Shock

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Shock

  1. 1. <ul><li>SHOCK </li></ul>
  2. 2. Outline <ul><li>Definition </li></ul><ul><li>Epidemiology </li></ul><ul><li>Physiology </li></ul><ul><li>Classes of Shock </li></ul><ul><li>Clinical Presentation </li></ul><ul><li>Management </li></ul><ul><li>Controversies </li></ul>
  3. 3. Definition <ul><li>A physiologic state characterized by </li></ul><ul><ul><li>Inadequate tissue perfusion </li></ul></ul><ul><li>Clinically manifested by </li></ul><ul><ul><li>Hemodynamic disturbances </li></ul></ul><ul><ul><li>Organ dysfunction </li></ul></ul>
  4. 4. Epidemiology <ul><li>Mortality </li></ul><ul><ul><li>Septic shock – 35-40% (1 month mortality) </li></ul></ul><ul><ul><li>Cardiogenic shock – 60-90% </li></ul></ul><ul><ul><li>Hypovolemic shock – variable/mechanism </li></ul></ul>
  5. 5. Pathophysiology <ul><li>Imbalance in oxygen supply and demand </li></ul><ul><li>Conversion from aerobic to anaerobic metabolism </li></ul><ul><li>Appropriate and inappropriate metabolic and physiologic responses </li></ul>
  6. 6. Pathophysiology <ul><li>Cellular physiology </li></ul><ul><ul><li>Cell membrane ion pump dysfunction </li></ul></ul><ul><ul><li>Leakage of intracellular contents into the extracellular space </li></ul></ul><ul><ul><li>Intracellular pH dysregulation </li></ul></ul><ul><li>Resultant systemic physiology </li></ul><ul><ul><li>Cell death and end organ dysfunction </li></ul></ul><ul><ul><li>MSOF and death </li></ul></ul>
  7. 7. Physiology <ul><li>Characterized by three stages </li></ul><ul><ul><li>Preshock (warm shock, compensated shock) </li></ul></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>End organ dysfunction </li></ul></ul>
  8. 8. Physiology <ul><li>Compensated shock </li></ul><ul><ul><li>Low preload shock – tachycardia, vasoconstriction, mildly decreased BP </li></ul></ul><ul><ul><li>Low afterload (distributive) shock – peripheral vasodilation, hyperdynamic state </li></ul></ul>
  9. 9. Pathophysiology <ul><li>Shock </li></ul><ul><ul><li>Initial signs of end organ dysfunction </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Metabolic acidosis </li></ul></ul><ul><ul><li>Oliguria </li></ul></ul><ul><ul><li>Cool and clammy skin </li></ul></ul>
  10. 10. Physiology <ul><li>End Organ Dysfunction </li></ul><ul><ul><li>Progressive irreversible dysfunction </li></ul></ul><ul><ul><li>Oliguria or anuria </li></ul></ul><ul><ul><li>Progressive acidosis and decreased CO </li></ul></ul><ul><ul><li>Agitation, obtundation, and coma </li></ul></ul><ul><ul><li>Patient death </li></ul></ul>
  11. 11. Classification <ul><li>Schemes are designed to simplify complex physiology </li></ul><ul><li>Major classes of shock </li></ul><ul><ul><li>Hypovolemic </li></ul></ul><ul><ul><li>Cardiogenic </li></ul></ul><ul><ul><li>Distributive </li></ul></ul>
  12. 12. Hypovolemic Shock <ul><li>Results from decreased preload </li></ul><ul><li>Etiologic classes </li></ul><ul><ul><li>Hemorrhage - e.g. trauma, GI bleed, ruptured aneurysm </li></ul></ul><ul><ul><li>Fluid loss - e.g. diarrhea, vomiting, burns, third spacing, iatrogenic </li></ul></ul>
  13. 13. Hypovolemic Shock <ul><li>Hemorrhagic Shock </li></ul>Crit Care. 2004; 8(5): 373–381. Lethargic Confused Anxious Normal CNS symptoms Negligible 5–15 20–30 >30 Urine output (ml/hour) >35 30–40 20–30 14–20 Respiratory rate (bpm) Decreased Decreased Decreased Normal Blood pressure >140 >120 >100 <100 Pulse rate (beats/min) >40% 30–40% 15–30% <15% Blood loss (%) >2000 1500–2000 750–1500 <750 Blood loss (ml) IV III II I Parameter
  14. 18. *
  15. 19. Cardiogenic Shock <ul><li>Results from pump failure </li></ul><ul><ul><li>Decreased systolic function </li></ul></ul><ul><ul><li>Resultant decreased cardiac output </li></ul></ul><ul><li>Etiologic categories </li></ul><ul><ul><li>Myopathic </li></ul></ul><ul><ul><li>Arrhythmic </li></ul></ul><ul><ul><li>Mechanical </li></ul></ul><ul><ul><li>Extracardiac (obstructive) </li></ul></ul>
  16. 20. Distributive Shock <ul><li>Results from a severe decrease in SVR </li></ul><ul><ul><li>Vasodilation reduces afterload </li></ul></ul><ul><ul><li>May be associated with increased CO </li></ul></ul><ul><li>Etiologic categories </li></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Neurogenic / spinal </li></ul></ul><ul><ul><li>Other (next page) </li></ul></ul>
  17. 21. Distributive Shock <ul><li>Other causes </li></ul><ul><ul><li>Systemic inflammation – pancreatitis, burns </li></ul></ul><ul><ul><li>Toxic shock syndrome </li></ul></ul><ul><ul><li>Anaphylaxis and anaphylactoid reactions </li></ul></ul><ul><ul><li>Toxin reactions – drugs, transfusions </li></ul></ul><ul><ul><li>Addisonian crisis </li></ul></ul><ul><ul><li>Myxedema coma </li></ul></ul>
  18. 24. Distributive Shock <ul><li>Septic Shock </li></ul>
  19. 27. Clinical Presentation <ul><li>Clinical presentation varies with type and cause, but there are features in common </li></ul><ul><li>Hypotension (SBP<90 or Delta>40) </li></ul><ul><li>Cool, clammy skin (exceptions – early distributive, terminal shock) </li></ul><ul><li>Oliguria </li></ul><ul><li>Change in mental status </li></ul><ul><li>Metabolic acidosis </li></ul>
  20. 30. Evaluation <ul><li>Done in parallel with treatment! </li></ul><ul><li>H&P – helpful to distinguish type of shock </li></ul><ul><li>Full laboratory evaluation (including H&H, cardiac enzymes, ABG) </li></ul><ul><li>Basic studies – CxR, EKG, UA </li></ul><ul><li>Basic monitoring – VS, UOP, CVP, A-line </li></ul><ul><li>Imaging if appropriate – FAST, CT </li></ul><ul><li>Echo vs. PA catheterization </li></ul><ul><ul><li>CO, PAS/PAD/PAW, SVR, SvO2 </li></ul></ul>
  21. 31. Treatment <ul><li>Manage the emergency </li></ul><ul><li>Determine the underlying cause </li></ul><ul><li>Definitive management or support </li></ul>
  22. 33. Manage the Emergency <ul><li>Your patient is in extremis – tachycardic, hypotensive, obtunded </li></ul><ul><li>How long do you have to manage this? </li></ul><ul><li>Suggests that many things must be done at once </li></ul><ul><li>Draw in ancillary staff for support! </li></ul><ul><li>What must be done? </li></ul>
  23. 34. Manage the Emergency <ul><li>One person runs the code! </li></ul><ul><li>Control airway and breathing </li></ul><ul><li>Maximize oxygen delivery </li></ul><ul><li>Place lines, tubes, and monitors </li></ul><ul><li>Get and run IVF on a pressure bag </li></ul><ul><li>Get and run blood (if appropriate) </li></ul><ul><li>Get and hang pressors </li></ul><ul><li>Call your senior/fellow/attending </li></ul>
  24. 35. Determine the Cause <ul><li>Often obvious based on history </li></ul><ul><li>Trauma most often hypovolemic (hemorrhagic) </li></ul><ul><li>Postoperative most often hypovolemic (hemorrhagic or third spacing) </li></ul><ul><li>Debilitated hospitalized pts most often septic </li></ul><ul><li>Must evaluate all pts for risk factors for MI and consider cardiogenic </li></ul><ul><li>Consider distributive (spinal) shock in trauma </li></ul>
  25. 37. Determine the Cause <ul><li>What if you’re wrong? </li></ul><ul><li>85 y/o M 4 hours postop S/P sigmoid resection for perforated diverticulitis is hypotensive on a monitored bed at 70/40 </li></ul><ul><li>Likely causes </li></ul><ul><li>Best actions for the first 5 minutes? </li></ul>
  26. 38. Definitive Management <ul><li>Hypovolemic – Fluid resuscitate (blood or crystalloid) and control ongoing loss </li></ul><ul><li>Cardiogenic - Restore blood pressure (chemical and mechanical) and prevent ongoing cardiac death </li></ul><ul><li>Distributive – Fluid resuscitate, pressors for maintenance, immediate abx/surgical control for infection, steroids for adrenocortical insufficiency </li></ul>
  27. 39. Controversies <ul><li>IVF Resuscitation </li></ul><ul><ul><li>Limited resuscitation in penetrating trauma </li></ul></ul><ul><ul><li>Use of hypertonic saline resuscitation in trauma </li></ul></ul><ul><ul><li>Endpoints for prolonged resuscitation </li></ul></ul><ul><li>Pressors </li></ul><ul><ul><li>Best pressors for distributive shock </li></ul></ul><ul><li>Monitoring </li></ul><ul><ul><li>Most appropriate timing and use for PA catheterization or intermittent echocardiogram </li></ul></ul>

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