SHOCK

1. SHOCK Susan Stroud, MD U. Of Utah Health Sciences Center Division of Emergency Services

2. Yesterday!!!!!!!!!!!

3. Tour Highlights • Definition • Categories of shock • Recognizing shock • Treating shock

4. Who described Shock? • LeDran coined the term “choc” to describe the clinical characteristics observed following severe gunshot trauma in 1773 • Shock - “a rude unhinging of the machinery of life” Samuel Gross 1872

5. What is shock? • The clinical manifestation of cellular disorganization • A physiological state that results in inadequate organ perfusion and tissue oxygenation • A transition state between illness and death

6. Pathophysiologyof Shock ok Stage I. Stage II. Stage III. Cellular membrane Injury Microcirculatory Failure Endothelial Damage Decreased perfusion Major End-Organ Dysfunction Low Cardiac Output or Vasodilatation Pathogenesis Compensated hypotension Decompensated hypotension Cellular Death ? Potentially reversible shock Irreversible shock

7. Limited to 180 beats/min before decreased CO due to decreased diastolic filling time CARDIAC OUTPUT =HR X SV Increased contractility Peripheral vasoconstriction Increase EDV via: Activation of Renin-Angiotensin System Venoconstriction Arteriolar constriction Renal reabsorption (10 min) Sympathetic n. system Catecholaminerelease (1 - 48 hrs) (30 seconds)

8. Acidosis produces vasodilatation and worsening hypotension Tissue Hypoperfusion leads to anaerobic metabolism and lactic acidosis The cycle of compensation and decompensation Compensatory Mechanisms Myocardial Perfusion and Cardiac Output decrease Hypoperfusion FAILURE Altered Mental Status Diminished peripheral pulse Oliguria Multi-system Organ Failure DEATH

9. Clinical pathophysiology of Shock • An abnormality of Heart Rate • An abnormality of Stroke Volume • An abnormality of Peripheral Resistance • A failure of any of these to compensate for an abnormality of the others • Vital signs are vital to recognizing shock

10. The Crucial Factor: OXYGEN • End organs are dependent on the circulatory system for an adequate supply of oxygen • If oxygen supply becomes limited, the body will work to preserve heart and brain function by sacrificing other systems

11. Inotropes Fluids Transfuse Partially dependent on FIO2 and pulmonary status TREATMENT OF SHOCK ENHANCING PERFUSION/OXYGEN DELIVERY Cardiac output Arterial O2 content Oxygen delivery = HR X SV X Hb X S02 X 1.34 + Hb X paO2

12. GOLDEN RULES OF SHOCK RESUSCITATION • Maintain ventilation • Enhance perfusion • Treat underlying cause

13. Classifying Shock • Hypovolemic shock - volume problem • Cardiogenic shock - pump problem • Distributive shock - tubing problem • Obstructive shock - pump function blocked by mechanical obstruction

14. CLINICAL ENDPOINTS OF SHOCK DECREASED BLOOD FLOW TO BRAIN AND HEART Restless, agitated, confused Hypotension Tachycardia Tachypnea END-STAGE SHOCK Bradycardia Arrythmias Death

15. Hypovolemic Shock • Hemorrhagic • Severe burn • GI losses • vomiting and diarrhea • Urinary • DKA, diabetes insipidus

16. Hypovolemic Shock

17. Trauma Ringdown • Radio report: We’re on our way with a 25 year old male in a head on MVA. He has sustained obvious chest and abdominal trauma and has a GCS of 13. • Current VS are: HR 125 RR 28 BP 100/50 T 36.0 Sa02 93% on NRBM

18. Trauma Exam • Patient is agitated and confused. His R chest wall appears to be deformed. • His abdomen is rigid, and appears to be getting larger.

19. WHAT DO WE DO NEXT? • Maintain ventilation • Enhance perfusion • Treat underlying cause

20. What studies or labs can help you immediately? • Think in terms of the ABC’s • Chest X-ray (B for breathing) • FAST exam (C for circulation) • Frequent vital signs and continuous cardiac and oxygen monitoring

21. Chest X-ray • What do you see on this chest xray? • Does it explain any of this patients vital signs? • What should you do about it?

22. Hemothorax

23. Hypovolemic Resuscitation • Give Oxygen • Assist Breathing if needed • Maximize Circulation by giving IV fluids or blood • Stop the bleeding and repair the damage

24. Have you saved the patient? • FAST exam to look for intra-abdominal free fluid

25. Cardiogenic Shock • Cardinal elements are hypotension (SBP < 90) and hypoperfusion with pulmonary congestion • Mortality is 50 - 80% before reperfusion therapy and cath lab availability • Acute myocardial ischemia is most common cause

26. Cardiac Case • 65 yr old female, c/o crushing chest pain, SOB, nausea, diaphoresis for three hours • VS are: BP 90/40 RR 28 T 36.5 Sa02 90% HR 115

27. WHAT DO WE DO NEXT? • Maintain ventilation • Enhance perfusion • Treat underlying cause

28. What studies or labs can help you immediately? • EKG • CXR • Frequent vital signs and continuous cardiac and oxygen monitoring

29. EKG

30. Chest X-ray

31. Cardiogenic Resuscitation • Maximize oxygenation • Stabilize breathing • Maximize circulation • Treat her heart - nitroglycerin, aspirin, beta-blocker, CATH LAB or thrombolysis

32. Neurogenic Shock • Usually the result of spinal cord injury • Loss of sympathetic tone and decreased vasomotor tone can result in hypotension and bradycardia • Patients may remain alert, warm, and dry despite the hypotension

33. More Trauma • 29 yo male, PVA while crossing the street, awake, complaining of severe back pain, and inability to move or feel his legs • VS are: HR 45 RR 25 BP 100/45 Sa02 98% T 34.0

34. WHAT DO WE DO NEXT? • Maintain ventilation • Enhance perfusion • Treat underlying cause

35. What studies or labs can help you immediately? • Xrays • FAST exam • Frequent vital signs and continuous cardiac and oxygen monitoring

36. Xrays from the trauma bay

37. Neurogenic Resuscitation • Adequate oxygenation • Assess breathing • Maximize circulation • IV fluids or blood • Pressors if necessary • Support heart rate if needed • atropine • Prepare for the OR and call a neurosurgeon now!

38. Anaphylactic Shock • An IgE mediated event that triggers massive release of immune response mediators • Results in widespread peripheral vasodilation, bronchial smooth muscle contraction, and local vascular dilatation

39. Attack of the Killer Bees • 40 yo male, living in Golden Gate park, set up his tent next to a bee hive and now reports multiple stings • VS are: RR 30 HR 130 BP 90/45 T 36.5 Sa02 92%

40. WHAT DO WE DO NEXT? • Maintain ventilation • Enhance perfusion • Treat underlying cause

41. What studies or labs can help you immediately? • Frequent vital signs and continuous cardiac and oxygen monitoring • Examine patient for clinical signs of anaphylaxis

42. Clinical Exam • Patient is covered in hives, is speaking in two word sentences, has loud wheezing sounds with respirations

43. Anaphylactic resuscitation • Maximize Oxygenation • Assist Breathing if needed • Bronchodilators • Consider intubation • Stabilize circulation • IV fluids, epinephrine, pressors • Stabilize immune system reaction • Steroids, histamine blockers (benadryl and H2 blocker)

44. Septic Shock • A blood borne infection widely disseminated to many areas of the body • Common features are high fever, vasodilation (especially in affected tissues) • Sludging of the blood, and RBC agglutination resulting in DIC

45. “I don’t feel right” • 35 yo male, reports “I’m dope-sick” c/o fever, chills, fatigue, sweating for one day. Last used heroin yesterday. Also c/o leg pain at site of last injection • VS are: BP 80/40 T 41.0 RR 26 Sa02 95% HR 130

46. WHAT DO WE DO NEXT? • Maintain ventilation • Enhance perfusion • Treat underlying cause

47. What studies or labs can help you immediately? • CXR, UA • Frequent vital signs and continuous cardiac and oxygen monitoring • Examine patient for clinical signs of sepsis • Echocardiogram

48. Treating septic shock • Maximize Oxygenation • Assist Breathing if needed • Maximize Circulation • IV Fluids, pressors • Start Antibiotics • Consider surgical intervention if needed

49. PRINCIPLES OF RESUSCITATION • Maintain ventilation • Enhance perfusion • Treat underlying cause

50. Inotropes Fluids Transfuse Partially dependent on FIO2 and pulmonary status TREATMENT OF SHOCK ENHANCING PERFUSION/OXYGEN DELIVERY Cardiac output Arterial O2 content Oxygen delivery = HR X SV X Hb X S02 X 1.34 + Hb X paO2