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Shock Management

Shock Management. Objectives. Understand the definition of the three different types of shock Be able to recognize the different types of shock in patient scenarios Understand and apply treatment guidelines for the different types of shock. What is Shock?.

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Shock Management

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  1. Shock Management

  2. Objectives • Understand the definition of the three different types of shock • Be able to recognize the different types of shock in patient scenarios • Understand and apply treatment guidelines for the different types of shock

  3. What is Shock? • Shock is the “physiologic state characterized by significant reduction of systemic tissue perfusion, resulting in decreased tissue oxygen delivery.” • Tissue perfusion is dependent on systemic vascular resistance (SVR) and cardiac output (COP). • Imbalance between oxygen delivery and oxygen consumption which leads to cell death, end organ damage, multi-system organ failure, and death

  4. Three Types of Shock • Cardiogenic • Hypovolemic • Distributive • Septic • Anaphylactic • Neurogenic • Combined

  5. Cardiogenic Shock • Shock caused as a result of cardiac pump failure • Results in a decrease in COP • SVR is increased in an effort to compensate to maintain organ perfusion • Causes: • Myocardial Infarction • Arrythmias (Atrial fibrillation, ventricular tachycardias, bradycardias, etc) • Mechanical abnormalities (valvular defects) • Extracardiac abnormalities (PE, pulm HTN, tension pneumothorax) Medscape Reference. 1994 (Online accessed 22 August 2013) URL: http://emedicine.medscape.com/article/152191-treatment#showall

  6. Treatment of Cardiogenic Shock • Correct hypotension: • Fluid resuscitation to correct hypovolemia • Inotropic or Vasopressor support: • Dobutamine • Milrinone • Norepinephrine • Dopamine • Epinephrine • Oxygenation • If MI – Aspirin, Heparin, and Revascularization • If arrthymia – correct arrthymia • If extracardiac abnormality – reverse or treat cause

  7. Hypovolemic Shock • Shock caused by decreased preload due to intravascular volume loss (1/5 of blood volume) • Results in decreased COP • SVR is typically increased in an effort to compensate • Causes: • Hemorrhagic – trauma, GI bleed, hemorrhagic pancreatitis, fractures • Fluid loss induced – Diarrhea, vomiting, burns Medscape LLC. 2013 (Online access on 22 August 2013) URL: http://emedicine.medscape.com/article/760145-treatment#2

  8. Treatment of Hypovolemic Shock • Maximize oxygen delivery • Control further blood loss • Tourniquets • Surgical intervention • Fluid resuscitation • NS fluid boluses • Blood product administration

  9. Distributive Shock • Shock as a result of severely diminished SVR • COP is typically increased in an effort to maintain perfusion • Subtypes: • Septic – secondary to an overwhelming infection • Anaphylactic – secondary to a life-threatening allergic reaction • Neurogenic – secondary to a sudden loss of the autonomic nervous system function Gaieski et al. 2009 (Online accessed 22 August 2013) URL: http://lijhs.sandi.net/faculty/rtenenbaum/ap-biology-folder/Links/Shock.utd.pdf

  10. Treatment of Septic Shock • Resuscitate • 30cc/kg of NS bolus • Identify Source • Pan cultures • CT scan • Line removal • Foley removal • Surgical exploration • Antibiotics Dellinger, R et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock:2012, 41: 580-637, 2013.

  11. Treatment of Anaphylactic Shock • Remove offending agent • Establish an airway and return circulation • Pharmacologic support: • Epinephrine – reverses peripheral vasodilation, dilates bronchial airways, increases myocardial contractility, and suppresses histamine/ leukotriene release • Antihistamine (benadryl) – may help counter histamine-mediated vasodilation and bronchoconstriction • Corticosteroids (hydrocortisone) – may help shorten reaction • Bronchodilators

  12. Treatment of Neurogenic Shock • Establish an airway to maintain adequate oxygenation and ventilation • Fluid resuscitation for MAP>65mmHg • Inotropic support • Dobutamine • Dopamine • Atropine for severe bradycardia • High dose methylprednisolone therapy

  13. All three types of shock can occur at the same time to have a combined shock picture.

  14. Summary Survival and outcomes improve with early perfusion, adequate oxygenation, and identification with appropriate treatment of the cause of shock.

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