Shock

1. Shock Tad Kim UF Surgery

2. Overview Definitions Initial Assessment � ABC Stages of Shock Physiologic Determinants of Shock Types of Shock Common Features of Shock H & P / Work-up Case scenarios and Management Take Home Points

3. Definitions Shock is a physiologic state characterized by systemic reduction in tissue perfusion, resulting in decreased tissue oxygen delivery Hypotension is not a requirement Poor tissue perfusion

4. Initial Assesment - ABC Airway: Does pt have mental status to protect airway? GCS less than �eight� means �intubate� Airway is compromised in anaphylaxis Breathing: If pt is conversing with you, A & B are fine Place patient on oxygen Circulation: Vitals (HR, BP) 2 large bore (#16g) IV, start fluids (careful if cardiogenic shock), put on continuous monitor

5. ABC �DE� In a trauma, perform ABCDE, not just ABC Deficit or Disability Assess for obvious neurologic deficit Moving all four extremities? Pupils? Glascow Coma Scale (V6, M5, E4) Exposure Remove all clothing on trauma patients

6. Stages / Spectrum of Shock �Preshock� aka compensated/warm shock Body is able to compensate for ?perfusion Up to ~10% reduction in blood volume Tachycardia to ?cardiac output & perfusion �Shock� Compensatory mechanisms overwhelmed See signs/symptoms of organ dysfunction ~20-25% reduction in blood volume �End-organ dysfunction� Leading to irreversible organ damage/death

7. Physiologic Determinants Global tissue perfusion is determined by: Cardiac output (CO) CO = Heart rate (HR) times Stroke Volume (SV) SV = function of Preload, Afterload, Contractility Systemic vascular resistance (SVR) Variables: Length, Inverse of Diameter, Viscosity

8. Types of Shock Hypovolemic shock � from ?preload Hemorrhage Fluid Loss (Vomiting, Diarrhea, Burns) Cardiogenic shock � pump failure or ?SV MI, arrhythmia, aortic stenosis, mitral regurg Extracardiac obstructive causes such as PE, tension pneumothorax, tamponade Distributive (vasodilatory) shock - ?SVR Septic, anaphylactic, and neurogenic shock Pancreatitis, burns, multi-trauma via activation of the inflammatory response

9. Common Features of Shock Hypotension (not an absolute requirement) SBP < 90mm Hg, not seen in �preshock� Cool, clammy skin Vasoconstrictive mechanisms to redirect blood from periphery to vital organs Exception is warm skin in early distrib. shock Oliguria (?kidney perfusion) Altered mental status (?brain perfusion)\ Metabolic acidosis

10. H&P / Work-up History to determine etiology Bleeding (recent surgery, trauma, GI bleed) Allergies or prior anaphylaxis Sx consistent with pancreatitis, EtOH history Hx of CAD, MI, current chest pain/diaphoresis Physical examination Mucous membranes, JVD, lung sounds, cardiac exam, abdomen, rectal (blood), neuro exam, skin (cold & clammy or warm) Labs/Tests directed toward suspected dx�s

11. Case 1 55yo male otherwise healthy who is fresh post-op from a colon resection for CA Called for tachycardia, hypotension, altered mental status, and abd distension On exam: pale, dry mucous membranes, disoriented, abdomen is tender and tense UOP is 15mL over past hour What else do you want to know? What is the most likely diagnosis?

12. Case 1 The one thing you want to know: Hct (Hgb) Dx: Hemorrhagic (hypovolemic) shock Management ABC (need intubation? IV access?) Wide open fluids and T&C 6 units PRBC Should send coags when sending for CBC Make sure it�s not an MI (chest pain, EKG) Give blood & prepare for re-exploration in OR

13. Case 2 75yo male PMH CAD, PVD, DM who is post-op from AAA repair complains of crushing substernal chest pain Vitals: SBP 80/50 Pale, diaphoretic, cool & clammy on exam What do you do? What is the diagnosis?

14. Case 2 ABC, get good access, continuous monitor Stat 12-lead EKG shows ST elevation in 2 contiguous leads Dx: Cardiogenic shock 2ndary to STEMI Treatment: �MONA� Oxygen, Aspirin, Nitroglycerin, Morphine Beta-blockade (no heparin or tPA due to surg) Stat cardiology consult for cardiac cath

15. Case 3 60yo male heavy drinker brought in by EMS with nausea, vomiting, severe epigastric pain radiating to the back Tachycardic, hypotensive Altered mentation, dry mucous membranes, minimal UOP after Foley What is the most likely diagnosis? Differential diagnosis? How do you manage this patient?

16. Case 3 Acute pancreatitis DDx of acute abdomen: Perforated viscus, acute mesenteric ischemia, cholecystitis, SBO, Ruptured AAA, MI Hypovolemic shock from vomiting and Distributive shock from the inflammation: vasodilation, vasopermeability (3rd-space) These pts require heavy, heavy fluid resus Treatment: Push heavy fluids, NPO, NGT Can feed post-pyloric, consider CT scan

17. Case 4 55yo male also post-op from colon resection for CA, epidural placed for post-operative pain control Called by nurse for hypotension and bradycardia Abdomen soft, no pallor, altered mentation Hct is 38 Most likely diagnosis?

18. Case 4 Neurogenic shock 2ndary to epidural Differentiated from hypovolemic due to bradycardia Treatment is: IVF Turn down or turn off epidural If BP does not respond, then alpha-agonist such as phenylephrine until above measures stabilize patient, then wean the vasopressor

19. Case 5 25yo male presents with diffuse abdominal pain of 1day duration, started initially as epigastric pain after a meal. Takes ibuprofen 3x a day. Vitals: hypotensive, tachycardic Tense abdomen, involuntary guarding, altered mental status, oliguric What is the diagnosis & management?

20. Case 5 Septic shock 2ndary to perf duodenal ulcer This patient has diffuse peritonitis Management: ABC, IV & resuscitation (requires heavy fluids) Broad-spectrum IV antibiotics Emergent OR for ex-lap, washout & repair If pt does not respond to fluids, may need vasopressors (norepinephrine, dopamine) Have beta-agonist effects to help pump function as well as alpha-agonist for periph vasoconstriction

21. Take Home Points Shock = poor tissue perfusion/oxygenation Know difference btw compensated/uncomp shock 3 types are based on physiology of shock Hypovolemic due to decreased preload Cardiogenic due to decreased SV or CO Distributive due to decreased SVR Know the common signs a/w shock Oliguria, AMS, cool/clammy skin, acidosis Work-up & management starts with ABC Aggressive resuscitation except if cardiogenic Vasopressors if hypotensive despite fluids