Your SlideShare is downloading. ×
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
The Many Faces Of Shock
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

The Many Faces Of Shock

1,195

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
1,195
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
0
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • Took 2 hours to present (more or less) Presented well, could fix the section on different fluid types (skipped over)? Or omit it Video of how to use pressure bags, Video of restoring intravascular volume and resuscitation of the patient Video of taking blood for big 5 and placing catheter Video of using the lactate pro
  • How many people are concerned about the heart rate?
  • Shock dose 20 ml/kg 1/4 to 1/3 dose 5 ml/kg boluses Treat to end points of resuscitation
  • Transcript

    • 1. The Many Faces of Shock Søren Boysen, DVM, DACVECC University of Montreal Saint Hyacinthe, Quebec, Canada Université de Montréal m m U
    • 2. Shock
      • What is the definition of shock?
    • 3. Shock
      • What is the definition of shock?
          • Inadequate oxygen delivery to the tissues to meet tissue demand
    • 4. Shock
      • What is the definition of shock?
          • Inadequate oxygen delivery to the tissues to meet tissue demand
          • What causes inadequate oxygen delivery to the tissues?
    • 5. Shock
      • What factors influence oxygen delivery (DO 2 )
    • 6. Oxygen Delivery (DO 2 )
      • Influenced by two important factors
        • Cardiac output
    • 7. Oxygen Delivery (DO 2 )
      • Influenced by two important factors
        • Cardiac output Arterial oxygen content
      O 2 O 2 O 2 O 2 O 2 O 2
    • 8. DO 2 = CO x CaO 2
    • 9. DO 2 = CO x CaO 2 What factors influence cardiac output?
    • 10. DO 2 = CO x CaO 2 Stroke volume Heart rate x
    • 11. DO 2 = CO x CaO 2 Stroke volume - Preload - Aferload - Contractility Heart rate x
    • 12. DO 2 = CO x CaO 2 What factors influence arterial oxygen content?
    • 13. DO 2 = CO x CaO 2 CaO 2 = ( Hgb × 1.34 × SaO 2 ) + ( PaO 2 × .003) Hematocrit Hemoblobin saturation Arterial oxygen pressure
    • 14. General Therapy for Shock
      • Increase cardiac output (CO)
        • Heart rate: Correct arrhythmias
        • Preload: Fluid therapy (except heart disease)
        • Afterload: Nitropursside, ACE inhibitors
        • Contractility: Positive ionotropes
      • Increase the arterial oxygen content (CaO 2 )
        • Blood transfusion: when indicated
        • Increased inspired oxygen content
      • Correct refractory (vasodilatory) hypotension
    • 15. Inadequate Oxygen Delivery Delivery of blood to the tissues Vascular diseases (volume, tone) Oxygenation of blood Severe pulmonary disease Problems with hemoglobin (anemia, MetHgb) Cardiac disease (arythmia, contractility) Oxygen uptake/use by cells Mitochondrial dysfunction (sepsis, cyanosis)
    • 16. Classifications of Shock
      • The cause
        • Hypovolemia
        • Hemorrhagic
        • Traumatic
        • Cardiogenic
        • Septic
        • Anaphylactic
        • Obstructive
        • Anemic
        • Hypoxemic
    • 17. Classifications of Shock
      • The physiologic state
        • Compensated (normal BP)
        • Uncompensated (low BP)
        • Terminal (about to die)
    • 18. Classifications of Shock
      • Cardiac output
        • Hyperdynamic
        • Hypodynamic
    • 19. Zola
      • 5 year old m/n Husky
      • 40 kg
      • Hit by car
    • 20. Zola
      • Physical examination
        • T 98.6 P 168 bpm R 38 BPM
        • MM: Pale CRT: > 2 seconds
        • Weak peripheral pulses
    • 21. Zola
      • Physical examination
        • T 98.6 P 168 bpm R 38 BPM
        • MM: Pale CRT: > 2 seconds
        • Weak peripheral pulses
        • Lung sounds increased (no crackles or wheezes)
        • Mentally depressed
    • 22. Zola
      • Physical examination
        • T 98.6 P 168 bpm R 38 BPM
        • MM: Pale CRT: > 2 seconds
        • Weak peripheral pulses
        • Lung sounds increased (no crackles or wheezes)
        • Mentally depressed
      • Is shock present?
    • 23. Zola
      • Physical examination
        • T 98.6 P 168 bpm R 38 BPM
        • MM: Pale CRT: > 2 seconds
        • Weak peripheral pulses
        • Lung sounds increased (no crackles or wheezes)
        • Mentally depressed
      • Is shock present?
    • 24. Shock
      • Immediate therapy
        • Place 2 large bore 18 g catheters
    • 25. Difficult IV Access?
      • Intraosseous catheter:
    • 26. Difficult IV Access?
      • Intraosseous catheter:
    • 27. Emergency Venous Cutdown
    • 28. Emergency Venous Cutdown
    • 29. Venous Jugular Cutdown
    • 30. Difficult IV Access?
      • Bone intraosseous gun?
    • 31.  
    • 32. Shock
      • Immediate therapy
        • Place 2 large bore 18 g catheters
        • Collect pre-treatment blood samples
    • 33. Zola: Minimum Data Base
      • Big 5 results
        • Hct 38% (37-55)
        • TS 5.5 mg/dL (6.0-7.8)
        • BUN 15-26 (<26)
        • Glu 185 mmol/L (70-120)
        • Lac 11.3 mmol/L (<2.5)
    • 34. Zola: Minimum Data Base
      • Blood pressure 76 mmHg systolic
      • ECG
    • 35. Shock Therapy for Zola
      • DO2 = C.O x CaO 2
        • Increase C.O:
          • Fluid therapy
          • Correct arrhythmia?
        • Increase CaO 2
          • Administer oxygen
          • Blood transfusion?
    • 36. Shock Therapy for Zola
      • DO2 = C.O x CaO 2
        • Increase C.O:
          • Fluid therapy
          • Correct arrhythmia?
        • Increase CaO 2
          • Administer oxygen
          • Blood transfusion?
    • 37. Shock Therapy
      • If cardiogenic shock can be ruled out, fluid resuscitation is the cornerstone of therapy for all other forms of shock
    • 38. What is a Shock Dose of Fluids?
    • 39. What is a Shock Dose of Fluids?
        • 90 ml/kg/hr in dogs
        • 40-60 ml/kg/hr in cats
    • 40. What is a Shock Dose of Fluids?
        • 90 ml/kg/hr in dogs
        • 40-60 ml/kg/hr in cats
        • Is every animal that receives the same “shock dose” going to respond in the same manner?
    • 41. What is a Shock Dose of Fluids?
        • Goal of shock fluid therapy?
    • 42. What is a Shock Dose of Fluids?
        • Goal of shock fluid therapy?
          • 1) reverse the symptoms of shock
    • 43. What is a Shock Dose of Fluids?
        • Goal of shock fluid therapy?
          • 1) reverse the symptoms of shock
          • 2) as quickly as possible
    • 44. What is a Shock Dose of Fluids?
        • Goal of shock fluid therapy?
          • 1) reverse the symptoms of shock
          • 2) as quickly as possible
          • 3) while minimizing side effects
    • 45. Fluid Resuscitation
      • This may require less than 90 ml/kg
    • 46. Fluid Resuscitation
      • This may require less than 90 ml/kg
      • May require more than 90 ml/kg
    • 47.
      • This may require less than 90 ml/kg
      • May require more than 90 ml/kg
      • May need to be given faster than 1 hour
      • 90 ml/kg/hr
      Fluid Resuscitation X
    • 48. Fluid Resuscitation
      • Calculate shock dose
      • Administer 1/4 to 1/3 the shock dose over 10 minutes (20-30 ml/kg for isotonic crystalloids)
    • 49. Fluid Resuscitation
      • Calculate shock dose
      • Administer 1/4 to 1/3 the shock dose over 10 minutes (20-30 ml/kg for isotonic crystalloids)
    • 50. Fluid Resuscitation
      • Calculate shock dose
      • Administer 1/4 to 1/3 the shock dose over 10 minutes (20-30 ml/kg for isotonic crystalloids)
      • Continue with 1/4 to 1/3 shock doses every 10 minutes……..
    • 51. Fluid Resuscitation
      • When do we stop fluid resuscitation for shock?
        • A) Animal is cardiovascularly stable
        • B) Intravascular volume is maximized
    • 52. Fluid Resuscitation
      • How do we determine when an animal is cardiovascularly stable?
    • 53. Fluid Resuscitation
      • Assess parameters that indicated the animal was unstable
    • 54. Fluid Resuscitation
      • Assess parameters that indicated the animal was unstable
      • Try to re-establish normal values for those parameters that indicated the patients was unstable
    • 55. End Points of Resuscitation
    • 56. Zola: Initial Resuscitation
      • 7.5% hypertonic saline : 4-6 ml/kg IV
    • 57. Zola: Initial Resuscitation
      • 7.5% hypertonic saline : 4-6 ml/kg IV
        • Concerns for concurrent cerebral or pulmonary edema
    • 58. Zola: Initial Resuscitation
      • 7.5% hypertonic saline : 4-6 ml/kg IV
        • Concerns for concurrent cerebral or pulmonary edema
      • Search for cause
        • low TS, low normal PCV: search for hemorrhage
    • 59. Zola
      • Abdominocentesis
        • Abdominal PCV 33%
        • Peripheral PCV 32%
    • 60. Abdominal Counterpressure
    • 61. Zola T 0 HR 186 bpm
    • 62. Zola T10 HR 154 bpm Hypertonic Saline Hydromophone Recheck: Hct 28% TS 3.8 mg/dl, Lactate 7.1mmol /L ABP: 86 mmHg
    • 63. Zola T10 HR 154 bpm Hypertonic Saline Hydromophone 30 ml/kg bolus LRS
    • 64. Zola T10 HR 154 bpm Hypertonic Saline Hydromophone 30 ml/kg bolus LRS PCV 21% TS 2.4 mg/dL ABP 98 mmHg
    • 65. Zola T10 HR 154 bpm Hypertonic Saline Hydromophone 30 ml/kg bolus LRS 2 units PRB’s
    • 66. Fluid Resuscitation
      • Animal remains unstable - how much fluid can be given before edema occurs?
    • 67. Fluid Resuscitation
      • Measure central venous pressure
          • (N = <5cm H 2 0)
          • Risk of edema increases around 10 cm H 2 0
    • 68. Fluid Resuscitation
      • How do you determine intravascular volume without a manometer?
    • 69. Fluid Resuscitation
      • How do you determine intravascular volume without a manometer?
    • 70. Estimating CVP
      • Positioning is important
        • Sternal recumbency
        • Head elevated
        • Neck gently extended
        • Shaving to visualize
        • the jugular furrow
    • 71. Estimating CVP
      • Normal animals
        • Jugular pulse < 1/3 of the way up the neck
        • Jugular distension < 1/3 of the way up the neck
    • 72. Estimating CVP
    • 73. Estimating CVP
    • 74. Fluid Resuscitation
      • What if the animal remains unstable but Intravascular volume is maximized?
    • 75. Fluid Resuscitation
      • What if the animal remains unstable but Intravascular volume is maximized?
        • Search for an underlying cause
          • Myocardial depression, electrolytes, acid base, glucose, on going hemorrhage, relative adrenal insufficiency?
        • Consider vasopressors
        • Consider emergency surgery
          • After resuscitative efforts have been exhausted
    • 76.
      • Why differentiate forms of shock?
    • 77. Tailored Therapies
      • Cardiogenic shock:
        • Reduce preload : furosemide
        • Reduce afteroad: arterial/venous vasodilators
        • Antiarrhythmia medications: lidocaine, procainomide
        • Heart rate reducers (beta blockers, digoxin, calcium channel)
        • Positive ionotropes: Dobutamine, pimobendan
    • 78. Tailored Therapies
      • Sepsis:
        • Antibiotics
        • Blood glucose concentrations
        • Surgical excision and debridement
        • Relative adrenal insufficiency: physiologic steroids
    • 79. Tailored Therapies
      • Vasodilatory shock
        • Vasopressor support
        • Epinephrine for anaphylactic shock
    • 80. Tailored Therapies
      • Hemorrhagic shock
        • Transfusion therapy
        • Possible surgical control of hemorrhage
    • 81. Summary
      • Consider the factors contributing to decreased oxygen delivery
      • Rule out cardiogenic shock
      • Start fluid resuscitation while underlying cause is sought
      • Tailor therapies once underlying cause is identified
    • 82. Questions?

    ×