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SHOCK

SHOCK. DEFINITION. Profound hemodyamic and metabolic disturbance characterized by failure of the circulatory system to maintain adequate perfusion of vital organs. Types of Shock. Cardiogenic (intracardiac vs extracardiac) Hypovolemic Distributive sepsis**** neurogenic (spinal shock)

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SHOCK

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  1. SHOCK

  2. DEFINITION • Profound hemodyamic and metabolic disturbance characterized by failure of the circulatory system to maintain adequate perfusion of vital organs

  3. Types of Shock • Cardiogenic (intracardiac vs extracardiac) • Hypovolemic • Distributive • sepsis**** • neurogenic (spinal shock) • adrenal insufficiency • anaphylaxis

  4. Cardiogenic Shock, intracardiac • Myocardial Injury or Obstruction to Flow • Arrythymias • valvular lesions • AMI • Severe CHF • VSD • Hypertrophic Cardiomyopathy

  5. Presentation of Cardiogenic Shock • Pulmonary Edema • JVD • hypotensive • weak pulses • oliguria

  6. Cardiogenic Shock, extracardiac(Obstructive) • Pulmonary Embolism • Cardiac Tamponade • Tension Pneumothorax • Presentation will be according to underlying disease process.

  7. Hypovolemic Shock • Reduced circulating blood volume with secondary decreased cardiac output • Acute hemorrhage • Vomiting/Diarrhea • Dehydration • Burns • Peritonitis/Pancreatitis

  8. Presentation of Hypovolemic Shock • Hypotensive • flat neck veins • clear lungs • cool, cyanotic extremities • evidence of bleeding? • Anticoagulant use • trauma, bruising • oliguria

  9. Distributive Shock • Peripheral Vasodilation secondary to disruption of cellular metabolism by the effects of inflammatory mediators. • Gram negative or other overwhelming infection. • Results in decreased Peripheral Vascular Resistance.

  10. Distributive Shock: Presentation • Febrile • Tachycardic • clear lungs, evidence of pneumonia • warm extremities • flat neck veins • oliguria

  11. Diagnosing Shock • Response to fluids • Echo/EKG • CXR • Evidence of infection • Swan-Ganz Catheter?

  12. Swan-Ganz Catheter • Utilized to differentiate types of shock and assist in treatment response. • Probably overused by physicians. Studies documenting increased mortality in patients with catheters versus no catheters, although somewhat swayed by selection bias.

  13. Swan-Ganz Catheter

  14. Swan-Ganz Interpretation

  15. Management • Correct underlying disorder if possible and then direct efforts at increasing the blood pressure to increase oxygen delivery to the tissues. • Maintain a mean arterial pressure of 60 (1/3 systolic + 2/3 diastolic) • Keep O2 sats >92%, intubate if neccesary

  16. Correction of hypotension • Normal Saline should be administered anytime a patient is hypotensive. If hypotension exists give more NS. *** • If possible give blood as it replaces colloid. • Vasopressors • Inotropic agents for cardiogenic shock • Intra-aortic Balloon Pump for cardiogenic

  17. Autonomic Drugs in Shock

  18. Management of Cardiogenic Shock • Attempt to correct problem and increase cardiac output by diuresing and providing inotropic support. IABP is utilized if medical therapy is ineffective. Catheterization if ongoing ischemia • Cardiogenic shock is the exception to the rule that NS is always given for hypotension NS will exacerbate cardiac shock.

  19. Intra-Aortic Balloon Pump

  20. Management of Septic Shock • Early goal directed therapy • Identification of source of infection • Broad Spectrum Antibiotics • IV fluids • Vasopressors • Steroids ?? • Recombinant human activated protein C ( Xygris) • Bicarbonate if pH < 7.1

  21. Management of Hypovolemic Shock • Correct bleeding abnormality • If PT or PTT elevated then FFP • Aggressive Fluid replacement with 2 large bore IV’s or central line. • Pressors are last line, but commonly required.

  22. Addison’s Disease • Deficiency of cortisol and aldosterone production in the adrenal glands • This is suspected when patient is non-responsive to fluids and antibiotics. • Electrolytes may reveal hyponatremia and hyperkalemia • Hydrocortisone 100 mg IV immediately then taper appropriately

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