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A State of Shock     Veronica Bonales, M.D.CEPAmerica, Emergency Medicine   Redwood Memorial Hospital
I am shocked, shocked...
ObjectivesWhat is Shock?Types of ShockStages and Symptoms of ShockTreatment of Shock
What is Shock?
What is Shock?
What is Shock?Inadequate tissue perfusion
What is Shock?Oxygen to lungsOxygen to RBC’sOxygen to tissuesCO2 in tissuesCO2 to RBC’sCO2 to lungs
What is Shock?Red Blood Cells  Hemoglobin  molecules    Carry O2 to    the tissues    and CO2 away    from the    tissues
What is Shock?        CO2 is a by-product of        cellular respiration
What is Shock?        CO2 is a by-product of        cellular respiration
What is Shock?
What is Shock?AnaerobicMetabolism  Leads to build  up of Lactic  Acid  Creates energy  debt
What is Shock?
What is Shock?Kidneys  Sense fall in  blood pressure  Release renin  Leads to  increased  blood pressure
What is Shock?       Carotid bodies         Sense           pH, O2 levels,           CO2
What is Shock?If pH decreased, O2 decreased, or CO2 increased   Signals sent via Vagus nerve       Decreased parasympathet...
Types of Shock
Types of ShockCardiogenicDistributiveHypovolemicObstructive
Types of Shock
Types of ShockCardiogenic Shock
Types of ShockCardiogenic Shock  Some condition doesn’t allow heart  to pump effectively
Types of ShockCardiogenic Shock  Some condition doesn’t allow heart  to pump effectively    Arrhythmia, MI, CHF, valvular ...
Types of ShockHeart not pumpingproperlyVessels compensateby increasing toneLess blood to endorgansIncreased venouspressure
Types of ShockCHF  Hypertensive  Tachycardic  Diaphoretic  Crackles
Types of ShockDistributive Shock  Anaphylactic  Neurogenic  Septic
Types of Shock“Relative hypovolemia”  Vasodilation  Leaky capillaries  Tissue edema
Types of ShockAnaphylaxis  Severe allergic  reaction  Histamine release  leads to  vasodilation &  capillary leakage
Types of ShockAnaphylaxis  Severe allergic  reaction  Histamine release  leads to  vasodilation &  capillary leakage
Types of Shock        Neurogenic          Spinal cord          damage          Leads to loss          of sympathetic      ...
Types of ShockSeptic Shock  Usually Gram negative  bacteria    Release toxins  Release of cellular  chemicals    Cytokines...
Types of ShockSeptic Shock  Usually Gram negative  bacteria    Release toxins  Release of cellular  chemicals    Cytokines...
Types of ShockCause vasodilationCause capillary leakageIncrease in lactateIncrease heart rate
Types of Shock        Hypovolemic Shock          Trauma          GI bleeds          Dehydration          Diabetes         ...
Types of Shock
Types of Shock   Obstructive
Stages & Symptoms     of Shock
Shock Stages &   Symptoms
Shock Stages &   Symptoms
Shock Stages &   Symptoms
Shock Stages &          SymptomsGrade 1 - 15% (750ml)  Mild tachycardia
Shock Stages &          SymptomsGrade 1 - 15% (750ml)  Mild tachycardiaGrade 2 - 15 - 30% (750 - 1500ml)  Moderate tachyca...
Shock Stages &          SymptomsGrade 1 - 15% (750ml)  Mild tachycardiaGrade 2 - 15 - 30% (750 - 1500ml)  Moderate tachyca...
Shock Stages &          SymptomsGrade 1 - 15% (750ml)  Mild tachycardiaGrade 2 - 15 - 30% (750 - 1500ml)  Moderate tachyca...
Shock Stages &   Symptoms
Shock Stages &        SymptomsInitial Stage
Shock Stages &        SymptomsInitial Stage  Hypoperfusion --> hypoxia
Shock Stages &        SymptomsInitial Stage  Hypoperfusion --> hypoxia  Hypoxia --> no ATP produced -->  anaerobic metabol...
Shock Stages &        SymptomsInitial Stage  Hypoperfusion --> hypoxia  Hypoxia --> no ATP produced -->  anaerobic metabol...
Shock Stages &        SymptomsInitial Stage  Hypoperfusion --> hypoxia  Hypoxia --> no ATP produced -->  anaerobic metabol...
Shock Stages &   Symptoms
Shock Stages &         SymptomsCompensatory Stage
Shock Stages &         SymptomsCompensatory Stage  Acidosis
Shock Stages &         SymptomsCompensatory Stage  Acidosis    Hypervent-    ilation
Shock Stages &         SymptomsCompensatory Stage  Acidosis    Hypervent-    ilation  Hypotension
Shock Stages &         SymptomsCompensatory Stage  Acidosis    Hypervent-    ilation  Hypotension    Tachycardia
Shock Stages &         SymptomsCompensatory Stage  Acidosis    Hypervent-    ilation  Hypotension    Tachycardia    Vasoco...
Shock Stages &         SymptomsCompensatory Stage   Blood shunted                     to heart,  Acidosis                 ...
Shock Stages &         SymptomsCompensatory Stage   Blood shunted                     to heart,  Acidosis                 ...
Shock Stages &         SymptomsCompensatory Stage   Blood shunted                     to heart,  Acidosis                 ...
Shock Stages &         SymptomsCompensatory Stage   Blood shunted                     to heart,  Acidosis                 ...
Shock Stages &      SymptomsProgressive (Decompensating) Stage  Increased acidosis -->  vasodilation & capillary leak --> ...
Shock Stages &      SymptomsRefractory (Irreversible) Stage  Multi-system organ failure  Brain death occurs  Death imminent
Shock Treatment
Treatment of Shock
Treatment of ShockCardiogenic - fix the underlyingproblem (angio, surgery, ECV)
Treatment of ShockCardiogenic - fix the underlyingproblem (angio, surgery, ECV)Anaphylactic - Epinephrine, anti-histamines...
Treatment of ShockCardiogenic - fix the underlyingproblem (angio, surgery, ECV)Anaphylactic - Epinephrine, anti-histamines...
Treatment of Shock
Treatment of ShockSeptic - massive amounts of fluids,antibiotics, pressor support, end-organsupport (ventilator, dialysis)
Treatment of ShockSeptic - massive amounts of fluids,antibiotics, pressor support, end-organsupport (ventilator, dialysis)...
Treatment of ShockSeptic - massive amounts of fluids,antibiotics, pressor support, end-organsupport (ventilator, dialysis)...
Questions..?
Questions..?
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FCA 0611 - Shock

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Field Care Audit, RMH
06/15/11

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  • Transcript of "FCA 0611 - Shock"

    1. 1. A State of Shock Veronica Bonales, M.D.CEPAmerica, Emergency Medicine Redwood Memorial Hospital
    2. 2. I am shocked, shocked...
    3. 3. ObjectivesWhat is Shock?Types of ShockStages and Symptoms of ShockTreatment of Shock
    4. 4. What is Shock?
    5. 5. What is Shock?
    6. 6. What is Shock?Inadequate tissue perfusion
    7. 7. What is Shock?Oxygen to lungsOxygen to RBC’sOxygen to tissuesCO2 in tissuesCO2 to RBC’sCO2 to lungs
    8. 8. What is Shock?Red Blood Cells Hemoglobin molecules Carry O2 to the tissues and CO2 away from the tissues
    9. 9. What is Shock? CO2 is a by-product of cellular respiration
    10. 10. What is Shock? CO2 is a by-product of cellular respiration
    11. 11. What is Shock?
    12. 12. What is Shock?AnaerobicMetabolism Leads to build up of Lactic Acid Creates energy debt
    13. 13. What is Shock?
    14. 14. What is Shock?Kidneys Sense fall in blood pressure Release renin Leads to increased blood pressure
    15. 15. What is Shock? Carotid bodies Sense pH, O2 levels, CO2
    16. 16. What is Shock?If pH decreased, O2 decreased, or CO2 increased Signals sent via Vagus nerve Decreased parasympathetic input Heart rate increases Increased sympathetic input Vessels contract increasing BP
    17. 17. Types of Shock
    18. 18. Types of ShockCardiogenicDistributiveHypovolemicObstructive
    19. 19. Types of Shock
    20. 20. Types of ShockCardiogenic Shock
    21. 21. Types of ShockCardiogenic Shock Some condition doesn’t allow heart to pump effectively
    22. 22. Types of ShockCardiogenic Shock Some condition doesn’t allow heart to pump effectively Arrhythmia, MI, CHF, valvular problem, CM
    23. 23. Types of ShockHeart not pumpingproperlyVessels compensateby increasing toneLess blood to endorgansIncreased venouspressure
    24. 24. Types of ShockCHF Hypertensive Tachycardic Diaphoretic Crackles
    25. 25. Types of ShockDistributive Shock Anaphylactic Neurogenic Septic
    26. 26. Types of Shock“Relative hypovolemia” Vasodilation Leaky capillaries Tissue edema
    27. 27. Types of ShockAnaphylaxis Severe allergic reaction Histamine release leads to vasodilation & capillary leakage
    28. 28. Types of ShockAnaphylaxis Severe allergic reaction Histamine release leads to vasodilation & capillary leakage
    29. 29. Types of Shock Neurogenic Spinal cord damage Leads to loss of sympathetic tone
    30. 30. Types of ShockSeptic Shock Usually Gram negative bacteria Release toxins Release of cellular chemicals Cytokines Free radicals
    31. 31. Types of ShockSeptic Shock Usually Gram negative bacteria Release toxins Release of cellular chemicals Cytokines Free radicals
    32. 32. Types of ShockCause vasodilationCause capillary leakageIncrease in lactateIncrease heart rate
    33. 33. Types of Shock Hypovolemic Shock Trauma GI bleeds Dehydration Diabetes Burns
    34. 34. Types of Shock
    35. 35. Types of Shock Obstructive
    36. 36. Stages & Symptoms of Shock
    37. 37. Shock Stages & Symptoms
    38. 38. Shock Stages & Symptoms
    39. 39. Shock Stages & Symptoms
    40. 40. Shock Stages & SymptomsGrade 1 - 15% (750ml) Mild tachycardia
    41. 41. Shock Stages & SymptomsGrade 1 - 15% (750ml) Mild tachycardiaGrade 2 - 15 - 30% (750 - 1500ml) Moderate tachycardia, prolonged cap refill
    42. 42. Shock Stages & SymptomsGrade 1 - 15% (750ml) Mild tachycardiaGrade 2 - 15 - 30% (750 - 1500ml) Moderate tachycardia, prolonged cap refillGrade 3 - 30 - 40% (1500 - 2000ml) Hypotension, tachycardia, low urine output
    43. 43. Shock Stages & SymptomsGrade 1 - 15% (750ml) Mild tachycardiaGrade 2 - 15 - 30% (750 - 1500ml) Moderate tachycardia, prolonged cap refillGrade 3 - 30 - 40% (1500 - 2000ml) Hypotension, tachycardia, low urine outputGrade 4 - 40 - 50% (2000 - 2500ml) Profound hypotension, end-organ damage, death
    44. 44. Shock Stages & Symptoms
    45. 45. Shock Stages & SymptomsInitial Stage
    46. 46. Shock Stages & SymptomsInitial Stage Hypoperfusion --> hypoxia
    47. 47. Shock Stages & SymptomsInitial Stage Hypoperfusion --> hypoxia Hypoxia --> no ATP produced --> anaerobic metabolism --> increased lactate
    48. 48. Shock Stages & SymptomsInitial Stage Hypoperfusion --> hypoxia Hypoxia --> no ATP produced --> anaerobic metabolism --> increased lactate No energy --> cell damage --> leaky walls --> loss of fluid
    49. 49. Shock Stages & SymptomsInitial Stage Hypoperfusion --> hypoxia Hypoxia --> no ATP produced --> anaerobic metabolism --> increased lactate No energy --> cell damage --> leaky walls --> loss of fluid No energy --> cells can’t function
    50. 50. Shock Stages & Symptoms
    51. 51. Shock Stages & SymptomsCompensatory Stage
    52. 52. Shock Stages & SymptomsCompensatory Stage Acidosis
    53. 53. Shock Stages & SymptomsCompensatory Stage Acidosis Hypervent- ilation
    54. 54. Shock Stages & SymptomsCompensatory Stage Acidosis Hypervent- ilation Hypotension
    55. 55. Shock Stages & SymptomsCompensatory Stage Acidosis Hypervent- ilation Hypotension Tachycardia
    56. 56. Shock Stages & SymptomsCompensatory Stage Acidosis Hypervent- ilation Hypotension Tachycardia Vasoconstric- tion
    57. 57. Shock Stages & SymptomsCompensatory Stage Blood shunted to heart, Acidosis brain, lungs Hypervent- ilation Hypotension Tachycardia Vasoconstric- tion
    58. 58. Shock Stages & SymptomsCompensatory Stage Blood shunted to heart, Acidosis brain, lungs Hypervent- Diaphoresis ilation Hypotension Tachycardia Vasoconstric- tion
    59. 59. Shock Stages & SymptomsCompensatory Stage Blood shunted to heart, Acidosis brain, lungs Hypervent- Diaphoresis ilation Kidneys Hypotension Tachycardia Vasoconstric- tion
    60. 60. Shock Stages & SymptomsCompensatory Stage Blood shunted to heart, Acidosis brain, lungs Hypervent- Diaphoresis ilation Kidneys Hypotension Increase Tachycardia volume by Vasoconstric- decreased tion UOP, Na+
    61. 61. Shock Stages & SymptomsProgressive (Decompensating) Stage Increased acidosis --> vasodilation & capillary leak --> edema Blood sludges --> microinfarcts Increasing loss of perfusion and end-organ damage
    62. 62. Shock Stages & SymptomsRefractory (Irreversible) Stage Multi-system organ failure Brain death occurs Death imminent
    63. 63. Shock Treatment
    64. 64. Treatment of Shock
    65. 65. Treatment of ShockCardiogenic - fix the underlyingproblem (angio, surgery, ECV)
    66. 66. Treatment of ShockCardiogenic - fix the underlyingproblem (angio, surgery, ECV)Anaphylactic - Epinephrine, anti-histamines, steroids
    67. 67. Treatment of ShockCardiogenic - fix the underlyingproblem (angio, surgery, ECV)Anaphylactic - Epinephrine, anti-histamines, steroidsNeurogenic - most difficult, steroidsor surgery
    68. 68. Treatment of Shock
    69. 69. Treatment of ShockSeptic - massive amounts of fluids,antibiotics, pressor support, end-organsupport (ventilator, dialysis)
    70. 70. Treatment of ShockSeptic - massive amounts of fluids,antibiotics, pressor support, end-organsupport (ventilator, dialysis)Hypovolemic - aggressive fluids, bloodproducts, treatment of underlying cause
    71. 71. Treatment of ShockSeptic - massive amounts of fluids,antibiotics, pressor support, end-organsupport (ventilator, dialysis)Hypovolemic - aggressive fluids, bloodproducts, treatment of underlying causeObstructive - treatment of underlyingcause (needle decompression,pericardiocentesis)
    72. 72. Questions..?
    73. 73. Questions..?

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