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    SHOCK SHOCK Presentation Transcript

    • DEFINITION• Profound hemodyamic and metabolicdisturbance characterized by failure of thecirculatory system to maintain adequateperfusion of vital organs
    • Types of Shock• Cardiogenic (intracardiac vs extracardiac)• Hypovolemic• Distributive– sepsis****– neurogenic (spinal shock)– adrenal insufficiency– anaphylaxis
    • Cardiogenic Shock, intracardiac• Myocardial Injury or Obstruction to Flow– Arrythymias– valvular lesions– AMI– Severe CHF– VSD– Hypertrophic Cardiomyopathy
    • Presentation of CardiogenicShock• Pulmonary Edema• JVD• hypotensive• weak pulses• oliguria
    • Cardiogenic Shock, extracardiac(Obstructive)• Pulmonary Embolism• Cardiac Tamponade• Tension Pneumothorax• Presentation will be according to underlyingdisease process.
    • Hypovolemic Shock• Reduced circulating blood volume withsecondary decreased cardiac output– Acute hemorrhage– Vomiting/Diarrhea– Dehydration– Burns– Peritonitis/Pancreatitis
    • Presentation of HypovolemicShock• Hypotensive• flat neck veins• clear lungs• cool, cyanotic extremities• evidence of bleeding?– Anticoagulant use– trauma, bruising• oliguria
    • Distributive Shock• Peripheral Vasodilation secondary to disruptionof cellular metabolism by the effects ofinflammatory mediators.• Gram negative or other overwhelming infection.• Results in decreased Peripheral VascularResistance.
    • Distributive Shock: Presentation• Febrile• Tachycardic• clear lungs, evidence of pneumonia• warm extremities• flat neck veins• oliguria
    • Diagnosing Shock• Response to fluids• Echo/EKG• CXR• Evidence of infection• Swan-Ganz Catheter?
    • Swan-Ganz Catheter• Utilized to differentiate types of shock andassist in treatment response.• Probably overused by physicians. Studiesdocumenting increased mortality in patientswith catheters versus no catheters, althoughsomewhat swayed by selection bias.
    • Swan-Ganz Catheter
    • Swan-Ganz InterpretationEtiology CO PCWP SVRcardiogenic decreased increased increasedhypovolemic decreased decreased increaseddistributive increased decreased decreasedobstructive decreased Increased increased
    • Management• Correct underlying disorder if possible andthen direct efforts at increasing the bloodpressure to increase oxygen delivery to thetissues.• Maintain a mean arterial pressure of 60(1/3 systolic + 2/3 diastolic)• Keep O2 sats >92%, intubate if neccesary
    • Correction of hypotension• Normal Saline should be administeredanytime a patient is hypotensive. Ifhypotension exists give more NS. ***• If possible give blood as it replaces colloid.• Vasopressors• Inotropic agents for cardiogenic shock• Intra-aortic Balloon Pump for cardiogenic
    • Autonomic Drugs in ShockDrug Indication Dose MOA Principal actionsDopamine Renal perfusion 2-5 mcg/kg/min Dopaminergic Renal a. dilationhypotension 5-10 mcg/kg/min β1 &dopaminergic+ inotropeHypotension >10 mcg/kg/min α1 vasoconstrictionDobutamine Cardiogenic shock 2.5-25 mcg/kg/min Selective β1 + inotropeNorepinephrine Hypotension 2-4 mcg/min α1 & β1 VasoconstrictionPhenylephrine Hypotension 40-180 mcg/min Selective α1 Vasoconstriction
    • Management of CardiogenicShock• Attempt to correct problem and increasecardiac output by diuresing and providinginotropic support. IABP is utilized ifmedical therapy is ineffective.Catheterization if ongoing ischemia• Cardiogenic shock is the exception to therule that NS is always given forhypotension NS will exacerbate cardiacshock.
    • Intra-Aortic Balloon Pump
    • Management of Septic Shock• Early goal directed therapy• Identification of source of infection• Broad Spectrum Antibiotics• IV fluids• Vasopressors• Steroids ??• Recombinant human activated protein C ( Xygris)• Bicarbonate if pH < 7.1
    • Management of HypovolemicShock• Correct bleeding abnormality• If PT or PTT elevated then FFP• Aggressive Fluid replacement with 2 largebore IV’s or central line.• Pressors are last line, but commonlyrequired.
    • Addison’s Disease• Deficiency of cortisol and aldosteroneproduction in the adrenal glands• This is suspected when patient is non-responsive to fluids and antibiotics.• Electrolytes may reveal hyponatremia andhyperkalemia• Hydrocortisone 100 mg IV immediatelythen taper appropriately