The patient is in uncompensated/hypotensive shock based on increased heart rate, cool extremities with prolonged capillary refill, and hypotension. The shock is likely hypovolemic due to fluid loss from the gunshot wounds and surgery. The initial management should be rapid fluid resuscitation with isotonic fluids to restore circulating volume and tissue perfusion.
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.
Shock
what is shock
stages of shock
types of shock, their presentation and management
presentation is made for medical students using kumar and clark and guyton.
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2. Learning Objectives
• Define shock
• Know the stages of shock
• Know the classifications of shock and generate
differential diagnosis of etiology
• Know the initial management of shock
3. What is shock?
• Inadequate perfusion to meet tissue
demands. A progressive process.
– Occurs in 2% of hospitalized patients.
– Mortality 10%
• Initially, effects are reversible. Eventually:
– Cell membrane ion pump dysfunction
– Cellular edema, leakage of cells’ contents
– Inadequate regulation of intracellular pH
– Cell death, organ failure, cardiac arrest, and death.
5. Stages Of Shock
• Compensated Shock:
• Cardiac output and SVR work to keep BP within normal.
– On exam: Tachycardia; decreased pulses & cool extremities in cold shock;
flushing and bounding pulses in warm shock;
• Hypotensive (Uncompensated) Shock:
• Compensatory mechanisms are overwhelmed.
– On exam: As above, plus hypotension, altered mental status;
– labs may show increased lactic acidosis
– quick progression to cardiac arrest.
• Irreversible Shock: Irreversible organ damage, cardiac arrest, death
occur.
6. HYPOTENSION FORMULA
Ages – 1 to 10 years
Hypotension is defined as SBP
< 70mmHg + [age in years X 2] mmHg
7.
8.
9. COMPENSATORY
MECHANISMS
• >> Heart rate
• >> Stroke volume
• >> Vascular SM tone
• >> O2 extraction from the blood
• Redistributing blood flow to
brain,kidneys,adrenals and heart at the
expense of skin and GIT
10. To compensate for the metabolic acidosis,
- >> RR with >>CO2 elimination
- Renal excretion of hydrogen ions
- Retention of bicarbonate ions
To maintain IV volume,
- Sodium regulation through RAAS
- ADH secretion
- Cortisol and catecholamine synthesis and release
17. CARDIOGENIC SHOCK
• Poor myocardial contractility leading to cardiac
pump failure
• Due to :
CHD
Myocarditis
Cardiomyopathies
Arrhythmias
18.
19.
20. • Caused by inadequate vasomotor tone
Capillary leak
Maldistribution of fluid into interstitium
• Post-spinal cord or brainstem injury
Anaphylaxis
Poisonings
21. Hypovolemic shock – blood VOLUME
problem
Cardiogenic shock - blood PUMP
problem
Distributive shock – blood VESSEL
problem
23. General initial management
• Overall goal: Normalization of BP and tissue
perfusion.
• Physiologic indicators that should be targeted
include:1
– Blood pressure: Normal (defined in next slide).
– Quality of central and peripheral pulses: Strong, distal
pulses equal to central pulses.
– Skin perfusion: Warm, with capillary refill 1-2 seconds.
– Mental status: Normal.
– Urine output: >1 mL/kg per hour, once effective
circulating volume is restored.
24. Shock: Evaluation pearls
• Tachycardia? - Non-specific early finding. Investigate further.
• Skin changes? - Typically, prolonged cap refill (vasoconstriction) with
compensated shock. Flash refill with early distributive shock and with
irreversible shock.
• Impaired mental status? - Defining mental status as accurately as possible
(GCS) is key to monitoring progression. Assess for yourself -- don’t rely on
other providers.
• Oliguria? - Watch for decreased GFR; re-order meds accordingly.
• Hypotension? - Late finding. Don’t accept from others that BP is “normal.”
Widened pulse pressure (>40 mmHg)? - May be present in distributive shock,
aortic insufficiency, AVMs, Cushing’s reaction
25. HYPOVOLEMIC SHOCK
GOAL – RESTORE CIRCULATING VOLUME AND TISSUE
PERFUSION , CORRECT THE CAUSE
1.Assess airway
2.Administer oxygen
3.Establish IV access
4.Fluid bolus of 20ml/kg isotonic fluid given
5.Continue fluid boluses (maximum of 3) until
perfusion improves or hepatomegaly develops
6.In case of shock refractory to fluids,start
inotrope (DOPAMINE)
26. CARDIOGENIC SHOCK
PATHOPHYSIOLOGY
Impaired pumping ability of LV
Inadequate systolic emptying of LV
>>LV filling pressure
>>Left atrial pressure
<< Stroke volume
<< CO
>>Pulmonary capillary pressure
Pulmonary interstitial and intralveolar edema
28. TREATMENT
GOAL - >> CO, treat reversible causes,
<< myocardial workload
1.Assess airway ,
2. oxygen/mechanical ventilation
3. IV access
4.Inotropic agents,vasoactive drugs to >> cardiac
contractility and to decrease SVR
29. (5-10ml/kg boluses over longer time)
5.Morphine to decrease preload and
anxiety
6.Vasodilators for afterload reduction
7.Short acting beta blockers for refractory
tachycardia
31. CLINICAL PRESENTATION
• Muffled heart sounds
• Distended neck veins
•Pulsus paradoxus ( << in SBP by
more than 10mmHg on inspiration )
• Signs of right heart failure plus
cyanosis,tachycardia,hypotension
PERICARDIAL
EFFUSION
PULMONARY
EMBOLISM
32. TREATMENT
• Pericardial drainage in case
of pericardial effusion
• Immediate needle decompression then
thoracostomy for chest tube in case of
tension pneumothorax
• Anticoagulants or embolectomy
for pulmonary embolism
33. DISTRIBUTIVE SHOCK
Some tissues inadequately
perfused
(splanchnic circulation)
Some tissues
over perfused
(skeletal muscle,
skin)
PATHOPHYSIOLOGY
Maldistribution of blood flow
35. CLINICAL PRESENTATION
• Tachypnoea without increased work of
breathing
• Hypotension/Normotension
• Bounding pulses/Weak pulses
• Brisk/delayed CFT
• Warm flushed skin/cold pale skin
36. TREATM
ENT
1. ANAPHYLACTIC SHOCK –
Airway,
IV epinephrine,
Antihistaminics,
Corticosteroids,
Withdrawal of Ag ,
Vasopressors,Inotropes,
Cautious fluid administration
37. 2. NEUROGENIC SHOCK –
Cautious fluid administration,
Vasopressors,Inotropes,
Correct hypothermia,
• Treat bradycardia with atropine,
• Observe and prevent DVT (due to peripheral
pooling of blood)
38.
39. DEFINITIONS
SIRS
• Requires 2 of the following 4 features to be
present:
o Temperature >38.5° or <36.0° C
o Tachypnea >2SD ABOVE NORMAL FOR AGE
o Tachycardia >2SD ABOVE NORMAL FOR AGE
o WBC ELEVATED OR DEPRESSED FOR AGE/>10%
IMMATURE NEUTROPHILS
40. INFECTION
• Suspected or proven infection or a clinical
syndrome associated with high probability
of infection
SEPSIS
• SIRS plus a suspected or proven infection
41. SEVERE SEPSIS
• Sepsis plus organ dysfunction,hypoperfusion
or hypotension
(including but not limited to lactic
acidosis,oliguria,acute mental status changes)
42.
43. Identifying Acute Organ Dysfunction as a
Marker of Severe Sepsis
Tachycardia
Hypotension
CVP
PAOP
Jaundice
Enzymes
Albumin
PT
Altered
Consciousness
Confusion
Psychosis
Tachypnea
PaO2 <70 mm Hg
SaO2 <90%
PaO2/FiO2 300
Oliguria
Anuria
Creatinine
Platelets
PT/APTT
Protein C
D-dimer
44. WORK
UP
• Laboratory studies
o CBP
o serum elec,abg,BUN,serum
creat,GRBS,LFT,serum lactate)
o Coagulation studies
o Blood & urine cultures
• Imaging studies
o Chest radiography
o Abdominal radiography
o Others according to the suspected cause.
46. •Antibiotics should be administered within the first hour of
recognition of septic shock
•Antibiotic choice must be broad spectrum, covering gram-positive,
gram-negative, and anaerobic bacteria when the source is unknown
•Regimen for septic shock of unknown cause is
oGentamicin
o3rd generation cephalosporin
o if pseudomonas is suspected,ceftazidime
47. • Vancomycin must be added if resistant
staphylococci or enterococci are suspected.
• If there is an abdominal source, a drug effective
against anaerobes should be included
“metronidazole”
• Antibiotics are continued for at least 5 days after
shock resolves and evidence of infection subsides
• Abscesses must be drained and necrotic
tissues (eg, infarcted bowel) surgically excised.
48. Case
• 15-year-old previously well boy is freshly from the PICU, POD #3 from
partial small bowel resection after multiple gunshot wounds to the
abdomen. The nurse pages because his HR has increased in the last
hour from 90 to 130, despite pain score of 1/10 on morphine drip. On
exam, he is afebrile, HR is 140, BP 80/50. Cap refill is >3 seconds in his
cool extremities and pulses are 1+.
• What is your assessment?
• What is the stage of shock?
• What is the classification of shock?
• What is your initial management?
