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.
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.
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
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