Shock-Definition,Types and Management

1. (Definition, Types and Management) (Definition, Types and Management) Presented by Ajas K Aliyar Ajas K Aliyar Intensive Care Outreach Nurse Intensive Care Outreach Nurse Al Mafraq Hospital Al Mafraq Hospital Abu Dhabi Abu Dhabi 05/07/2019 05/07/2019 1 1

2. OBJECTIVES To develop an understanding of the definition and Pathophysiology and Stages of shock. To develop an understanding and overview of the different types of shock. To discuss Management of different Types of Shock.

3. What is shock? Inadequate Tissue Perfusion of Oxygenated Blood

4. Definition of Shock Empirical Criteria for Diagnosis of Empirical Criteria for Diagnosis of Circulatory Shock Circulatory Shock Oxygen delivery ≠ Oxygen Consumption (DO2 ≠ VO2) Systemic Arterial Hypotension (SBP <90 mm Hg/ MAP <65 mmHg associated tachycardia) O2 Consumption O2 Delivery Clinical Signs of Tissue Hypoperfusion (Cutaneous, Renal, Neurologic) “A state of cellular and tissue hypoxia due to Reduced oxygen delivery and/or Increased oxygen consumption or Inadequate oxygen utilization” Hyperlactatemia (Abnormal Cellular Oxygen Metabolism)

5. Understanding of Shock Physiology The major physiologic determinants of tissue perfusion (and systemic blood pressure [BP]) are Cardiac output (CO) and Systemic Vascular resistance (SVR) BP = CO X SVR CO is the product of heart rate (HR) and stroke volume (SV): CO = HR X SV Biologic processes that change any one of these physiologic parameters can result in hypotension and shock.

6. Understanding Shock-SVR SVR regulated by Vessel length, Blood viscosity, blood vessel Diameter/tone. Dilatation opens blood vessels and increases volume to area but decreases return to heart Constriction decreases volume to area but increases return to heart

7. Understanding Shock-Stroke Volume Volume of blood pumped by the heart in one Cycle What affect stroke volume ? Blood volume Rhythm problems Heart muscle problem Mechanical obstruction

8. Understanding of Shock Tissue perfusion is driven by Blood Pressure! Tissue perfusion is driven by Blood Pressure! So…. In other words When the blood flow (pressure) and O2 delivery to the cell are too low There will be shock!!!!

9. Why should you care Shock? High mortality 20%-90% O2 Deprivation and Build Up of waste products Could be fatal without timely management Rapidly become Irreversible>>>Multiorgan failure (MOF)>>>Death Irreversible>>>Multiorgan failure (MOF)>>>Death The early stages of shock are more amenable to therapy and are more likely to be reversible Early , timely and appropriate management -Deterioration can be prevented -Signs of impending deterioration can be reversed -Reduces mortality

10. Pathophysiology and Stages of shock

11. Stages Of Shock Irreversible(Refractory) Non-Progressive(Decompensated) Progressive(Compensated) • Stage Of “Pre shock” • Compensatory Response to decreased Perfusion • Decreased CO is maintained by Increase in HR and SVR • Comp. Tachycardia • MAP Maintained • Cool Extremities (Vasoconstriction) • Mildly Elevated lactate • Adequate UOP • Cerebral Perfusion Intact • Reversible • Stage of “Shock” • Compensatory Mechanism Fails • Dyspnea • Symptomatic Tachycardia • MAP drops more than 15 MMHG • Cool, clammy skin • Cerebral Perfusion low- Decreased LOC/Restless • Oliguria • Metabolic acidosis- Worsens • Reversible If Recognized and treated appropriately • Stage of “End-organ dysfunction” • Irreversible organ damage, multiorgan failure (MOF), and Death • Severe drops in MAP/Refractory • Aneuric, AKI • Acidemia- Depress CO • Hyperlactatemia often worsens • Profound Decrease in Cerebral Perfusion/Obtundation/Co ma • Irreversible • Death

12. TYPES OF SHOCK • Blood Volume Problem Hypovolemic Hypovolemic Shock Shock • Blood Pump Problem Cardiogenic Cardiogenic Shock Shock • Blood Vessel Problem Distributive Distributive shock shock • Extra-cardiac Pump Failure Problem Obstructive shock

13. Types and Etiology of Shock • Hemorrhagic • Non-Hemorrhagic • Cardiomyopathic Cardiomyopathic • Arrythmogenic Arrythmogenic • Mechanical Mechanical COMBINED COMBINED SHOCK SHOCK Example: Sepsis/Pancreatiti s + Hypovolemic + Cardiogenic shock Hypovolemic Shock Cardiogenic Shock Severe Traumatic Injury>>Hypovole mic + Distributive Distributive Shock Obstructive Shock • Septic Shock Septic Shock • Non Non- -septic septic • Pulmonary Pulmonary vascular vascular • Mechanical Mechanical

14. Epidemiology of Shock In a Trial of 1600 Patients in ICU Study of 103 Patients in a busy Urban ED Distributive(Septic) 62% Hypovolemic 16% Septic Shock 33% Cardiogenic 16% Hypovolemic 33% Obstructive 4% Cardiogenic 29% Other Distributive Shock 2% Other forms of Shock 2% 4%2% 2% 34% 30% 16% 16% 62% 34%

15. EVALUATIONS OF SHOCK Resuscitation should be started even while investigation of the cause is ongoing Once identified, the cause must be corrected rapidly Undifferentiated Shock!!!! Medical History Physical Examination-ABCDEFG,SAMPLE ABCDEFG,SAMPLE Clinical Investigations

17. Initial Treatment Approach to Shock Initial Treatment Approach to Shock Key Principles in the Treatment of Shock 1. Recognize shock early 2. Assess for type of shock present 3. Initiate therapy simultaneous with the evaluation into the etiology of shock 4. Restoration of oxygen delivery is the aim of therapy 5. Identify etiologies of shock which require additional lifesaving interventions

18. Initial Approach to all types of Shock Initial Approach to all types of Shock ❑ Early, adequate hemodynamic support of patients in shock is crucial ❑ The initial management of shock is problem-oriented, and the goals are therefore the same, regardless of the cause Important components of resuscitation is The VIP rule The VIP rule VENTILATE • O2 Administration INFUSE • Fluids Administration PUMP • Vasoactive Drug administration

19. The Initial management of shock A B C • Establish A Patent Airway • Basic Airway Manure • Intubation/MV • Administration of oxygen • To increase oxygen delivery and prevent pulmonary hypertension • Fluids Resuscitation(Type, Rate and Objective of Fluids) • Vasoactive Agents (Vasopressors, Inotropic Agents, Vasodilators) • Mechanical Support (IABP,ECMO) TYPE OF FLUID>> CRYSTALLOIDS, COLLOIDS RATE OF FLUID>>300-500ML OVER 20-30 MINS OBJECTIVE OF FLUID ADMINISTRATION>>INCREASE SYSTEMIC ART PRESSURE>>HR>>UOP

20. Prognosis Prognosis Sepsis and septic shock Are associated with long-term morbidity and mortality Requiring placement into long-term acute care facilities or post-acute care centers. Septic shock has a mortality rate between 40% and 50%. Cardiogenic shock Mortality rate ranging from 50% to 75%, an improvement over prior mortality rates. Hypovolemic and obstructive shock Generally have much lower mortality and respond better to timely treatment.

21. 68 Years of Male with History of HTN and Duodenal Ulcer presents to the ER with epigastric abdominal pain with radiation to his back and dizziness. The patient is hypotensive, tachycardic, Afebrile, and with cool and clammy skin What type of Shock is this?

22. Hypovolemic Shock Hypovolemic Shock Due to reduced intravascular volume (i.e., reduced preload), which, in turn, reduces CO Non-hemorrhagic Hemorrhagic

23. Hypovolemic Shock Hypovolemic Shock- -Causes Causes Non-hemorrhagic Gastrointestinal losses Skin losses Renal losses Third space losses into the extra vascular space Hemorrhagic Trauma Gastrointestinal bleeding Intraoperative and postoperative bleeding Retroperitoneal bleeding Tumor or abscess erosion into major vessels Ruptured ectopic pregnancy, postpartum hemorrhage, uterine or vaginal hemorrhage

24. CLASSIFICATION OF HEMORRHAGIC SHOCK PULSE B.P CNS STATUS CLASS URINE OUTPUT BLOOD LOSS FLUID REPLACEMEN T CLASS I <100 BPM NORMAL SLIGHTLY ANXIOUS >30ML/HR <15% 750CC CRYSTALLOID S CLASS II >100 BPM NORMAL MILDLY ANXIOUS 15-20ML/HR 15%-30% 750-1500 CC CRYSTALLOID S CLASS III >120 BPM DECREASED CONFUSED 5-15 ML/HR 30%-40% 1500-2500 CC CRYSTALLOID S+BLOOD CLASS IV >140 BPM DECREASED LETHARGIC NIL 40% >2500 CC CRYSTALLOID S+BLOOD In a normal Adult, a tachycardia after blood loss indicates at least a 15% loss of blood volume(<750 MLs)

25. Hypovolemic Hypovolemic Shock Shock- -Management Management Maximize oxygen delivery Maximize oxygen delivery Control further blood loss Control further blood loss Fluid resuscitation Fluid resuscitation Adequate Ventilation, Increase O2 saturation of Blood and Restoring Blood Flow Trauma External bleeding should be controlled with direct pressure Internal bleeding-surgical Long-bone fractures -Traction to decrease blood loss. Crystalloids Vs colloids (?? Best for resuscitation) -Assess Airway and Breathing -High Flow O2/ Ventilatory Support -IPPV GI Bleed PPI Vasopressin/ Octriotide infusion Endoscopy, Sengstaken-Blakemore tube -Two large-bore IV lines/EJV/CVC/IO -Arterial line (ABP,ABG) -Initial fluid resuscitation -Crystalloids-RL/NS (1-2 L) -Type O blood -Position Gynecological bleeding Surgical intervention. Both crystalloid and type O blood (Marked Hypotension, Class IV Bleed)

26. A 55 YO/M with HTN,DM presents in ED with “Crushing” substernal chest pain, diaphoresis, hypotension, tachycardia and cool, clammy extremities. What Type of Shock is This?

27. Cardiogenic Shock Clinical Definition of Cardiogenic Shock is “Decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume”

28. Cardiogenic Shock criteria Persistent (>30 minutes) Hypotension with systolic arterial pressure <90mm Hg Signs and symptoms of end organ hypoperfusion (Restlessness, Confusion, cold cyanotic extremities, oliguria<30ml/hr) Reduction in cardiac index <2.2 litres /min/m2 Presence of elevated left ventricle filling pressure(PCWP>18 mm Hg)

29. Cardiogenic Shock-Causes Cardiomyopathic Cardiomyopathic Mechanical Mechanical Arrythmogenic Arrythmogenic …. Myocardial infarction Severe valvular insufficiency Tachyarrhythmia Severe right ventricle infarction Acute valvular rupture Bradyarrhythmia Myocarditis, Myocardial contusion Acute or severe ventricular septal wall defect Ruptured ventricular wall aneurysm Acute exacerbation of severe heart failure from dilated cardiomyopathy ,

30. Cardiogenic Shock-Investigation ECG Chest X-ray Echocardiography ABG, Lactate, Electrolytes, Cardiac enzymes, Renal parameters Right heart catheter (to measure cardiac output, central venous, pulmonary artery and wedge pressures and mixed venous blood) Urinary catheter(measure hourly urine output)

31. Cardiogenic Shock-Management 1.LIFE SAVING INTERVENTIONS Emergency revascularization: either PCI (if coronary anatomy amenable) or CABG (if coronary anatomy not amenable to PCI) in MI Peri-interventional antiplatelet and antithrombotic medication CS due to mechanical complications: Urgent Interventional surgical Closure CS due to Arrythmogenic: Correct Arrhythmia 2.PHARMACOLOGIC CIRCULATORY SUPPORT Fluid administration Vasoactive agents (Vasopressors and Inotropic support)

32. Cardiogenic Shock-Management 3.MECHANICAL CIRCULATORY SUPPORT (MCS) Percutaneous short-term MCS devices (IABP, TandemHeart and Impella CP,ECMO) Surgical mechanical circulatory support devices and heart transplantation

35. DISTRIBUTIVE SHOCK Vasodialatory shock“ Caused by Loss of Vasomotor Control resulting in arteriolar/venular dilation. Characterized by severe peripheral vasodilation and low SVR Systemic vasodilation leads to decreased blood flow to the brain, heart, and kidneys causing damage to vital organs

36. 81 Y/F presents in ED with Chest infection and altered mental status. She is febrile to 39.4, hypotensive with a widened pulse pressure, tachycardic and with warm extremities. What Type of Shock is This?

37. Septic Shock Septic Shock Sepsis Two or more of SIRS criteria • Temp > 38 or < 36 C • HR > 90 • RR > 20 • WBC > 12,000 or < 4,000 • Plus the presumed existence of infection • Blood pressure can be normal! Sepsis,Severe Sepsis and Septic Shock • Sepsis: Systemic host response to infection with SIRS • Severe Sepsis: Sepsis plus end-organ dysfunction or hypo perfusion • Septic Shock: Sepsis with hypotension, despite fluid resuscitation; evidence of inadequate tissue perfusion

38. Septic Shock Septic Shock

39. Septic Shock Septic Shock- -Treatment Treatment

40. Septic Shock Septic Shock- -Treatment Antibiotics Antibiotics- - Survival correlates with how quickly the correct Survival correlates with how quickly the correct drug was given drug was given Cover gram positive and gram negative bacteria Add additional coverage as indicated Pseudomonas- Gentamicin or Cefepime MRSA- Vancomycin Intra-abdominal or head/neck anaerobic infections- Clindamycin or Metronidazole Asplenic- Ceftriaxone for N. meningitidis, H. infuenzae Neutropenic – Cefepime or Imipenem Treatment

41. A 34 YO/F presents to 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 with Dyspnea. What Type of Shock is This?

42. Anaphylactic Shock Anaphylaxis is a Rapid, Generalized often unanticipated, Anaphylaxis is a Rapid, Generalized often unanticipated, immunologically mediated events immunologically mediated events that occur after exposure to certain foreign substance. that occur after exposure to certain foreign substance. Causes: Foods (Milk, soy, eggs, nuts, and shellfish) Medications (Antibiotics [penicillin], NSAIDs, Anesthetics) Venom (Hymenoptera stings) Intravenous contrast materials, and latex. Idiopathic-Up to 20%

43. Anaphylactic Shock-Symptoms First>>Pruritus, flushing Urticaria appear Next>>Throat fullness, Anxiety Chest tightness, SOB Lightheadedness Finally>>Altered mental status Respiratory distress a Circulatory collapse

44. Anaphylactic Shock-Common Features Angioedema Bronchoconstriction Vasodilatation Hypotension Urticaria rash

45. 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 bite Labs have no role

46. Anaphylactic Shock-Treatments Airway Breathing Circulation Disability Exposure ECG, Cardiac /Hemodynamic Monitoring, Pulse Oxymetry, IV Cannulations Establish Patent Airway Establish Patent Airway High Flow O High Flow O2 2, , IV Fluids Challenge IV Fluids Challenge Medications Medications Consider Early Intubation/Surgical Consider Early Intubation/Surgical Airway Airway Consider Epinephrine Infusion if Consider Epinephrine Infusion if Shock Shock

47. Anaphylactic Shock-Treatments Epinephrine 0.3 mg IM of 1:1000 (Epi-pen) Anterolateral Thigh Repeat every 5-15 min as needed Caution with patients taking beta blockers IV Fluid Challenge 1-2 L in First Hour

48. Anaphylactic Shock-Treatments Corticosteroids Methylprednisolone 1-2 mg /KG IV /Prednisone 0.5-1 mg/KG PO Antihistamines H1 blocker- Diphenhydramine 25-50 mg IV/IM/PO H2 blocker- Ranitidine 50 mg IV/IM,150MG PO Severe Wheeze/Dyspnea Sabutamol 5 MG X 3 Doses in an hour Atrovent nebulizer Magnesium sulfate 2 g IV over 20 minutes

49. A A 41 41 YO/M Presents to ER after a car accident, Complaining of YO/M Presents to ER after a car accident, Complaining of decreased sensation below his waist and is now hypotensive, decreased sensation below his waist and is now hypotensive, bradycardic, with warm extremities bradycardic, with warm extremities What Type of Shock is This?

50. Neurogenic Shock “Vasogenic shock” ▪ Associated with cervical and high thoracic spine injury ▪ Primary spinal cord SCI occurs within minutes and Secondary SCI occurs hours to days after the initial insult ▪ A Combination of both primary and secondary injury that lead to loss of sympathetic tone and thus unopposed parasympathetic response driven by the Vagus nerve ▪ Leads to decreased tissue perfusion and initiation of the shock response. Hypotension, Brady arrhythmia, and Temperature dysregulation/flushed warm skin