Shock

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Shock

  1. 1. Shock Overview Salah Abusin, MD, MRCP Cardiology Fellow Chicago, IL Secretary GeneralSudanese American Medical Association
  2. 2. Shock• Shock is the clinical syndrome that results from inadequate tissue perfusion resulting in reduced oxygen delivery• Usually accompanied with hypotension – Mean BP < 65 – Mean BP = DBP + 1/3 Pulse pressure – Pulse Pressure= SBP - DBP
  3. 3. Cardinal Signs• Hypotension – Absolute hypotension (systolic blood pressure <90 mmHg) or – Relative hypotension (ea drop in systolic blood pressure >40 mmHg from baseline).• Oliguria – < 0.5 ml/kg/hr• Altered Mental Status• Cold Clammy Skin• Lactic Acidosis
  4. 4. Types of Shock• Hypovolemic• Cardiogenic• Septic• Other – Traumatic – Neurogenic – Hypoadrenal
  5. 5. Hemodynamic Parameters• Blood Pressure = Cardiac Output x Peripheral Resistance• Cardiac Output (COP) – is the volume of blood being pumped by the heart in one minute – Measured in liters/min – 4-8 l/min• Cardiac Index (CI) – Relates Cardiac Output to body surface area – Measures in liters/min/m2 – 2.6-4.2 l/min/m2
  6. 6. Hemodynamic Parameters• Central Venous Pressure (CVP) – The pressure of blood in the thoracic vena cava – Equivalent to the pressure in the right atrium – 5-10 mmHg
  7. 7. Hemodynamic Parameters• Pulmonary Capillary Wedge Pressure – pressure measured by wedging a pulmonary catheter with an inflated balloon into a small pulmonary arterial branch – Reflects Left ventricle End Diastolic Pressure (aka Filling Pressure) in the absence of mitral stenosis – 6-12 mmHg
  8. 8. Hypovolemic Shock• Reduced Preload due to loss of intravascular volume• Symptoms – hematemesis, hematochezia, melena, – vomiting, diarrhea, or abdominal pain.• Suggestive Signs – decreased skin turgor (in younger patients), – dry skin, dry axillae, dry tongue, or dry oral mucosa – postural hypotension, – decreased jugular venous pressure – Decreased CVP
  9. 9. Causes
  10. 10. Mild Moderate Severe<20% Blood loss 20-40% Blood >40% Blood Loss LossCool extremities Same plus: Same, plus:Increased capillary Tachycardia Hemodynamicrefill time Tachypnea instabilityDiaphoresis Oliguria Marked tachycardiaCollapsed veins Postural HypotensionAnxiety changes Mental status deterioration (coma
  11. 11. Cardiogenic Shock• Due to Pump Failure• Symptoms – Dyspnea – Chest Pain – Palpitations – History of Cardiac Disease• Signs – Diffuse Lung crackles – New murmur, gallops, or soft heart sounds – Increased JVP – Increased CVP – Diminished Distal Pulses
  12. 12. Cardiogenic Shock• Suggestive Findings on Investigations – Pulmonary Congestion on CXR – Recent or Current Ischemia on ECG – Elevated Cardiac Enzymes – Echocardiogram may demonstrate etiology
  13. 13. Cardiogenic Shock - Causes• Acute myocardial infarction – Pump failure due to Large MI – Mechanical complications • Acute MR due to papillary muscle rupture or severe dysfunction • Ventricular septal defect • Left ventricular free wall rupture • Right ventricular infarction
  14. 14. Cardiogenic Shock - Causes• End-stage cardiomyopathy• Myocarditis• Left ventricular outflow tract obstruction – Aortic stenosis – Hypertrophic obstructive cardiomyopathy• Obstruction to left ventricular filling – Mitral stenosis – Left atrial myxoma• Acute mitral regurgitation (chordal rupture)• Acute aortic insufficiency• Myocardial contusion• Prolonged cardiopulmonary bypass
  15. 15. Septic/Distributive Shock• Symptoms – dyspnea, productive cough, – dysuria, hematuria, – chills, myalgias, rashes, fatigue, malaise, – headache, photophobia• Signs – fever, – tachypnea, tachycardia, – Altered mental status, – flushing
  16. 16. Hypovolemic Shock• Cardiac Output • Decreased• PCWP • Low• CVP/RAP • Low• Blood Pressure • Low• Systemic Vascular Resistance • Increases
  17. 17. Cardiogenic Shock• Cardiac Output • reduced• PCWP • Increased• CVP/RAP • increased• Blood Pressure • Low• Systemic Vascular Resistance • Increased
  18. 18. Septic/Distributive Shock• Cardiac Output • Normal or increased• PCWP • normal• CVP/RAP • Increased or reduced• Blood Pressure • Low• Systemic Vascular Resistance • Reduced
  19. 19. Physiologic Preload Pump Afterload Tissuevariable function perfusionClinical Pulmonary Cardiac output Systemic Mixed venousmeasurement capillary vascular oxygen wedge resistance saturation pressureHypovolemic ↓ ↓ ↑ ↓Cardiogenic ↑ ↓ ↑ ↓Distributive ↓ or ↔ ↑ ↓ ↑
  20. 20. Monitoring• Admission to ICU with 1:1 Nursing• Hourly Vital Signs (as a minimum) – HR, BP, RR• Foley Catheter – Hourly measurement of urine output• Monitoring of Mental Status• Central Venous Access• Invasive BP Monitoring
  21. 21. Central Venous Access• Use – Large Volume Resuscitation if inadequate peripheral access (i.e. >18G in a proximal vein) – Administration of Vasopressors – Measurement of CVP & Central Venous Oxygen saturation• Sites – Internal Jugular Vein – Subclavian Vein
  22. 22. Invasive BP Monitoring via Peripheral Arterial Line• Uses – Accurate measurement of BP • Sphygmomanometer less accurate in shock, and when vasopressors are being used – Frequent Arterial Blood Gas Sampling • In patients on mechanical ventilators &/or Respiratory Failure – Alternative to venipuncture if central venous access is not in place
  23. 23. Pulmonary Artery Catheterization• Diagnosis of Type of Shock• Direct Measurement of – Cardiac Output – Pulmonary Capillary Wedge Pressure – Mixed Venous Oxygen Saturation• Calculate the Systemic Vascular Resistance
  24. 24. Thank You

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