Pharmacotherapy
of Shock
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

03/02/14...
Introduction






03/02/14

Review the current view on
etiology, pathophysiology and
management of shock with
emphasi...
Topics of Discussion




Pathophysiology of Shock
Types of Circulatory Shock
Management of Shock
Inotropic Agents
 Vas...
Shock






03/02/14

Term “choc” – French for “push” or
impact was first published in 1743
by the physician LeDran
Bel...
Determinants of Shock









03/02/14

Inadequate tissue perfusion
Sustained loss of effective circulatory
blood vo...
Hemodynamic States of
Shock




Hyperdynamic State
Hypodynamic State
Related to:
Cardiac Output (CO)
 Systemic Vascula...
Pathophysiology of
Shock


03/02/14

Shock develops with inadequate
capillary perfusion by decreased
Cardiac Output follo...
Mediators of Shock


Toxins




Oligo- and polypeptides






Arachidonic acid metabolites

Varia


03/02/14

Comp...
Main Classes of Shock
Hypovolemic Shock
 Distributive Shock
 Cardiogenic Shock
 Obstructive Shock


03/02/14

www.indi...
Hypovolemic Shock
Hemorrhagic/Traumatic
 Dehydrative
 Burn


03/02/14

www.indiandentalacademy.com

10
Distributive Shock
Septic
 Anaphylactic/
Anaphylactoid
 Neurogenic


03/02/14

www.indiandentalacademy.com

11
Obstructive Shock
Pulmonary Embolism
 Cardiac Tamponade
 Pneumothorax


03/02/14

www.indiandentalacademy.com

12
Question
Which one of the folowing is the most common cause of severe
Lactic acidosis (blood lactate concentration >5 mmol...
Management of Shock






03/02/14

Shock begins when DO2 to the
cells is inadequate to meet
metabolic demand
The major...
Pulmonary Artery
Catheter Waveforms
Right Atrium Right Ventricle Pulmonary Artery

03/02/14

www.indiandentalacademy.com

...
Hemodynamic Characteristics in
Different Types of Shock
Type

Preload

CO

PVR

SVR

Hemmorrhagic
Anaphylactic

/

Cardiog...
Question
The wavefrom shown in this figure was observed while
attempting to advance a pulmonary arterial catheter, with th...
Inotropic Agents and
Vasodilators






Vasoactive drugs are an important
pharmacologic defense in the
treatment of sho...
Effects of Inotropic
1
Agents and Vasodilators
Drug
Epinephrine

Receptor

CO

SVR

α1 ,β1, (β2)

Norepinephrine α1, β1

D...
Effects of Inotropic
2
Agents and Vasodilators
Drug

CO

SVR

Dose Range

Nifedipine

0-

0.5 - 10

Nitroglycerin

0-

3-5...
Dopamine

An endogenous precursor of norepinephrine with
multiple dose-related effects


Low Dose (0.5 - 3 mg/kg/min)

...
Question

03/02/14

www.indiandentalacademy.com

22
Reference
Pharmacotherapy of Shock. In: The Pharmacologic
Approach to the Critically Ill Patient, 3rd ed. Williams
& Wilki...
Thank you
For more details please visit
www.indiandentalacademy.com

03/02/14

www.indiandentalacademy.com

24
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Pharmacotherapy of shock /certified fixed orthodontic courses by Indian dental academy

  1. 1. Pharmacotherapy of Shock INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com 03/02/14 www.indiandentalacademy.com 1
  2. 2. Introduction     03/02/14 Review the current view on etiology, pathophysiology and management of shock with emphasis on pharmacotherapy. Daniel Game, M.D. O. D. Polk, Jr., M.D. Wayne Davis, M.D. www.indiandentalacademy.com 2
  3. 3. Topics of Discussion    Pathophysiology of Shock Types of Circulatory Shock Management of Shock Inotropic Agents  Vasodilators  03/02/14 www.indiandentalacademy.com 3
  4. 4. Shock    03/02/14 Term “choc” – French for “push” or impact was first published in 1743 by the physician LeDran Belief – symptoms arose from fear or some other form of altered cerebral function Crile in 1899 showed that replacement of blood volume decreased mortality experimentally www.indiandentalacademy.com 4
  5. 5. Determinants of Shock      03/02/14 Inadequate tissue perfusion Sustained loss of effective circulatory blood volume Breakdown of cellular metabolism and microcirculatory homeostasis Hypoperfusion of peripheral tissue that leads to a diminutive transcapillary exchange function Disproportion between VO2 and DO2 www.indiandentalacademy.com 5
  6. 6. Hemodynamic States of Shock    Hyperdynamic State Hypodynamic State Related to: Cardiac Output (CO)  Systemic Vascular Resistance (SVR)  03/02/14 www.indiandentalacademy.com 6
  7. 7. Pathophysiology of Shock  03/02/14 Shock develops with inadequate capillary perfusion by decreased Cardiac Output following heart attack (cardiogenic shock) or blood/volume loss (hypovolemic shock) www.indiandentalacademy.com 7
  8. 8. Mediators of Shock  Toxins   Oligo- and polypeptides     Arachidonic acid metabolites Varia  03/02/14 Complement Factors Opiods TNF, Interleukins Fatty Acid Derivatives   Endotoxins Calcium www.indiandentalacademy.com 8
  9. 9. Main Classes of Shock Hypovolemic Shock  Distributive Shock  Cardiogenic Shock  Obstructive Shock  03/02/14 www.indiandentalacademy.com 9
  10. 10. Hypovolemic Shock Hemorrhagic/Traumatic  Dehydrative  Burn  03/02/14 www.indiandentalacademy.com 10
  11. 11. Distributive Shock Septic  Anaphylactic/ Anaphylactoid  Neurogenic  03/02/14 www.indiandentalacademy.com 11
  12. 12. Obstructive Shock Pulmonary Embolism  Cardiac Tamponade  Pneumothorax  03/02/14 www.indiandentalacademy.com 12
  13. 13. Question Which one of the folowing is the most common cause of severe Lactic acidosis (blood lactate concentration >5 mmol/L)? a. b. c. d. e. 03/02/14 Ethanol intoxication Severe liver disease Circulatory shock Ischemic bowel Acute asthma www.indiandentalacademy.com 13
  14. 14. Management of Shock    03/02/14 Shock begins when DO2 to the cells is inadequate to meet metabolic demand The major therapeutic goals in shock therefore are sufficient tissue perfusion and oxygenation Early diagnosis remains a major problem www.indiandentalacademy.com 14
  15. 15. Pulmonary Artery Catheter Waveforms Right Atrium Right Ventricle Pulmonary Artery 03/02/14 www.indiandentalacademy.com PCWP 15
  16. 16. Hemodynamic Characteristics in Different Types of Shock Type Preload CO PVR SVR Hemmorrhagic Anaphylactic / Cardiogenic Septic (Hyperdynamic) Septic (Hypodynamic) 03/02/14 www.indiandentalacademy.com 16
  17. 17. Question The wavefrom shown in this figure was observed while attempting to advance a pulmonary arterial catheter, with the Balloon inflated, from the proximal pulmonatry artery to a “wedged” position. Which one of the following best explains the terminal portion of the depicted waveform? W a. Pulmonary hypertension h b. Mitral regurgitation i c. Severe left ventricular dysfunction c d. Obstruction of the catheter tip h e. Pericardial www.indiandentalacademy.com tamponade 03/02/14 17
  18. 18. Inotropic Agents and Vasodilators    Vasoactive drugs are an important pharmacologic defense in the treatment of shock. May be required to support BP in the early stages of shock. These agents may be needed to:   03/02/14 Enhance CO through the use of inotropic agents Increase SVR through the use of vasopressors www.indiandentalacademy.com 18
  19. 19. Effects of Inotropic 1 Agents and Vasodilators Drug Epinephrine Receptor CO SVR α1 ,β1, (β2) Norepinephrine α1, β1 Dose Range 0.02 – 0.5 0- 0.05 – 0.5 Dopamine β2, DR, (α) 2 -12 Dobutamine β1 , β2 2 - 12 Dopexamine β1, β2, DR Vasopressin Angiotensin III Amrinone PDI 03/02/14 00- 0.9 - 5 5 - 20 5 -10 www.indiandentalacademy.com (µg/kg/min) 19
  20. 20. Effects of Inotropic 2 Agents and Vasodilators Drug CO SVR Dose Range Nifedipine 0- 0.5 - 10 Nitroglycerin 0- 3-5 Nitroprusside 0- 0.5 - 5 Prostacyclin 10 - 40 (µg/kg/min) 03/02/14 www.indiandentalacademy.com 20
  21. 21. Dopamine An endogenous precursor of norepinephrine with multiple dose-related effects  Low Dose (0.5 - 3 mg/kg/min)    Positive inotropic effects High Dose (>20 mg/kg/min)  03/02/14 Enhanced blood flow to renal and splanchnic beds Moderate Dose (5 -10 mg/kg/min)   β2 and dopaminergic (DR) effects α-actions (vasoconstriction) www.indiandentalacademy.com 21
  22. 22. Question 03/02/14 www.indiandentalacademy.com 22
  23. 23. Reference Pharmacotherapy of Shock. In: The Pharmacologic Approach to the Critically Ill Patient, 3rd ed. Williams & Wilkins,1994, pp 1104 – 1121. 03/02/14 www.indiandentalacademy.com 23
  24. 24. Thank you For more details please visit www.indiandentalacademy.com 03/02/14 www.indiandentalacademy.com 24

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