it gives brief description about the types of shock, its diagnosis and treatment.

1. SHOCKSHOCK
By Dr Sneha KhobragadeBy Dr Sneha Khobragade
Guided by Dr Deepak RuparelGuided by Dr Deepak Ruparel
GMC NagpurGMC Nagpur

2. Definition of ShockDefinition of Shock
 Inadequate tissue perfusion to meet tissueInadequate tissue perfusion to meet tissue
demandsdemands
 Usually result of inadequate blood flowUsually result of inadequate blood flow
and/or oxygen deliveryand/or oxygen delivery

3. What is Shock?What is Shock?

4. pathophysiologypathophysiology

6. CLASSIFICATIONCLASSIFICATION

7. CAUSE?CAUSE?

8. Cause?Cause?
Cardiogenic
shock
Hypovolemic
shock
Septic shock
Pulse pressure Decreases Decreases Increases
Diastolic pressure Decreases Decreases Decreases
Extremities Cool Cool Warm
Nailbed blood return Slow Slow Rapid
Jugular venous pressure Increases Decreases Decreases
Respiratory creptitions +++ - -
S3,S4 gallop rhythm +++ - -
Chest radiograph Large heart,
Pulmonary edema
Diminished
cardiac size
Normal,unless
pneumonia
presesnt
Identified site of infection - - +++

9. Cause?Cause?

10. Hypovolemic shockHypovolemic shock
Decrease circulating blood volumeDecrease circulating blood volume

11. ClassificationClassification

12.  Compensation – increase endogenousCompensation – increase endogenous
catecholaminescatecholamines
 Increase HR – increase C.O., O2 deliveryIncrease HR – increase C.O., O2 delivery
 Increase SVR – increase BP (esp diastolic)Increase SVR – increase BP (esp diastolic)
 Lactic acidosisLactic acidosis
 Increase in serum lactate- early indicator ofIncrease in serum lactate- early indicator of
tissue hypoperfusiontissue hypoperfusion

13.  Aim- reverse organ hypoperfusionAim- reverse organ hypoperfusion
( Optimizing the tissue o2 delivery)( Optimizing the tissue o2 delivery)
- requires sufficient hemoglobin concentration- requires sufficient hemoglobin concentration
- adequate intravascular volume- adequate intravascular volume
- dobutamine (despite adequate preload, cardiac- dobutamine (despite adequate preload, cardiac
output is not sufficient)output is not sufficient)

14. Determinants of Oxygen DeliveryDeterminants of Oxygen Delivery

15.  Oxygen content = 1.34 (Hb x SaO2) +Oxygen content = 1.34 (Hb x SaO2) +
(PaO2 x 0.0031)(PaO2 x 0.0031)
 SaO2: arterial hemoglobin Oxygen saturationSaO2: arterial hemoglobin Oxygen saturation
 Hb: Hemoglobin concentrationHb: Hemoglobin concentration
 PaO2: arterial oxygen tensionPaO2: arterial oxygen tension
 To improve Oxygen contentTo improve Oxygen content
 Increase Hemoglobin concentrationIncrease Hemoglobin concentration
 Increase saturationIncrease saturation

16.  Cardiac outputCardiac output
 C.O. = Heart rate x stroke volumeC.O. = Heart rate x stroke volume
 To improve Cardiac outputTo improve Cardiac output
 Increase Heart rateIncrease Heart rate
 Increase Stroke VolumeIncrease Stroke Volume
 Preload – volume of blood in the ventriclePreload – volume of blood in the ventricle
 Afterload – resistance to contractionAfterload – resistance to contraction
 Contractility – force appliedContractility – force applied

17. ManagementManagement
 Goal :Goal :
1. control the source of hemorrhage1. control the source of hemorrhage
2. administer adequate intravascular volume2. administer adequate intravascular volume
replacementreplacement
 Clinical picture:Clinical picture:
- SBP <90 mm hg- SBP <90 mm hg
- MAP <60 mm hg- MAP <60 mm hg
- lactate > 4 mmol/L- lactate > 4 mmol/L

18. simultaneouslysimultaneously
- control source of bleeding- control source of bleeding
- establish vascular access- establish vascular access
(8.5 fr central venous catheter/(8.5 fr central venous catheter/
two 14 G peripheral vein catheter)two 14 G peripheral vein catheter)

20.  Measure hemoglobinMeasure hemoglobin
- > 9 g/dl- > 9 g/dl  administer 0.9 NaCl / RLadminister 0.9 NaCl / RL
- < 9 g/dl- < 9 g/dl  RBC transfusion until Hg >RBC transfusion until Hg >
9g/dl and correct any9g/dl and correct any
identified coagulation oridentified coagulation or
platelet abnormalitiesplatelet abnormalities

21. In on going hemorrhage:
- administer 2 – 4 l of crystalloid
- group ‘0’ blood should be given
Rh - positive - men and women who are in non
childbearing age
Rh - negative – women in childbearing age
- Type specific blood administered after first four
units of non-typed blood are given
- Goal – maintain hemoglobin > 9 g/dl

23. Adjunctive TherapiesAdjunctive Therapies
Therapy Rationale
Airway control -To provide appropriate gas exchange
- to prevent aspiration
Cardiac/hemodynamic monitoring -To identify dysrhythmias and inadequate fluid
resuscitaion
Platelet/fresh frozen plasma
adminsitration
- required because of dilutional effect
of crystalloid and blood
- Consumption due to ongoing bleeding
- Platelet count > 50,000 /mm3
Calcium chloride
Magnesium chloride
-To reverse ionized hypocalcemia and
hypomagnesemia resulting from administration
of citrate with transfused blood
Antibiotics -When open and contaminated wounds are
present
Corticosteroids -For patients presumed to have adrenal injury
and unable to mount stress response

24. Cardiogenic ShockCardiogenic Shock
Cardiac dysfunctionCardiac dysfunction
Inadequate circulationInadequate circulation
Compromised organ perfusionCompromised organ perfusion

25. when to say?when to say?
Prolonged hypotension (SBP< 90 mmhg) inProlonged hypotension (SBP< 90 mmhg) in
settings of decreased cardiac output (< 1.8settings of decreased cardiac output (< 1.8
L/min/m2 without support and <2.2 L/min/m2L/min/m2 without support and <2.2 L/min/m2
with support) despite adequate intravascularwith support) despite adequate intravascular
volume (left ventricular end-diastolic pressure >volume (left ventricular end-diastolic pressure >
18 mm Hg and/or pulmonary artery occlusion18 mm Hg and/or pulmonary artery occlusion
pressure >15 mm Hg)pressure >15 mm Hg)

26. EtiologyEtiology
 Acute myocardial infarctionAcute myocardial infarction
 Mechanical causesMechanical causes
 Severe cardiomyopathy /congestive heart failureSevere cardiomyopathy /congestive heart failure
 Acute myocarditisAcute myocarditis
 Calcium channel or beta blocker overdoseCalcium channel or beta blocker overdose
 Acute /severe valvular insufficiencyAcute /severe valvular insufficiency
 Obstruction to left ventricular outflowObstruction to left ventricular outflow
 Obstruction to ventricular filling

27. PathophysiologyPathophysiology

28. SymptomsSymptoms
 TachycardiaTachycardia
 TachypneaTachypnea
 Respiratory distressRespiratory distress
 Mental status changeMental status change
 Cool extremitiesCool extremities
 oliguriaoliguria

29. ManagementManagement

30. Suspected cardiogenic shockSuspected cardiogenic shock
SBP< 90 mm HgSBP< 90 mm Hg
Signs of low cardiac output stateSigns of low cardiac output state
Initial evaluation & rapid stabilizationInitial evaluation & rapid stabilization
Immediate ECGImmediate ECG
Look for evidence of AMILook for evidence of AMI

31. EvaluationEvaluation

32. Supplement oxygen/mech ventilation (for hypoxia)Supplement oxygen/mech ventilation (for hypoxia)
BP supportBP support
SBP< 90 mm Hg - dopamine (5 – 15 mcg/kg/min)SBP< 90 mm Hg - dopamine (5 – 15 mcg/kg/min)
SBP< 80 mm Hg – add norepinephrineSBP< 80 mm Hg – add norepinephrine
(1 – 20 mcg/kg/min)(1 – 20 mcg/kg/min)
Goal MAP> 65 mm HgGoal MAP> 65 mm Hg
(all pt should have intra-arterial monitoring)(all pt should have intra-arterial monitoring)

34. Suitable for revascularization
-PCI (Infarct artery only)
-emergent CABG
(3V dz, L main dz, PCI not
possible)
No revascularization
possible
-ct medical support
If BP stable
Consider inotropic support
-dobutamine
(2.5- 10 mcg/min)
-milrinone
(0.375-0.75 mcg/kg/min)
Avoid in hypotension, renal
failure (milrinone)
REFRACTORY SHOCK
consider left ventricular assist device, transplantation evaluation

35. Distributive ShockDistributive Shock
Abnormal vessel toneAbnormal vessel tone
(decreased afterload)(decreased afterload)

36. VasodilatationVasodilatation
Venous PoolingVenous Pooling
Decreased AfterloadDecreased Afterload
Maldistribution of regional blood flowMaldistribution of regional blood flow

37.  Diminished or absent sympathetic toneDiminished or absent sympathetic tone
 Reduce peripheral vascular toneReduce peripheral vascular tone
 Peripheral pooling of blood volumePeripheral pooling of blood volume
 Inadequate venous returnInadequate venous return
 Decreased perfusion, acidosis, hypotensionDecreased perfusion, acidosis, hypotension

38. Septic ShockSeptic Shock
 Terminology in SepsisTerminology in Sepsis
 Infection = response to micro organismInfection = response to micro organism
 Bacteremia = bug in bloodBacteremia = bug in blood
 Systemic Inflammatory Response SyndromeSystemic Inflammatory Response Syndrome
(SIRS)(SIRS)
 Sepsis = SIRS as response to a knownSepsis = SIRS as response to a known
infectioninfection

39.  Terminology in SepsisTerminology in Sepsis
 severe sepsis - acute organ dysfunctionsevere sepsis - acute organ dysfunction
secondary to documented or suspectedsecondary to documented or suspected
infectioninfection
 septic shock - severe sepsis + hypotension notseptic shock - severe sepsis + hypotension not
reversed with fluid resuscitationreversed with fluid resuscitation
 Multiple Organ Dysfunction Syndrome (MODS)Multiple Organ Dysfunction Syndrome (MODS)
– two or more organ dysfunction that requires– two or more organ dysfunction that requires

40.  Sepsis-induced tissue hypoperfusionSepsis-induced tissue hypoperfusion
- infection-induced hypotension,- infection-induced hypotension,
- elevated lactate,- elevated lactate,
- oliguria- oliguria

41. Recognition of Septic ShockRecognition of Septic Shock
 Early –Early – warm shockwarm shock
 Late –Late – Cold shockCold shock

42. Early vs Late Septic ShockEarly vs Late Septic Shock
EarlyEarly LateLate
Heart rateHeart rate TachycardiaTachycardia Tachycardia/Tachycardia/
bradycardiabradycardia
Blood pressureBlood pressure NormalNormal decreaseddecreased
PeripheralPeripheral
PerfusionPerfusion
Warm/coolWarm/cool
Dec./inc. pulsesDec./inc. pulses
CoolCool
Dec. pulsesDec. pulses

43. Early vs Late Septic ShockEarly vs Late Septic Shock
EarlyEarly LateLate
End-organ: skinEnd-organ: skin Dec. cap refillDec. cap refill Very dec. capVery dec. cap
RefillRefill
BrainBrain Irritable,Irritable,
restlessrestless
Lethargic,Lethargic,
unresponsiveunresponsive
KidneysKidneys OliguriaOliguria Oliguria,Oliguria,
AnuriaAnuria

44. DiagnosisDiagnosis
 General variables:General variables:
1. Fever (> 38.3°C)1. Fever (> 38.3°C)
Hypothermia (core temperature < 36°C)Hypothermia (core temperature < 36°C)
2.Heart rate > 90/min2.Heart rate > 90/min
3.Tachypnea3.Tachypnea
4. Altered mental status4. Altered mental status

45. 5. Significant edema or positive fluid balance (>5. Significant edema or positive fluid balance (>
20mL/kg over 24hr)20mL/kg over 24hr)
6. Hyperglycemia (plasma glucose > 140mg/dL or6. Hyperglycemia (plasma glucose > 140mg/dL or
7.7 mmol/L) in the absence of diabetes7.7 mmol/L) in the absence of diabetes

46.  Inflammatory variables:Inflammatory variables:
1. Leukocytosis (WBC count > 12,000 µL–1)1. Leukocytosis (WBC count > 12,000 µL–1)
2. Leukopenia (WBC count < 4000 µL–1)2. Leukopenia (WBC count < 4000 µL–1)
3. Normal WBC count with greater than3. Normal WBC count with greater than
10% immature forms10% immature forms
4. Increased Plasma C-reactive protein4. Increased Plasma C-reactive protein
5. Increased Plasma procalcitonin5. Increased Plasma procalcitonin

47.  Hemodynamic variables:Hemodynamic variables:
- Arterial hypotension:- Arterial hypotension:
SBP < 90mm HgSBP < 90mm Hg
MAP < 65mm HgMAP < 65mm Hg
- SVO2 > 70%- SVO2 > 70%
- CI > 3.5 L/min/m2- CI > 3.5 L/min/m2

48.  Organ dysfunction variables:Organ dysfunction variables:
1.1. Arterial hypoxemia (Pao2/Fio2 < 300)Arterial hypoxemia (Pao2/Fio2 < 300)
2. Acute oliguria (urine output < 0.5mL/kg/hr2. Acute oliguria (urine output < 0.5mL/kg/hr
for at least 2 hrs despite adequate fluidfor at least 2 hrs despite adequate fluid
resuscitation)resuscitation)
3. Creatinine increase > 0.5mg/dL or 44.2 µmol/L3. Creatinine increase > 0.5mg/dL or 44.2 µmol/L

49. 4. Coagulation abnormalities4. Coagulation abnormalities
(INR > 1.5 )(INR > 1.5 )
5. Ileus (absent bowel sounds)5. Ileus (absent bowel sounds)
6. Thrombocytopenia (platelet count < 100,000 /µL)6. Thrombocytopenia (platelet count < 100,000 /µL)
7. Hyperbilirubinemia (plasma total bilirubin >7. Hyperbilirubinemia (plasma total bilirubin >
4mg/dL or 70 µmol/L)4mg/dL or 70 µmol/L)

50.  Tissue perfusion variables:Tissue perfusion variables:
Hyperlactatemia (> 1 mmol/L)Hyperlactatemia (> 1 mmol/L)
Decreased capillary refill or mottlingDecreased capillary refill or mottling

51. Severe sepsisSevere sepsis
 Lactate above upper limits laboratoryLactate above upper limits laboratory
 Urine output < 0.5mL/kg/hr for more than 2 hrsUrine output < 0.5mL/kg/hr for more than 2 hrs
despite adequate fluid resuscitationdespite adequate fluid resuscitation
 Acute lung injury with Pao2/Fio2 < 250 in theAcute lung injury with Pao2/Fio2 < 250 in the
absence of pneumonia as infection sourceabsence of pneumonia as infection source

52.  Acute lung injury with Pao2/Fio2 < 200 in theAcute lung injury with Pao2/Fio2 < 200 in the
presence of pneumonia as infection sourcepresence of pneumonia as infection source
 Creatinine > 2.0mg/dL (176.8 µmol/L)Creatinine > 2.0mg/dL (176.8 µmol/L)
 Bilirubin > 2mg/dL (34.2 µmol/L)Bilirubin > 2mg/dL (34.2 µmol/L)
 Platelet count < 100,000 µLPlatelet count < 100,000 µL
 Coagulopathy (international normalized ratio >Coagulopathy (international normalized ratio >
1.5)1.5)

53. Treatment Strategies inTreatment Strategies in
ShockShock

54. MonitoringMonitoring
 Blood pressureBlood pressure
 Heart rateHeart rate
 Respiratory rateRespiratory rate
 Urine outputUrine output
 Blood CBCBlood CBC
 Pulse - oximetryPulse - oximetry
 ECGECG
 U/S , CT , X-rayU/S , CT , X-ray

55. Special MonitoringSpecial Monitoring
 CARDIO – VASCULAR:CARDIO – VASCULAR:
1. Central venous pressure1. Central venous pressure
2. Cardiac output :2. Cardiac output :
- Pulmonary catheter- Pulmonary catheter
- Doppler ultrasound- Doppler ultrasound
- Pulse waveform analysis- Pulse waveform analysis

56.  SYSTEMIC & ORGAN PERFUSIONSYSTEMIC & ORGAN PERFUSION
1. - Clinically - urine output & LOC1. - Clinically - urine output & LOC
- Sr. Lactate estimation- Sr. Lactate estimation
- Blood gas analysis- Blood gas analysis
- Mixed venous O2 saturation- Mixed venous O2 saturation
2. Newer methods2. Newer methods
- Muscle tissue O2 probes- Muscle tissue O2 probes
- Near –infrared spectroscopy- Near –infrared spectroscopy
- Sublingual capnometry- Sublingual capnometry

57. Severe sepsis bundleSevere sepsis bundle
 Design to optimize the timing ,sequence, andDesign to optimize the timing ,sequence, and
goals of the individual element care.goals of the individual element care.
 Includes:Includes:
- goal directed hemodynamic stabilization- goal directed hemodynamic stabilization
- early appropriate antimicrobial therapy- early appropriate antimicrobial therapy
- associated adjunctive therapy- associated adjunctive therapy

58. SURVIVING SEPSIS CAMPAIGN BUNDLESSURVIVING SEPSIS CAMPAIGN BUNDLES
TO BE COMPLETED WITHIN 3 HOURS:TO BE COMPLETED WITHIN 3 HOURS:
1) Measure lactate level1) Measure lactate level
2) Obtain blood cultures prior to administration of2) Obtain blood cultures prior to administration of
antibioticsantibiotics
3) Administer broad spectrum antibiotics3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or4) Administer 30 mL/kg crystalloid for hypotension or
lactate > 4mmol/Llactate > 4mmol/L

59. TO BE COMPLETED WITHIN 6 HOURS:TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension not5) Apply vasopressors (for hypotension not
responding to initial fluid resuscitation)responding to initial fluid resuscitation)
6) persistent arterial hypotension despite volume6) persistent arterial hypotension despite volume
resuscitation or initial lactate 4 mmol/L measure:resuscitation or initial lactate 4 mmol/L measure:
- central venous pressure- central venous pressure
- central venous oxygen saturation- central venous oxygen saturation
7) Remeasure lactate7) Remeasure lactate

60. Fluid managementFluid management

62. ADJUNCTIVE THERAPIESADJUNCTIVE THERAPIES

64. Antibiotic ManagementAntibiotic Management
Is patient
immunocompromised?
 HIV
 Neutropenia
 Chronic corticosteroids
 Malnutrition
 Receiving chemotherapy
Give antibiotic therapy to
opportunistic pathogens
+
Bacterial pathogens
Consider likely bacterial
infection based on clinical
presenatation
Human immunodeficiency
antibodies
Extended spectrum beta-
lactamase
Methicillin resistant
staphylococcus aureus

65. Risk factors for healthcare-
associated infection present:
• Recent hospitalization
• residence in nursing
home/rehabilitation
• Regular visits to hospital
• Home infusion or
wound therapy
Consider nosocomial bacterial
pathogens that are potentially
antibiotic resistant:
• MRSA
• pseudomonas aeruginosa
• acinetobacter species
•Klebsiella pneumonia
• E - coli
Consider community-based
bacterial pathogens that are
antibiotic sensitive :
•Streptococcus pneumoniae
• e coli
• legionaella pneumophila
• haemophillia influenza
• klebsiella pneumonia
* Broad spectrum cephalosporin /
* Carbapenam /
* Beta-lactam /
* Fluroquinolone /
* Aminoglycoside /
* MRSA- Directed agent
(vancomycin, linezolid,
tigecycline)

66. Select single agent therapy:
• ceftriaxone
• fluroquinolone
• ampicillin/sulbactum
• macrolides (azithromycin,
clarithromycin, telithromycin)
Modify and/or narrow antibiotic
regimen based on organism
identified and susceptibilty
testing

67. Activated Protein CActivated Protein C
(drotrecogin - alpha)(drotrecogin - alpha)
 Recombinant Human Activated Protein CRecombinant Human Activated Protein C
 Prevent DIC cascade with antithrombotic activityPrevent DIC cascade with antithrombotic activity
by inhibiting factors Va & VIIIaby inhibiting factors Va & VIIIa
 May exerts anti-inflammatory effects by inhibitingMay exerts anti-inflammatory effects by inhibiting
TNF and by blocking leukocytes adhesionsTNF and by blocking leukocytes adhesions

68.  Side effectsSide effects
 BleedingBleeding
 Pediatric trial terminated early (03/04) due toPediatric trial terminated early (03/04) due to
no benefit to known risk of bleedingno benefit to known risk of bleeding

69. Anaphylactic shockAnaphylactic shock

70.  Immunoglobulin E mediated immediateImmunoglobulin E mediated immediate
hypersensitivity reactionhypersensitivity reaction
 It involve mast cell and basophil degranulationsIt involve mast cell and basophil degranulations
 Clinically it is indistinguishable fromClinically it is indistinguishable from
anaphylactoid reactions (direct mast cellanaphylactoid reactions (direct mast cell
degranulation)degranulation)

71.  Reaction develop in < 1hour after exposure toReaction develop in < 1hour after exposure to
triggering substancestriggering substances
 Initial symptoms:Initial symptoms:
- flushing- flushing
- pruritis- pruritis
- sense of doom- sense of doom

72. Causes?Causes?
Anaphylaxis (IgE mediated) Anaphylactoid reaction
-Foods (nuts, egg, fish, shellfish,
cows
milk)
- vaccines
- anesthetic agents
- insulin and other harmones
- antitoxins
- blood and blood products
- insect stings and bites (bee,
wasp
and ant)
- snake bites
- latex
- allergy immunotherapy
-NSAIDs
- opiates
- sulfites
- radioconstrast media
- neuromuscular blocking agents
- gamma globulin
- antisera
- exercise

73. Clinical ManifestationsClinical Manifestations
1. Cardiovascular collapse (shock) – seen in 20%1. Cardiovascular collapse (shock) – seen in 20%
 Results from:Results from:
- hypovolemia induced by increased vascular- hypovolemia induced by increased vascular
permeability and loss of intravascular volume.permeability and loss of intravascular volume.
- hypotension from peripheral vasodilation- hypotension from peripheral vasodilation
- myocardial depression- myocardial depression
- bradycardia- bradycardia

74. 2. Respiratory symptoms - seen in 50% of2. Respiratory symptoms - seen in 50% of
patientspatients
 Can results in :Can results in :
- severe upper airway edema- severe upper airway edema
- bronchospasm- bronchospasm
- cardiogenic and non- cardiogenic pulmonary- cardiogenic and non- cardiogenic pulmonary
edemaedema
 Biphasic reactions occurs in 20 % within, 1 to 8Biphasic reactions occurs in 20 % within, 1 to 8
hours after initial reactionshours after initial reactions

75. 3. Eyes :3. Eyes :
- pruritus- pruritus
- lacrimation- lacrimation
- conjunctival erythema- conjunctival erythema
- periorbital edema- periorbital edema
4. Gastrointestinal :4. Gastrointestinal :
- nausea / vomiting- nausea / vomiting
- diarrhoea- diarrhoea
- abdominal pain- abdominal pain

76. 5. skin:5. skin:
- pruritus- pruritus
- flushing- flushing
- urticaria- urticaria
- angioedema- angioedema
6. Neurologic :6. Neurologic :
- anxiety and sense of doom- anxiety and sense of doom
- syncope- syncope
- seizures- seizures

77. Acute TreatmentAcute Treatment

80.  Remember….Remember….
- intravenous steroids have no role in the acute- intravenous steroids have no role in the acute
treatment of anaphylaxis but may preventtreatment of anaphylaxis but may prevent
phase 2 reactionphase 2 reaction
- given IV methyl prednisolone 1-2 mg/kg and- given IV methyl prednisolone 1-2 mg/kg and
continue up to 4 days (IV / Orally)continue up to 4 days (IV / Orally)
- on discharge, refer the patient to allergist for- on discharge, refer the patient to allergist for
testing and monitoring and provide with hometesting and monitoring and provide with home
epinephrine self – injectors (EpiPen)epinephrine self – injectors (EpiPen)

81. Practically Speaking….Practically Speaking….
 Know how to distinguish different types of shockKnow how to distinguish different types of shock
and treat accordingly.and treat accordingly.
 Look for early signs of shock.Look for early signs of shock.
 Monitor the patient using the HR, MAP, mentalMonitor the patient using the HR, MAP, mental
status, urine output.status, urine output.
 SHOCK is not equal to hypotension.SHOCK is not equal to hypotension.
 Start antibiotics within an hour !Start antibiotics within an hour !
 Do not wait for cultures or blood work.Do not wait for cultures or blood work.

82. THANK YOUTHANK YOU