This document provides an overview of shock, including:
1) Definitions of shock as a syndrome resulting in inadequate tissue perfusion and oxygenation affecting multiple organ systems.
2) Physiology of shock as a complex cascade involving hypoperfusion, inflammation, and organ dysfunction.
3) Treatment approach focusing on airway control, circulation optimization, oxygen delivery, and achieving resuscitation end points.
4) Types of shock like hypovolemic, septic, cardiogenic, anaphylactic, neurogenic, and obstructive shock are described with examples.
A simple presentation on hypokalemia. The most common electrolyte disorder in the Critical Care practice.The presentation is based on a mortality and morbidity case report and discussion. It covers all the basic aspects of understanding the causes of hypokalemia in ICU and its management. Target audience are residents ICU and ER but all health care workers can benefit.
A simple presentation on hypokalemia. The most common electrolyte disorder in the Critical Care practice.The presentation is based on a mortality and morbidity case report and discussion. It covers all the basic aspects of understanding the causes of hypokalemia in ICU and its management. Target audience are residents ICU and ER but all health care workers can benefit.
* Fluid resuscitation is mandatory in shock from traumatic haemorrhage * Massive use of resuscitative fluids following injury is now being disputed * Adequate resuscitation is no longer judged by presence of normal vital signs * Normalcy of organ and tissue specific measured values are to be achieved * Search for a single endpoint that works for all trauma patients, is unrealistic * Resuscitate with appropriate fluid, in appropriate amount, at appropriate time
DIC is one condition that always trouble patients and doctor, though its a nightmare for any clinician , its also a potent question in both UG and PG exams. I hope this will help you in answering those questions well.
* Fluid resuscitation is mandatory in shock from traumatic haemorrhage * Massive use of resuscitative fluids following injury is now being disputed * Adequate resuscitation is no longer judged by presence of normal vital signs * Normalcy of organ and tissue specific measured values are to be achieved * Search for a single endpoint that works for all trauma patients, is unrealistic * Resuscitate with appropriate fluid, in appropriate amount, at appropriate time
DIC is one condition that always trouble patients and doctor, though its a nightmare for any clinician , its also a potent question in both UG and PG exams. I hope this will help you in answering those questions well.
Definition of shock
Initial Assessment of shock – ABC
Types of Shock
Stages of Shock
Physiologic Determinants of Shock
Common Features of Shock
Work-up of shock
General Approach to management of shock
Shock: A review of hypovolemic, septic, cardiogenic and neurogenic shock.Joseph A. Di Como MD
A review of different types of shock encountered in patients. Hypovolemic, septic, cardiogenic and neurogenic shock. We review etiology, pathophysiology, diagnosis, treatment and how to differentiate between them.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
3. Definition of Shock
• Multifactorial syndrome resulting in inadequate
tissue perfusion and cellular oxygenation
affecting multiple organ systems……
Machinery of life
• Perfusion may be decreased either
systemically or limited to regional
maldistribution.
4. Definition of Shock
• Regardless of etiology or severity, all forms of
shock have the commonality of perfusion
inadequate to meet metabolic demands at the
cellular level.
• Decreased organ perfusion leads to tissue
hypoxia, anaerobic metabolism, activation of
an inflammatory cascade, and eventual vital
organ dysfunction.
5. Definition of Shock
• Shock can occur with a normal
blood pressure and hypotension
can occur without shock.
7. PHYSIOLOGY
Local vasoconstriction, thrombosis,
regional malperfusion, release of
superoxide radicals, and direct
cellular damage Activation of
neutrophils and release of
proinflammatory cytokines.
8. Understanding Shock
• Inadequate systemic oxygen delivery
activates autonomic responses to maintain
systemic oxygen delivery
• Sympathetic nervous system
• NE, epinephrine, dopamine, and cortisol release
• Causes vasoconstriction, increase in HR, and increase of
cardiac contractility (cardiac output)
• Renin-angiotensin axis
• Water and sodium conservation and vasoconstriction
• Increase in blood volume and blood pressure
9. Understanding Shock
• Cellular responses to decreased systemic oxygen
delivery
• ATP depletion → ion pump dysfunction
• Cellular edema
• Hydrolysis of cellular membranes and cellular
death
• Goal is to maintain cerebral and cardiac perfusion
• Vasoconstriction of splanchnic, musculoskeletal,
and renal blood flow
• Leads to systemic metabolic lactic acidosis that
overcomes the body’s compensatory mechanisms
10. Global Tissue Hypoxia
• Endothelial inflammation and disruption
• Inability of O2 delivery to meet demand
• Result:
• Lactic acidosis
• Cardiovascular insufficiency
• Increased metabolic demands
11. Multiorgan Dysfunction
Syndrome (MODS)
• Progression of physiologic effects as
shock ensues
• Cardiac depression
• Respiratory distress
• Renal failure
• DIC
• Result is end organ failure
12. • ABCs
• Cardiorespiratory monitor
• Pulse oximetry
• Supplemental oxygen
• IV access
• ABG, labs
• Foley catheter
• Vital signs including rectal temperature
Approach to the Patient in Shock
14. Further Evaluation
• CT of head/sinuses
• Lumbar puncture
• Wound cultures
• Acute abdominal series
• Abdominal/pelvic CT or US
• Cortisol level
• Fibrinogen, FDPs, D-dimer
15. Approach to the Patient in Shock
• History
• Recent illness
• Fever
• Chest pain, SOB
• Abdominal pain
• Comorbidities
• Medications
• Toxins/Ingestions
• Recent hospitalization or
surgery
• Baseline mental status
• Physical examination
• Vital Signs
• CNS – mental status
• Skin – color, temp,
rashes, sores
• CV – JVD, heart sounds
• Resp – lung sounds, RR,
oxygen sat, ABG
• GI – abd pain, rigidity,
guarding, rebound
• Renal – urine output
16. Is This Patient in Shock?
• Patient looks ill
• Altered mental status
• Skin cool and mottled or
hot and flushed
• Weak or absent
peripheral pulses
• SBP <110
• Tachycardia
Yes!
These are all signs and
symptoms of shock
17. Shock
• Do you remember how to
quickly estimate blood
pressure by pulse?
60
80
70
90
• If you palpate a pulse,
you know SBP is at
least this number
18. Goals of Treatment
• ABCDE
• Airway
• control work of Breathing
• optimize Circulation
• assure adequate oxygen Delivery
• achieve End points of resuscitation
19. Airway
• Determine need for intubation but remember:
intubation can worsen hypotension
• Sedatives can lower blood pressure
• Positive pressure ventilation decreases preload
• May need volume resuscitation prior to
intubation to avoid hemodynamic collapse
20. Control Work of
Breathing
• Respiratory muscles consume a significant
amount of oxygen
• Tachypnea can contribute to lactic acidosis
• Mechanical ventilation and sedation
decrease WOB and improves survival
21. Optimizing Circulation
• Isotonic crystalloids
• Titrated to:
• CVP 8-12 mm Hg
• Urine output 0.5 ml/kg/hr (30 ml/hr)
• Improving heart rate
• May require 4-6 L of fluids
• No outcome benefit from colloids
22. Maintaining Oxygen Delivery
• Decrease oxygen demands
• Provide analgesia and anxiolytics to relax muscles
and avoid shivering
• Maintain arterial oxygen saturation/content
• Give supplemental oxygen
• Maintain Hemoglobin > 10 g/dL
• Serial lactate levels or central venous oxygen
saturations to assess tissue oxygen
extraction
23. End Points of Resuscitation
• Goal of resuscitation is to maximize survival
and minimize morbidity
• Use objective hemodynamic and physiologic
values to guide therapy
• Goal directed approach
• Urine output > 0.5 mL/kg/hr
• CVP 8-12 mmHg
• MAP 65 to 90 mmHg
• Central venous oxygen concentration > 70%
25. Practically Speaking….
• Keep one eye on these patients
• Frequent vitals signs:
• Monitor success of therapies
• Watch for decompensated shock
• Let your nurses know that these
patients are critical!
27. What Type of Shock is This?
• 68 yo M with hx of HTN and DM
presents to the ER with abrupt
onset of diffuse abdominal pain
with radiation to his low back.
The pt is hypotensive,
tachycardic, afebrile, with cool
but dry skin
Types of Shock
• Hypovolemic
• Septic
• Cardiogenic
• Anaphylactic
• Neurogenic
• Obstructive
Hypovolemic Shock
30. Hypovolemic Shock
• ABCs
• Establish 2 large bore IVs or a central line
• Crystalloids
• Normal Saline or Lactate Ringers
• Up to 3 liters
• PRBCs
• O negative or cross matched
• Control any bleeding
• Arrange definitive treatment
31. Evaluation of Hypovolemic Shock
• CBC
• ABG/lactate
• Electrolytes
• BUN, Creatinine
• Coagulation studies
• Type and cross-match
• As indicated
• CXR
• Pelvic x-ray
• Abd/pelvis CT
• Chest CT
• GI endoscopy
• Bronchoscopy
• Vascular radiology
32. Infusion Rates
Access Gravity Pressure
18 g peripheral IV 50 mL/min 150 mL/min
16 g peripheral IV 100 mL/min 225 mL/min
14 g peripheral IV 150 mL/min 275 mL/min
8.5 Fr CV cordis 200 mL/min 450 mL/min
33. What Type of Shock is This?
• An 81 yo F resident of a nursing
home presents to the ED with
altered mental status. She is
febrile to 39.4, hypotensive with a
widened pulse pressure,
tachycardic, with warm
extremities
Types of Shock
• Hypovolemic
• Septic
• Cardiogenic
• Anaphylactic
• Neurogenic
• Obstructive
Septic
35. Sepsis
• Two or more of SIRS criteria
• Temp > 38 or < 36 C
• HR > 90
• RR > 20
• WBC > 12,000 or < 4,000
• Plus the presumed existence of
infection
• Blood pressure can be normal!
36. Septic Shock
• Sepsis (remember definition?)
• Plus refractory hypotension
• After bolus of 20-40 mL/Kg patient still has
one of the following:
• SBP < 90 mm Hg
• MAP < 65 mm Hg
• Decrease of 40 mm Hg from baseline
38. Pathogenesis of Sepsis
Nguyen H et al. Severe Sepsis and Septic-Shock: Review of the Literature and Emergency Department Management Guidelines. Ann Emerg Med. 2006;42:28-54.
39. Septic Shock
• Clinical signs:
• Hyperthermia or hypothermia
• Tachycardia
• Wide pulse pressure
• Low blood pressure (SBP<90)
• Mental status changes
• Beware of compensated shock!
• Blood pressure may be “normal”
40. Ancillary Studies
• Cardiac monitor
• Pulse oximetry
• CBC, Chem 7, coags, LFTs, lipase, UA
• ABG with lactate
• Blood culture x 2, urine culture
• CXR
• Foley catheter (why do you need this?)
41. Treatment of Septic
Shock
• 2 large bore IVs
• NS IVF bolus- 1-2 L wide open (if no
contraindications)
• Supplemental oxygen
• Empiric antibiotics, based on suspected
source, as soon as possible
42. Treatment of Sepsis
• Antibiotics- Survival correlates with how quickly
the correct drug was given
• Cover gram positive and gram negative bacteria
• Zosyn (Tazocin) 3.375 grams IV and ceftriaxone
(Rocephin) 1 gram IV or
• Imipenem (Tienam) 1 gram IV
• Add additional coverage as indicated
• Pseudomonas- Gentamicin or Cefepime
• MRSA- Vancomycin
• Intra-abdominal or head/neck anaerobic infections-
Clindamycin or Metronidazole
• Asplenic- Ceftriaxone for N. meningitidis, H. infuenzae
• Neutropenic – Cefepime or Imipenem
43. Persistent Hypotension
• If no response after 2-3 L IVF, start a
vasopressor (norepinephrine, dopamine,
etc) and titrate to effect
• Goal: MAP > 60
• Consider adrenal insufficiency:
hydrocortisone 100 mg IV
44. Early Goal Directed Therapy
• Septic Shock Study 2001
• 263 patients with septic shock by refractory
hypotension or lactate criteria
• Randomly assigned to EGDT or to
standard resuscitation arms (130 vs 133)
• Control arm treated at clinician’s discretion
and admitted to ICU ASAP
• EGDT group followed protocol for 6 hours
then admitted to ICU
Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med. 2001:345:1368-1377.
46. EGDT Group
• First 6 hours in ED
• More fluid (5 L vs 3.5 L)
• More transfusion (64.1% vs 18.5%)
• More dobutamine (13.7% vs 0.8%)
• Outcome
• 3.8 days less in hospital
• 2 fold less cardiopulmonary complications
• Better: SvO2, lactate, base deficit, PH
• Relative reduction in mortality (46.5%
control vs 30.5% EGDT)
47. What Type of Shock is This?
• A 55 yo M with hx of HTN,
DM presents with “crushing”
substernal CP, diaphoresis,
hypotension, tachycardia
and cool, clammy extremities
Types of Shock
• Hypovolemic
• Septic
• Cardiogenic
• Anaphylactic
• Neurogenic
• Obstructive
Cardiogenic
50. Etiologies
What are some causes of cardiogenic shock?
• AMI
• Sepsis
• Myocarditis
• Myocardial contusion
• Aortic or mitral stenosis, HCM
• Acute aortic insufficiency
51. Pathophysiology of Cardiogenic Shock
• Often after ischemia, loss of LV function
• Lose 40% of LV clinical shock ensues
• CO reduction = lactic acidosis, hypoxia
• Stroke volume is reduced
• Tachycardia develops as compensation
• Ischemia and infarction worsens
53. Treatment of Cardiogenic Shock
• Goals- Airway stability and improving
myocardial pump function
• Cardiac monitor, pulse oximetry
• Supplemental oxygen, IV access
• Intubation will decrease preload and result
in hypotension
• Be prepared to give fluid bolus
54. Treatment of Cardiogenic Shock
• AMI
• Aspirin, beta blocker, morphine, heparin
• If no pulmonary edema, IV fluid challenge
• If pulmonary edema
• Dopamine – will ↑ HR and thus cardiac work
• Dobutamine – May drop blood pressure
• Combination therapy may be more effective
• PCI or thrombolytics
• RV infarct
• Fluids and Dobutamine (no NTG)
• Acute mitral regurgitation or VSD
• Pressors (Dobutamine and Nitroprusside)
55. What Type of Shock is This?
• A 34 yo F presents to the ER after
dining at a restaurant where shortly
after eating the first few bites of her
meal, became anxious, diaphoretic,
began wheezing, noted diffuse
pruritic rash, nausea, and a
sensation of her “throat closing off”.
She is currently hypotensive,
tachycardic and ill appearing.
Types of Shock
• Hypovolemic
• Septic
• Cardiogenic
• Anaphylactic
• Neurogenic
• Obstructive
Anaphalactic
57. Anaphylactic Shock
• Anaphylaxis – a severe systemic
hypersensitivity reaction characterized by
multisystem involvement
• IgE mediated
• Anaphylactoid reaction – clinically
indistinguishable from anaphylaxis, do not
require a sensitizing exposure
• Not IgE mediated
58. What are some symptoms of anaphylaxis?
Anaphylactic Shock
• First- Pruritus, flushing, urticaria appear
•Next- Throat fullness, anxiety, chest tightness,
shortness of breath and lightheadedness
•Finally- Altered mental status, respiratory
distress and circulatory collapse
59. • Risk factors for fatal anaphylaxis
• Poorly controlled asthma
• Previous anaphylaxis
• Reoccurrence rates
• 40-60% for insect stings
• 20-40% for radiocontrast agents
• 10-20% for penicillin
• Most common causes
• Antibiotics
• Insects
• Food
Anaphylactic Shock
60. • Mild, localized urticaria can progress to full anaphylaxis
• Symptoms usually begin within 60 minutes of exposure
• Faster the onset of symptoms = more severe reaction
• Biphasic phenomenon occurs in up to 20% of patients
• Symptoms return 3-4 hours after initial reaction has cleared
• A “lump in my throat” and “hoarseness” heralds life-
threatening laryngeal edema
Anaphylactic Shock
61. Anaphylactic Shock-
Diagnosis
• Clinical diagnosis
• Defined by airway compromise, hypotension,
or involvement of cutaneous, respiratory, or GI
systems
• Look for exposure to drug, food, or insect
• Labs have no role
62. • ABC’s
• Angioedema and respiratory compromise require
immediate intubation
• IV, cardiac monitor, pulse oximetry
• IVFs, oxygen
• Epinephrine
• Second line
• Corticosteriods
• H1 and H2 blockers
Anaphylactic Shock- Treatment
63. • Epinephrine
• 0.3 mg IM of 1:1000 (epi-pen)
• Repeat every 5-10 min as needed
• Caution with patients taking beta blockers- can cause
severe hypertension due to unopposed alpha stimulation
• For CV collapse, 1 mg IV of 1:10,000
• If refractory, start IV drip
Anaphylactic Shock- Treatment
64. • Corticosteroids
• Methylprednisolone 125 mg IV
• Prednisone 60 mg PO
• Antihistamines
• H1 blocker- Diphenhydramine 25-50 mg IV
• H2 blocker- Ranitidine 50 mg IV
• Bronchodilators
• Albuterol nebulizer
• Atrovent nebulizer
• Magnesium sulfate 2 g IV over 20 minutes
• Glucagon
• For patients taking beta blockers and with refractory hypotension
• 1 mg IV q5 minutes until hypotension resolves
Anaphylactic Shock - Treatment
65. • All patients who receive epinephrine
should be observed for 4-6 hours
• If symptom free, discharge home
• If on beta blockers or h/o severe
reaction in past, consider admission
Anaphylactic Shock - Disposition
66. What Type of Shock is This?
• A 41 yo M presents to the ER
after an MVC complaining of
decreased sensation below his
waist and is now hypotensive,
bradycardic, with warm
extremities
Types of Shock
• Hypovolemic
• Septic
• Cardiogenic
• Anaphylactic
• Neurogenic
• Obstructive
Neurogenic
68. Neurogenic Shock
• Occurs after acute spinal cord injury
• Sympathetic outflow is disrupted leaving
unopposed vagal tone
• Results in hypotension and bradycardia
• Spinal shock- temporary loss of spinal reflex
activity below a total or near total spinal cord
injury (not the same as neurogenic shock, the
terms are not interchangeable)
69. • Loss of sympathetic tone results in
warm and dry skin
• Shock usually lasts from 1 to 3 weeks
• Any injury above T1 can disrupt the
entire sympathetic system
• Higher injuries = worse paralysis
Neurogenic Shock
70. • A,B,Cs
• Remember c-spine precautions
• Fluid resuscitation
• Keep MAP at 85-90 mm Hg for first 7 days
• Thought to minimize secondary cord injury
• If crystalloid is insufficient use vasopressors
• Search for other causes of hypotension
• For bradycardia
• Atropine
• Pacemaker
Neurogenic Shock- Treatment
71. Neurogenic Shock- Treatment
• Methylprednisolone
• Used only for blunt spinal cord injury
• High dose therapy for 23 hours
• Must be started within 8 hours
• Controversial- Risk for infection, GI bleed
72. What Type of Shock is This?
• A 24 yo M presents to the ED
after an MVC c/o chest pain
and difficulty breathing. On PE,
you note the pt to be
tachycardic, hypotensive,
hypoxic, and with decreased
breath sounds on left
Types of Shock
• Hypovolemic
• Septic
• Cardiogenic
• Anaphylactic
• Neurogenic
• Obstructive
Obstructive
77. Obstructive Shock
• Aortic stenosis
• Resistance to systolic ejection causes
decreased cardiac function
• Chest pain with syncope
• Systolic ejection murmur
• Diagnosed with echo
• Vasodilators (NTG) will drop pressure!
• Rx: Valve surgery
78. Identification of the hypoperfused state,
quantification of its severity and prognosis, and
rapid restoration of cellular perfusion to avoid
organ dysfunction and failure .
The challenge to the intensivist
Assessment of regional tissue perfusion by review of end-organ function can help to document the presence of shock before the late signs of systemic malperfusion are evident with their associated detrimental impact on patient outcome
SmvO2 – mixed venous oxygen saturation from a PAC
ScvO2 – central venous oxygen saturation from central line