2. Goals and objectives
• Definition of shock
• Understand the basic physiology of shock
• Understand the different types of shock
• Understand acute management of shock
3. “A momentary pause in the act of
death”
JC Warren – 1895
“A rude unhinging of the
machinery of life”
SG Gross - 1872
WHAT IS SHOCK?
4. What is Shock?
• A physiologic state characterized by
• Decrease in tissue perfusion
• Inadequate oxygen delivery to meet
metabolic needs
• BP is in classic definition suboptimal
8. Case 1
27 y/o male crashed his
motorcycle at a high rate
of speed
VS: BP 80/ palp
HR 122
Physical Exam:
pt. is diaphoretic,
agitated, abdomen is
tense and distended
9. Hemorrhagic Shock: Epidemiology
• 30k deaths annually (U.S.)
– 50% in 1st few minutes
– Remaining deaths die < 12hr
– >12 hr, generally not due to hemorrhage
• Leading cause of death age 1-44
• In the next 30 min. (U.S.)
– 6 people will die
– 1000 people will have a disabling injury
– $24 million will be spent on these patients
10. Hemorrhagic Shock: how would
they present ?
• Tachycardia
• Tachypnea
• Weak / thready pulse
• Hypotension
• Cool & Clammy
• Anxiety
• ↓↓ Urine output
11. Hemorrhagic Shock: immediate
actions?
• ABCs
• STOP THE
BLEEDING!!!!!!
• 2 large bore IV’s (14
or 16 gauge)
• Fluid resuscitation
until SBP > 100mmHg
– 2L initial infusion
Consider blood products
13. Case 2
• 18 y/o male diving into
lake
• Friends say he dove into
shallow area
• Was initially unresponsive
but now complaining of
inability to feel his legs
• BP 70/40
• HR 40’s
What kind of
shock does this
patient have
14. Neurogenic Shock
• Functional
hypovolemia w/o
compensation
• Paralysis of
sympathetic chain
controlling vascular
tone
• Distributive shock
• Occurs in pts w/SCI
above T6
• ↓SVR & bradycardia
from unopposed
parasympathetic
input to SA node
16. Immediate management?
• Volume Resuscitation (1-2 L)
• Vasopressors
– Norepinephrine
– Phenylephrine
Avoid vagal stimulation
Atropine 0.5mg IV
Rule out other forms of shock before
considering neurogenic shock as a
diagnosis
18. Case 3
• 77 y/o female c/o
increased lethargy,
confusion.
• Vitals: BP 90/40
• HR 110, Temp:38.9
19. Immediate actions at this time?
• ABCs
• IV fluids
• Critical labs :Lactate
• Give BROAD
Spectrum antibiotics
• Assess fluid
status/hemodynamic
monitoring
(CVP,US,Art line)
20. Sepsis
• 750,000 cases/yr of severe sepsis in US
• 215,000 deaths/yr directly related to
sepsis
• Tenth leading cause of death in USA
• Rate of sepsis cases is increasing faster
than the population
• 37% of severe sepsis patients come
through the ED
21. SIRS
• S ystemic
• I nflammtory
• R esponse
• S yndrome
Systemic response to
insult resulting in ≥2
of the following
-Temp > 38 C or < 35 C
-HR ≥ 90 bpm
-RR > 20 breaths per
minute or paC02 < 32
mm Hg
-WBC > 12,000 or <
4,000 mm3 or > 10%
bands
23. INSULT
SIRS
Sepsis
Severe
Sepsis
Septic
Shock
ED to ICU: a continuum….
SIRS w/ presumed
or confirmed infection
Sepsis with ≥1 sign
of organ failure
Sepsis w/ Refractory hypotension
despite fluid rescucitation
Bone et al Chest 1992
24. Early Goal Directed Therapy
(in a nutshell…)
• Early aggressive management of severe
sepsis/septic shock
• Early aggressive fluid resuscitation
coupled with early initiation of broad
spectrum antibiotics
• Intensive hemodynamic monitoring and
optimization
25. Severe sepsis confirmed
Supplemental oxygen ±
endotracheal intubation and
mechanical ventilation
Central venous and
arterial catheterization
CVP
Crystalloid
Colloid
<8 mm Hg
MAP
8-12 mm Hg
Vasopressor
<65 mm Hg
>90 mm Hg
ScvO2
≥65 and ≤90 mm Hg
Goals
achieve
d
≥70%
Hospital admission
Yes
No
Sedation and/or
paralysis
(if intubated)
Transfusion of red cells to
hematocrit ≥30%
<70%
Dobutamine
<70%
≥70%
Edwards Lifesciences
Rivers et al NEJM 2001
In hospital mortality/
30 day mortality
and 60 day
mortality show %16
benefit in EGDT
treatment group
27. Case 4
• 26 y/o female
• Presents to ED in
acute respiratory
distress from cafeteria
HEENT-swollen lips
Lungs-diminshed bilateral
CV-tachycardic
Abd-soft
Ext- diffuse erythematous
rash
HR 118
BP 80/40
What would you immediately do now?
28. Anaphylaxis
• Generally IgE-
mediated reactions
w/release of mast cell
products
• Chemical mediators
vaso-active
– smooth muscle spasm
– bronchospasm
– mucosal edema
– inflammation
– increased capillary
permeability
• Incidence of
anaphylaxis w/shock-
8:100,000
– 10% food
– 18% drugs
– 59%
invenomations/insect
Yocurn et al J Clin Imm 1999
29. Anaphylaxis: Immediate
Management
• Epinephrine Dose
– 0.2-0.5 ml of 1:1000
dilution IM
– 0.1mg (1:10,000
dilution) IV in severe
cases
• Antihistamines
– H1 (Diphenhydramine
50mg IV)
– H2 (Ranitadine 300mg
IV)
• Intubate early if
needed
• Corticosteroids
(Decadron 10mg IV)
– 20% of patients will
have recurrent sxs
w/in 8hrs
31. Case #5
• 56 y/o male
• Presents cool
clammy diaphoretic
after clutching his
chest and dropping
to the floor
• BP 60/palp
• HR 100
Lungs: diffuse crackles
throughout
HEENT- prominent JVD
Cardiac exam-
holosystolic murmur at
apex
Ext: cool
32.
33. Cardiogenic shock
• Most common
etiology is acute
myocardial infarction
• >40% of myocardium
effected
• 6-8% of all AMI
• Mortality of 80%
35. Cardiogenic Shock: Other Etiologies
• Complications of MI:
– Papillary Mm Rupture
– Ventricular aneurysm
– Ventricular septal
rupture
• Other causes:
– Cardiomyopathies
– Tamponade
– Tension
pneumothorax
– Arrhythmias
– Valve disease
– Aortic dissection
36. Cardiogenic shock
management?
• Airway managment
(intubate if necessary)
• If due to AMI
-ASA
-Heparin
-NTG
*Fluid bolus challenge
• Inotropes
-dobutamine –if SBP
>70mmhg
-dopamine- if SBP < 70
mmhg
37. Management of Cardiogenic Shock:
AHA/ACC Recommendation
Early revascularization is a Class I
recommendation for ST elevation/Q
wave or new LBBB acute MI.
If due to mechanical complications
VSD/ruptured valve- Intraoartic
balloon pump and early surgical
repair
39. Case #6
• 50 y/o male with a 40 pack year of
smoking presents with acute onset
shortness of breath while taking a drag off
a cigarette.
• VS HR 120, BP 80/40, sat 99%
• EXAM: right lung breath sounds absent
• What is the most likely diagnosis?
40. What are your immediate actions ?
• Needle decompression
• Chest tube thoracostomy
41. Obstructive shock
• Mechanical obstruction causing impaired
filling or emptying of the heart or great
vessels
• what are other mechanisms to develop
obstructive shock?
cardiac tamponade
massive pulmonary embolism
43. Summary
• Common factor in ALL forms of shock is
global tissue hypoperfusion
• Early recognition of shock is vital
• Aggressive correction and monitoring of
patients in shock can improve outcomes
