Conshock

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Conshock

  1. 1. Shock
  2. 2. Definition <ul><li>Multi system organ hypoperfusion </li></ul><ul><li>Tissue hypoperfusion </li></ul>
  3. 3. Rapid Clinical Evaluation <ul><li>Mean BP < 60mmHg or SBP < 90 mmHg </li></ul><ul><li>Altered mental status </li></ul><ul><li>Oliguria (< 30 cc/hr) </li></ul><ul><li>Lactic acidosis </li></ul>
  4. 4. Cardiogenic Shock (1) <ul><li>Left ventricular failure </li></ul><ul><ul><li>Systolic dysfunction </li></ul></ul><ul><ul><li>Diastolic dysfunction </li></ul></ul><ul><ul><li>Valvular dysfunction </li></ul></ul><ul><ul><li>Cardiac dysrhythmias </li></ul></ul><ul><li>Right ventricular failure </li></ul>
  5. 5. Cardiogenic Shock (2) <ul><li>Low cardiac output: </li></ul><ul><ul><li>Echo / radionuclear study: Reduced EF; thermodilution: CI < 2.2 L/min/m2 </li></ul></ul><ul><li>Elevated LVEDP: </li></ul><ul><ul><li>PA cath: Elevated CVP, RAP, PCWP (> 18mmHg) </li></ul></ul><ul><li>PE: </li></ul><ul><ul><li>Hypotension, JVE(+), basal rales, S3 </li></ul></ul>
  6. 6. Decreased Venous Return <ul><li>Hypovolemic shock </li></ul><ul><li>Neurogenic shock </li></ul><ul><li>Compression of heart </li></ul><ul><li>Obstruction of veins </li></ul>
  7. 7. Hypovolemic Shock <ul><li>Decreased intravascular volume – decreased venous return </li></ul><ul><li>Endogenous catecholamines compensate up to 25% reduction in intravascular volume </li></ul><ul><li>Orthostasis: BP drops 10 mmHg, PR rises 30 beats/min. </li></ul><ul><li>“ No reflow” phenomenon: > 40% blood loss > 2hr – cannot be resuscitated! </li></ul>
  8. 8. Shock in Trauma <ul><li>Hypovolemia </li></ul><ul><li>“ Third spacing” </li></ul><ul><li>Inflammatory mediators – SIRS (resembling septic shock) </li></ul><ul><li>Myocardial depressant substances </li></ul><ul><li>Myocardial contusion </li></ul>
  9. 9. Neurogenic Shock <ul><li>Decreased tone of venous capacitance bed – decreased venous return </li></ul><ul><li>E.g. C-spine cord injuries </li></ul>
  10. 10. Compression of the Heart <ul><li>Cardiac tamponade, tension pneumothorax – decreased venous return </li></ul><ul><li>PE: JVE (+), high RA pressure </li></ul><ul><li>Cardiac tamponade: </li></ul><ul><ul><li>Echo: Pericardial fluid, diastolic collapse of atria and RV, inspiratory right-to-left septal shift. </li></ul></ul><ul><ul><li>PA cath: Equal RA, RV diastolic, PA diastolic, and PA occlusion pressures </li></ul></ul>
  11. 11. Obstruction of Veins <ul><li>Decreased venous return </li></ul><ul><li>IVC obstruction </li></ul><ul><li>SVC obstruction </li></ul><ul><li>Tension pneumothorax </li></ul>
  12. 12. Septic Shock (1) <ul><li>Reduced arterial vascular tone and reactivity – high cardiac output hypotension </li></ul><ul><li>Septic shock: 2/3  G(-) bacilli </li></ul><ul><li>G(-) bacteremia: 1/3  Septic shock </li></ul><ul><li>Lactic acidosis </li></ul><ul><ul><li>Abnormal distribution of blood flow – mismatch between O2 supply and demand </li></ul></ul><ul><ul><li>Cellular defect in metabolism </li></ul></ul>
  13. 13. Septic Shock (2) <ul><li>Hypoperfusion </li></ul><ul><ul><li>Redistribution of blood flow (major) </li></ul></ul><ul><ul><li>Myocardial depressant factor of sepsis (minor) </li></ul></ul><ul><ul><li>Non-survivors  Diastolic dysfunction </li></ul></ul>
  14. 14. Septic Shock (3) <ul><li>Treatment: </li></ul><ul><ul><li>Mainstay: IV crystalloids + Early antibiotics </li></ul></ul><ul><ul><li>Surgical drainage of abscesses </li></ul></ul><ul><ul><li>Vassopressors: Dopamine / Levophed </li></ul></ul><ul><ul><li>Colloids: Be cautious in ARDS </li></ul></ul><ul><ul><li>Steroids: Not recommended </li></ul></ul><ul><ul><li>Antiendotoxin antibodies </li></ul></ul>
  15. 15. Initial Management <ul><li>Primary survey </li></ul><ul><ul><li>A – B – C </li></ul></ul><ul><li>Resuscitation </li></ul><ul><ul><li>O2 – IV – Monitors </li></ul></ul><ul><li>Vital signs </li></ul><ul><ul><li>BP – PR - RR </li></ul></ul><ul><li>Etiology </li></ul><ul><ul><li>Rate – Volume – Pump </li></ul></ul>
  16. 16. Primary survey: A – B – C <ul><li>Airway intubation + Mechanical ventilation </li></ul><ul><ul><li>Airway protection </li></ul></ul><ul><ul><li>External masks  O2 delivery not reliable </li></ul></ul><ul><ul><li>Increase FiO2 and PEEP </li></ul></ul><ul><ul><li>Sedation and paralysis (respiratory muscle fatigue  Metabolic acidosis) </li></ul></ul><ul><ul><li>Intervene early and fast if unconscious, RR > 30/min, abdominal paradoxical respiratory motion, accessory muscle use </li></ul></ul>
  17. 17. Resuscitation: O2 – IV – Monitors <ul><li>O2 </li></ul><ul><ul><li>Airway intubation + Mechanical ventilation </li></ul></ul><ul><li>IV </li></ul><ul><ul><li>Hypovolemia: 2 or more 16# or larger IV, large bore CVP (trauma kit), X-match blood products </li></ul></ul><ul><li>Monitors </li></ul><ul><ul><li>ECG; BP (A-line); SpO2; Foley; NG </li></ul></ul><ul><ul><li>ABGs; echocardiography </li></ul></ul>
  18. 18. Volume or Vasoactive drugs? <ul><li>Cardiologist-intensivists: </li></ul><ul><ul><li>PA cath and vasopressors as priority </li></ul></ul><ul><ul><li>Delay volume expansion </li></ul></ul><ul><li>Surgical/anesthesiologist-intensivists: </li></ul><ul><ul><li>Vasopressors accompany volume therapy to raise BP quickly </li></ul></ul><ul><li>Common pitfalls: </li></ul><ul><ul><li>Inadequate circulating volume long after the 1 st hour of urgent resuscitation! </li></ul></ul>
  19. 19. Volume or Vasoactive drugs? <ul><li>Working diagnosis of cardiogenic shock: </li></ul><ul><ul><li>250 cc NS in 20 min </li></ul></ul><ul><ul><li>Frequent reassessments for end points: </li></ul></ul><ul><ul><ul><li>Increased BP and pulse pressure </li></ul></ul></ul><ul><ul><ul><li>Increased JVP or CVP, new gallop or extra heart sounds, lung edema </li></ul></ul></ul><ul><ul><li>Vasoactive drugs only after volume infusion be pushed to a discernable “to much”: </li></ul></ul><ul><ul><ul><li>Dobutamine 2-10 ug/kg/min (inotropy) </li></ul></ul></ul><ul><ul><ul><li>Dopamine 2-5 ug/kg/min (renal perfusion) </li></ul></ul></ul>
  20. 20. Definitive Therapy <ul><li>Hypovolemia: Volume expansion </li></ul><ul><li>Hemorrhage: Surgical/endoscopic hemostasis </li></ul><ul><li>Sepsis: Volume + Antibiotics +/- Drainage </li></ul><ul><li>AMI: Surgical reperfusion / IABP </li></ul><ul><li>Tamponade: Pericardiocentesis </li></ul><ul><li>Pneumothorax: Pleurocentesis/thoracostomy </li></ul><ul><li>Bradycardia: TCP/Atropine/Dopamine/Adrenaline </li></ul><ul><li>Tachycardia: Cardioversion/Lidocaine/verapamil </li></ul><ul><li>Lactic acidosis: Hyperventilation (PaCO2 to 25mmHg), NaHCO3 if pH < 7.0, hemodialysis. </li></ul>
  21. 21. Case <ul><li>55Y female: Confused, BP 80/50, PR 135, RR 24, dry skin, clear BS, cold limbs. </li></ul><ul><li>Tx: 3L NS total </li></ul><ul><ul><li>BP normalize  Hypovolemia </li></ul></ul><ul><ul><ul><li>Seek bleeder or cause of dehydration </li></ul></ul></ul><ul><ul><li>BP low, fever 39.5C, warm limbs  Sepsis </li></ul></ul><ul><ul><ul><li>Antibiotics, septic work-up, +/- Dopamine </li></ul></ul></ul><ul><ul><li>BP low, rales, S3, JVE, cool limbs  Cardiogenic shock </li></ul></ul><ul><ul><ul><li>Vasoactive drugs </li></ul></ul></ul>
  22. 22. Goal of Therapy (1) <ul><li>Tables of normal hemodynamic values are frequently misleading: </li></ul><ul><ul><li>E.g. Septic shock: </li></ul></ul><ul><ul><ul><li>“ Numerically normal” CO  too low </li></ul></ul></ul><ul><ul><ul><li>“ Numerically normal” BP  over-hydration (lung edema, ARDS) or over-vasoconstriction (increased O2 demand and worsened tissue hypoxia) </li></ul></ul></ul>
  23. 23. Goal of Therapy (2) <ul><li>Intubation + Mechanical ventilation +/- Sedation / paralysis  to rest respiratory muscles </li></ul><ul><li>PEEP  Reduced venous return in cardiogenic shock  Increased cardiac output </li></ul><ul><li>Adequate volume infusions  to make vasoactive drugs more effective </li></ul><ul><li>Adequate Hb / Hct  to increase O2-carrying capacity </li></ul><ul><li>Hyperventilate / NaHCO3/ HD  to correct lactic acidosis </li></ul>
  24. 24. Outcome <ul><li>Cardiogenic shock </li></ul><ul><ul><li>90% mortality with medical tx alone </li></ul></ul><ul><ul><li>Predictors: blood lactate (> 5 mmol/L), cardiac output, arterial pressure </li></ul></ul><ul><li>Septic shock </li></ul><ul><ul><li>MSOF  mortality > 60% </li></ul></ul><ul><ul><li>Predictors: cardiac output, high blood bacterial concentrations, failure to mount a febrile response, age, preexisting illness </li></ul></ul>
  25. 25. Thank You

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