fam med presentation

1. SHOCK

2. DEFINITION
• Profound hemodyamic and metabolic
disturbance characterized by failure of the
circulatory system to maintain adequate
perfusion of vital organs

3. Types of Shock
• Cardiogenic (intracardiac vs extracardiac)
• Hypovolemic
• Distributive
– sepsis****
– neurogenic (spinal shock)
– adrenal insufficiency
– anaphylaxis

5. Cardiogenic Shock, intracardiac
• Myocardial Injury or Obstruction to Flow
– Arrythymias
– valvular lesions
– AMI
– Severe CHF
– VSD
– Hypertrophic Cardiomyopathy

6. Presentation of Cardiogenic
Shock
• Pulmonary Edema
• JVD
• hypotensive
• weak pulses
• oliguria

7. Cardiogenic Shock, extracardiac
(Obstructive)
• Pulmonary Embolism
• Cardiac Tamponade
• Tension Pneumothorax
• Presentation will be according to underlying
disease process.

8. Hypovolemic Shock
• Reduced circulating blood volume with
secondary decreased cardiac output
– Acute hemorrhage
– Vomiting/Diarrhea
– Dehydration
– Burns
– Peritonitis/Pancreatitis

9. Presentation of Hypovolemic
Shock
• Hypotensive
• flat neck veins
• clear lungs
• cool, cyanotic extremities
• evidence of bleeding?
– Anticoagulant use
– trauma, bruising
• oliguria

10. Distributive Shock
• Peripheral Vasodilation secondary to disruption
of cellular metabolism by the effects of
inflammatory mediators.
• Gram negative or other overwhelming infection.
• Results in decreased Peripheral Vascular
Resistance.

11. Distributive Shock: Presentation
• Febrile
• Tachycardic
• clear lungs, evidence of pneumonia
• warm extremities
• flat neck veins
• oliguria

12. Diagnosing Shock
• Response to fluids
• Echo/EKG
• CXR
• Evidence of infection
• Swan-Ganz Catheter?

13. Swan-Ganz Catheter
• Utilized to differentiate types of shock and
assist in treatment response.
• Probably overused by physicians. Studies
documenting increased mortality in patients
with catheters versus no catheters, although
somewhat swayed by selection bias.

14. Swan-Ganz Catheter

16. Swan-Ganz Interpretation
Etiology CO PCWP SVR
cardiogenic decreased increased increased
hypovolemic decreased decreased increased
distributive increased decreased decreased
obstructive decreased Increased increased

17. Management
• Correct underlying disorder if possible and
then direct efforts at increasing the blood
pressure to increase oxygen delivery to the
tissues.
• Maintain a mean arterial pressure of 60
(1/3 systolic + 2/3 diastolic)
• Keep O2 sats >92%, intubate if neccesary

18. Correction of hypotension
• Normal Saline should be administered
anytime a patient is hypotensive. If
hypotension exists give more NS. ***
• If possible give blood as it replaces colloid.
• Vasopressors
• Inotropic agents for cardiogenic shock
• Intra-aortic Balloon Pump for cardiogenic

19. Autonomic Drugs in Shock
Drug Indication Dose MOA Principal actions
Dopamine Renal perfusion 2-5 mcg/kg/min Dopaminergic Renal a. dilation
hypotension 5-10 mcg/kg/min β1& + inotrope
dopaminergic
Hypotension >10 mcg/kg/min α1 vasoconstriction
Dobutamine Cardiogenic shock 2.5-25 mcg/kg/min Selective β
1 + inotrope
Norepinephrine Hypotension 2-4 mcg/min αβ
1& 1 Vasoconstriction
Phenylephrine Hypotension 40-180 mcg/min Selective α
1 Vasoconstriction

20. Management of Cardiogenic
Shock
• Attempt to correct problem and increase
cardiac output by diuresing and providing
inotropic support. IABP is utilized if
medical therapy is ineffective.
Catheterization if ongoing ischemia
• Cardiogenic shock is the exception to the
rule that NS is always given for
hypotension NS will exacerbate cardiac
shock.

21. Intra-Aortic Balloon Pump

22. Management of Septic Shock
• Early goal directed therapy
• Identification of source of infection
• Broad Spectrum Antibiotics
• IV fluids
• Vasopressors
• Steroids ??
• Recombinant human activated protein C ( Xygris)
• Bicarbonate if pH < 7.1

23. Management of Hypovolemic
Shock
• Correct bleeding abnormality
• If PT or PTT elevated then FFP
• Aggressive Fluid replacement with 2 large
bore IV’s or central line.
• Pressors are last line, but commonly
required.

24. Addison’s Disease
• Deficiency of cortisol and aldosterone
production in the adrenal glands
• This is suspected when patient is non-
responsive to fluids and antibiotics.
• Electrolytes may reveal hyponatremia and
hyperkalemia
• Hydrocortisone 100 mg IV immediately
then taper appropriately