Basic Principles of Critical Care

1. SHOCK
Gradian Health Systems
Basic Principles of Critical Care
CARDIOVASCULAR SYSTEM

2. Disclaimer
Basic Principles of Critical Care Training I Shock
Disclaimer: Gradian Health Systems cannot provide formal recommendations or indications
regarding medical care and clinical service delivery. The tables, checklists, and other clinical
documents referenced in this training have not been validated in all settings. These documents are
intended to serve as examples only. We recognize that all clinical training content and activities
must be customized to meet the needs of each facility and its clinical staff, factoring in available
resources, practitioner skill level, and other environmental considerations.
For any questions regarding the contents or applications of this training,
please contact Gradian Health Systems:
40 W 25th St, 6th Floor
New York, NY 10010 USA
+1 212-537-0340
training@gradianhealth.org

3. Module 3
Gradian Health Systems
Basics Principles of Critical Care
Cardiovascular System

4. Module 3: Cardiovascular System
MODULE OVERVIEW
Lesson 1 I Cardiovascular System Anatomy and Physiology
Lesson 2 I Hemodynamic Monitoring
Lesson 3 I Shock
Lesson 4 I Fluid Replacement
Lesson 5 I Vasoactive Medications
Lesson 6 I Basic ECG Interpretation
Basic Principles of Critical Care Training I Shock

5. Components of the Gradian CCV SystemLesson 3: Shock
Lesson Objectives
• Differentiate between the different categories of shock
• Related management of the different types of shock
Basic Principles of Critical Care Training I Shock

6. Components of the Gradian CCV SystemLesson 3: Shock
Key Concepts
• Classification of shock
• Management of shock
Basic Principles of Critical Care Training I Shock

7. Components of the Gradian CCV SystemShock
Shock
A state of circulatory failure that results in tissue hypoperfusion and hypoxia
Classifications of Shock
1. Distributive shock
• Examples: septic shock; neurogenic; anaphylaxis
2. Cardiogenic shock
• Examples: arrhythmic; mechanical; cardiomyopathy
3. Hypovolemic shock
• Examples: hemorrhagic; non-hemorrhagic
4. Obstructive shock
• Examples: pulmonary embolism; tension pneumothorax
Basic Principles of Critical Care Training I Shock

8. Components of the Gradian CCV SystemShock
Distributive Shock
• A state of shock due to hypovolemia resulting from redistribution of
intravascular fluid
• May also result from excessive vasodilation
• Septic shock and anaphylaxis are the most common forms of distributive
shock
• In most cases, inflammatory mediators are significant factors in the clinical
picture
Basic Principles of Critical Care Training I Shock

9. Components of the Gradian CCV SystemShock
Distributive Shock
History and physical examination are directed towards signs and symptoms of
infection or allergens to determine the cause of the shock. Some findings on
physical examination will include:
• Altered mental status
• Tachycardia and tachypnea
• Hypotension
• Warm extremities with bounding pulses in early shock
• Hypo or hyperthermia
• Decreased urine output
• Low oxygen saturation
Basic Principles of Critical Care Training I Shock

10. Components of the Gradian CCV SystemShock
Distributive Shock Management
• Airway and breathing
• Oxygen therapy and/or intubation with ventilation
• Circulation
• Wide bore IV access
• ECG, CVP and BP monitoring
• Fluid bolus 250-500 mls
• Use of vasopressors (e.g. epinephrine or norepinephrine)
Basic Principles of Critical Care Training I Shock

11. Components of the Gradian CCV SystemShock
Distributive Shock Management
• Investigations
• Lab work to identify tissue injury and infection site – may include blood
cultures, blood gas, lactate etc.
• Chest X-ray
• Ultrasound
• Echocardiography
Basic Principles of Critical Care Training I Shock

12. Components of the Gradian CCV SystemShock
Cardiogenic Shock
A state where tissue hypoperfusion results from cardiac dysfunction. The causes
of impaired cardiac dysfunction are:
• Acute myocardial infarction
• Arrhythmias (brady and tachy arrhythmias)
• Mechanical obstruction (e.g. stenosis of valves)
The cardiac dysfunction results in reduced cardiac output and blood pressure.
Primary symptoms include:
• Impaired level of consciousness
• Cool extremities
• Reduced urine output
• Dyspnea and pulmonary congestion
Basic Principles of Critical Care Training I Shock

13. Components of the Gradian CCV SystemShock
Cardiogenic Shock Management
• Airway and breathing
• Oxygen therapy and/or intubation with ventilation
• Circulation
• Wide bore IV access
• ECG, CVP and BP monitoring
• Fluid bolus 250-500 mls
• Use of vasopressors (e.g. epinephrine or norepinephrine)
Basic Principles of Critical Care Training I Shock

14. Components of the Gradian CCV SystemShock
Cardiogenic Shock Management
• Investigations
• 12-lead ECG
• Lab work – full blood count, blood gas, lactate, blood sugar, cardiac
enzymes, etc.
• Chest X-ray
• Ultrasound
• Echocardiography
• Coronary reperfusion (PCI) for those with indications
Basic Principles of Critical Care Training I Shock

15. Components of the Gradian CCV SystemShock
Cardiogenic Shock Management
• Drugs
• Used according to indication
• Aspirin (160-325 mg)
• Nitrates and morphine if there is chest pain
• Contraindicated if SBP < 90 mmHg
• Beta blockers
• Anticoagulants
Basic Principles of Critical Care Training I Shock

16. Components of the Gradian CCV SystemShock
Hypovolemic Shock
• Shock due to loss of intravascular volume, either from hemorrhagic or non-
hemorrhagic causes
• Hemorrhagic causes can either be traumatic or non-traumatic
• Common non-traumatic include aortic rupture, obstetric hemorrhage and
gastrointestinal hemorrhage
• Hemorrhagic hypovolemia can result from injuries and burns
• Results in reduction in the preload, therefore a drop in cardiac output
• Coagulation disturbances can occur, especially in the context of polytrauma
Basic Principles of Critical Care Training I Shock

17. Components of the Gradian CCV SystemShock
Hypovolemic Shock Management
• Airway and breathing
• Oxygen therapy and/or intubation with ventilation
• Circulation
• Wide bore IV access
• ECG, CVP and BP monitoring
• Crystalloid fluid bolus 250mls - 2L
• Control of bleeding
• Blood transfusion (red blood cells, whole blood, platelets, fresh frozen
plasma, and coagulation factors)
• Use of vasopressors (e.g. epinephrine or norepinephrine, dopamine)
Basic Principles of Critical Care Training I Shock

18. Components of the Gradian CCV SystemShock
Hypovolemic Shock Management
• Investigations
• Lab work – full blood count, grouping and crossmatching, blood gas,
lactate, blood sugar, coagulation profile
• Chest X-ray
• Ultrasound
• Echocardiography
• Surgery to control bleeding (if indicated)
• Drugs
• Used according to indication
• Tranexamic acid
Basic Principles of Critical Care Training I Shock

19. Components of the Gradian CCV SystemShock
Obstructive Shock
• Results from obstruction of the blood vessels or the heart
• Common causes: tension pneumothorax, pericardial tamponade, massive
pulmonary embolism, and high PEEP during ventilation
• Symptoms like those of cardiogenic shock
• Important to distinguish between the cardiogenic and obstructive shock as
treatment is not the same
• History and physical examination is important to confirm obstructive shock
Basic Principles of Critical Care Training I Shock

20. Components of the Gradian CCV SystemShock
Obstructive Shock Management
• Airway and breathing
• Oxygen therapy
• Circulation
• Wide bore IV access
• ECG, CVP and BP monitoring
• Crystalloid fluid bolus 250mls - 2L
• Relief of obstruction, depending on the cause
• Needle decompression (tension pneumothorax) and chest tube insertion
• Pericardiocentesis (drainage of pericardial fluid)
• Anticoagulation and/or thrombolysis (pulmonary embolism)
• Reduction of PEEP
Basic Principles of Critical Care Training I Shock

21. Components of the Gradian CCV SystemShock
Obstructive Shock Management
• Investigations
• Lab work – full blood count, blood gas, lactate, blood sugar, coagulation
profile
• Chest X-ray
• Ultrasound
• Echocardiography
Basic Principles of Critical Care Training I Shock

22. Components of the Gradian CCV SystemLesson 3: Summary
There are four categories of shock:
• Distributive
• Cardiogenic
• Hypovolemic
• Obstructive
Distinguishing between the various types of shock is important to ensure correct
management and tp prevent morbidity and mortality.
Basic Principles of Critical Care Training I Shock