstructive

What Type of Shock is This?

Neurogenic

neurogenic shock treatment
Neurogenic Shock- Treatment
  • A,B,Cs
    • Remember c-spine precautions
  • Fluid resuscitation
    • Keep MAP at 85-90 mm Hg
    • If crystalloid is insufficient use vasopressors
  • Search for other causes of hypotension
  • For bradycardia
    • Atropine
    • Pacemaker
what type of shock is this5
A 24 yo M presents to the ED after an RTA c/o chest pain and difficulty breathing. On Physical examination, you note the patient to be tachycardic, hypotensive, hypoxic, and with decreased breath sounds on left

Types of Shock

Hypovolemic

Septic

Cardiogenic

Anaphylactic

Neurogenic

Obstructive

What Type of Shock is This?

Obstructive