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SHOCK
DOOMSDAY
1
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Slide 2
Vicken Y. Totten
Shock lecture
Thanks to David Cheng MD
And all who taught me
Slide 3
Definition
SHOCK:
inadequate organ
perfusion to meet
the tissues
oxygenation
demand
Slide 4
PATHOPHYSIOLOGY OF SHOCK
SYNDROME
Cells switch from aerobic to anaerobic metabolism
lactic acid production
Cell function ceases & cells swell
membranes becomes more permeable
electrolytes & fluids seep in & out of cell
Cells Die in Many Organs Death
Slide 5
Stages of shock
Slide 6
Symptoms of Shock
General Symptoms
Anxious
Dizziness
Weakness
Faintness
Thirsty
I am sick
Specific Symptoms
Fevers / Rigors
(sepsis)
SSCP (cardiogenic)
Wheezing
(anaphylaxis)
Trauma pain
(hypovolemia)
Slide 7
+/-restless
Slide 8
Hypoperfusion can be
present in the absence of
significant hypotension.
(Dont only relay on BP for
diagnosisng shock)
-fccs course
8
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Slide 9
Cyanotic
AMS->Coma
Anuria
Slide 10
Cardiovascular
Myocardial
depression
Vasogenic effects
Pulmonary
Ischemic bowel
Hematologic
Neutropenia,
Thrombocytopenia
DIC (Gm- > Gm+)
Renal
ARF
Hepatic
Increased LFTs, liver failure
ARDS
GI
CNS
coma
Slide 11
Mortality (%)
0.8
6.8
26.2
48.5
68.8
83.3
*Adapted from Irwin and Rippes Critical Care Medicine 5th Edition, pg 1837
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Slide 12
Circumferential
Subendocardial
Infarction due
to Shock
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Slide 13
Shock
Lung
Slide 14
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Slide 18
Remember
Slide 19
Slide 20
Components:
Blood (fluid)
Heart (pump)
Blood Vessels
(pipes)
Slide 21
Types of Shock
Hypovolemic (fluids)
Cardiogenic (pump)
Redistributive (pipes)
(septic, neurogenic, anaphylactic)
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Slide 23
BP = SVR x CO
BP = blood pressure
CO = cardiac output (pump & fluids)
SVR = systemic vascular resistance (pipes)
Slide 24
An Approach to Shock
If the blood pressure is low, then either the:
CO is low
or
SVR is low
or
BOTH
Slide 25
Low SVR
There are only a few causes of low SVR.
They ALL cause vasodilation:
Septic shock
Neurogenic (spinal cord injury) shock
Anaphylaxis Shock
Vasodilator (antihypertensive) Posioning
Slide 26
Slide 27
Pale
Poor cap refill (>2 seconds)
Cool arms/legs (>2 degree C difference)
Thready pulses (narrow pulse pressure (incr DBP))
Cause of shock (low BP) is then:
low CO
Slide 28
CO = HR x SV
CO = cardiac output
HR = heart rate
SV = stroke volume
Slide 29
HR Problems
Slide 30
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Slide 33
Components of BP summary
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Slide 34
Why Monitor?
Serial monitoring
Slide 35
Slide 36
Diagnosis of Shock
Slide 37
Slide 38
Pulse Pressure=SBP-DBP
The difference between the systolic (fxn of
ejection fraction) and diastolic pressures (function of
SVR and distensibility (elastic recoil) of the aorta
Wide
Narrow
Slide 39
Invasive Markers
Global Markers
Regional Markers
Base Deficit
Lactate
Gastric pH
Sublingual CO2
Slide 40
Base Deficit
Inadequate tissue perfusion leads to tissue
acidosis
Amount of base required to titrate 1 L of
whole arterial blood to a pH of 7.4
Normal range +3 to 3 mmol per L
Elevated base deficit correlates with the
presence and severity of shock
Slide 41
Base Deficit
Inadequate tissue perfusion leads to tissue
acidosis
Amount of base required to titrate 1 L of
whole arterial blood to a pH of 7.4
Normal range +3 to 3 mmol per L
Elevated base deficit correlates with the
presence and severity of shock
Slide 42
Initial Lactate
Slide 43
lactate level
of >4.0 mmol/L
was identified as a
strong
independent
predictor of
mortality
and morbidity
and suggests that
tissue
hypoperfusion
Slide 44
Slide 45
Gastric Intramucosal pH
Blood flow is not uniformly distributed to all tissue
beds
Regions with inadequate tissue perfusion may exist
while global markers are normal
Gut mucosa among the first to be affected during
shock and the last to be restored to normal
Intramucosal pH falls when perfusion becomes
inadequate
Slide 46
Sublingual capnometry:
A new noninvasive measurement for diagnosis and
quantitation of severity of circulatory shock
Slide 47
Sublingual CO2
Slide 48
Sublingual capnometry:
A new noninvasive measurement for diagnosis and
quantitation of severity of circulatory shock
P SL CO2
provides a
prompt
indication of the
reversal of
tissue
hypercarbia
when
circulatory
shock is
reversed
Slide 49
Slide 50
INDICATIONS
COMPLICATIONS
volume status
cardiac status
technical
anatomic
physiologic
Slide 51
Swan-Ganz Catheter
Slide 52
PLACEMENT
Slide 53
Slide 54
Standard Parameters
Measured
Blood pressure
Pulmonary A.
pressure
Heart rate
Cardiac Output
Stroke volume
Wedge pressure
CVP
Calculated
Mean BP
Mean PAP
Cardiac Index
Stroke volume
index
SVRI
LVSWI
BSA
Slide 55
Why Index?
PATIENT A
60 yo male
50 kg
CO = 4.0 L/min
BSA = 1.86
CI = 2.4 L/min/m2
PATIENT B
60 yo male
150 kg
CO = 4.0 L/min
BSA = 2.64
CI = 1.5 L/min/m2
Slide 56
Slide 57
PA Insertion
20
15
10
5
RA = 5
RV = 22/4
0
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PA 19/10
PAOP(wedge) = 9
Slide 58
CVP
Slide 59
PAOP (wedge)
End expiration
Wedge adjustment with positive pressure
Measured PAOP - PEEP = real PAOP
Slide 60
Vascular Resistance
SYSTEMIC (SVR)
MAP - CVP
x 80
C0
SVR = vasoconstriction
SVR = vasodilation
PULMONARY (PVR)
MPAP - PAOP
CO
PVR = constriction
PE, hypoxia
x 80
Slide 61
Cardiac Cycle
PVR
MPAP
RVSW
pulmonary
Right ventricle
CVP
Left ventricle
systemic
SVR
PCWP
MAP
LVSW
Slide 62
CO
PCWP
SVR
cardiogenic
decreased
increased
increased
hypovolemic
decreased
decreased
increased
distributive
increased
decreased
decreased
Slide 63
Slide 64
Definitions
O2 Delivery - volume of gaseous O2
delivered to the LV/min.
O2 Consumption - volume of gaseous O2
which is actually used by the tissue/min.
Slide 65
Slide 66
CO/CI
Hgb
SaO2
O2 consumption
SV/SVI
Slide 67
Sepsis
AV shunts/fistulae
Slide 68
Oxycalculations
Slide 69
Break Time
Slide 70
Goals of Shock
Resuscitation
Restore
blood pressure
Normalize
Preserve
systemic perfusion
organ function
Slide 71
Parameters of Adequate
Resuscitation
Urine output (0.5 - 1.0 ml/kg/hr)
acceptable renal perfusion
Reversal of lactic acidosis (nl. pH)
improved perfusion
Normal mental status
adequate cerebral perfusion
Slide 72
it !!!
. SHOTGUN approach
Normalization of BP, pulse, UOP
Hemodynamic parameters
Restoration of aerobic
metabolism, elimination of tissue
acidosis, repayment of O2 debt
Slide 73
-fccs course
73
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Slide 75
Management
ABCs
Maintain airway
Decrease work of breathing & Optimize 02
Circulation & Control Hemorrhage includes:
Direct pressure
Pressure points
Fluids & Drugs
Slide 76
Management priorities
in hypoperfused states
Priority # Physiology to Intervention
improve
1
Volume
Fluids
Pressure
Vasopressor
Flow
Inotrope
Parameter to target
CVP 10-15
PAC
targets
DO2
Low Sao2
See CXR
Low SV, DO2
High HR,
Resistances
DO2
BP potency: Dopamine...NEVasopressin/Phenylephrine
Avoid
Slide 77
Hypovolemia
Slide 78
Time
Outcomes of same vol. lost over diff. periods of time. Slow losses (III, IV)
allow compensations to take effect. Rapid loss (I, II) of same vol. is fatal
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Slide 79
Class II
Class III
Class IV
Blood Loss
< 750
750-1500
1500-2000
> 2000
% Blood Vol.
< 15%
15 30%
30 40%
> 40%
Pulse
< 100
> 100
> 120
> 140
Blood Pressure
Normal
Normal
Decreased
Decreased
Pulse Pressure
Normal
Decreased
Decreased
Decreased
Resp. Rate
14 20
20 30
30 40
> 40
UOP
> 30
20 30
5 15
negligible
Mental Status
sl. Anxious
mildly anx
confused
lethargic
Fluid
crystalloid
crystalloid
blood
blood
Slide 80
Clinical Signs
Slightly increased heart rate
15-30
30-50
> 50
Slide 81
Hypovolemic Shock
Causes
hemorrhage
vomiting
diarrhea
dehydration
third-space loss
burns
Signs
cardiac output
PAOP/CVP
SVR
Slide 82
Treatment - Hypovolemic
500 ml whole blood increases Hct 2-3%, 250ml PRBCs increases Hct 3-4%
Increases oxygen carrying capacity
Used with acute hemorrhaging (mntn Hct 24% and Hgb 8g/dL)
Pressors?
Slide 83
Resuscitation
Slide 84
Role of PASG?
Splinting role
Slide 85
Cardiogenic Shock
Mech
Signs
Slide 86
Cardiogenic Shock
Severe Arrhythmia
Slide 87
Symptoms of Cardiogenic
Shock
Heart:
Slide 88
Cardiogenic Shock
Assess for:
Signs of heart failure
Signs of tamponade
Cardiac dysrrhythmia
Myocardial infarction
Tachycardia
Muffled heart sounds or third heart sound
Engorged neck veins with hypotension
Dyspnea
Edema in feet and ankles
Slide 89
Coronary Perfusion
Pressure
Coronary PP = DBP - PAOP
coronary perfusion = P across coronary a.
Slide 90
Treatment of Cardiogenic
Shock
Slide 91
Slide 92
Slide 93
Distributive Shock
Types
Sepsis
Anaphylactic
Acute adrenal insufficiency
Neurogenic
Signs
cardiac output
PAOP
SVR
Slide 94
Anaphylaxis
Slide 95
Anaphylactic Shock
Rapid onset
Bronchoconstriction
Slide 96
Symptoms
Onset within seconds and
progression to death in minutes
Cutaneous manifestations
urticaria, erythema, pruritis,
angioedema
Respiratory compromise
stridor, wheezing, bronchorrhea, resp.
distress
Circulatory collapse
tachycardia, vasodilation,
hypotension
CNS
apprehension->ams->coma
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Diagnosis
History and physical alone make the
diagnosis
Lab values serve no role
Slide 98
Treatment
Slide 99
Treatment
2nd line:
H1 blocker: Diphenhydramine 25-50 mg IV
H2 blocker: Ranitidine 50 mg or Famotidine 20 mg IV.)
Steroids (Methylprednisolone 125 mg IV or Prednisone
40-60 mg po)
Albuterol
For patients taking Beta-blockers with refractory
hypotension, think about glucagon
Slide 100
Septic Shock
Slide 101
SEPSIS
Slide 102
Slide 103
What is Sepsis?
Slide 104
Septic Shock
Slide 105
Septic/Inflammatory Shock
Signs:
Slide 106
Septic Shock TX
If MAP < 60
Dopamine = 2 - 3 g/kg/min
Norepinephrine = titrate (1-100 g/min)
Slide 107
Neurogenic shock
Slide 108
Neurogenic Shock
Essential derangement:
paralysis of the
sympathetic chain which
controls vascular tone from
injury to thoracic or
cervical level spinal cord
injury.
Produces decreased SVR
from loss of vascular tone
and bradycardia from
unopposed
parasympathetic input to
SA node.
Slide 109
Caused by:
Slide 110
Treatment of Neurogenic
Shock
Slide 111
Obstructive Shock
Causes
Cardiac Tamponade
Tension Pneumothorax
Massive Pulmonary Embolus
Signs
cardiac output
PAOP/CVP
SVR
Treatment
Needle decompression
Embolectomy / TPA
Slide 112
Adrenal Crisis
Distributive Shock
Causes
Autoimmune adrenalitis
Adrenal apoplexy = B hemorrhage or infarct
Slide 113
Vasopressor Agents?
Slide 114
Dopamine
Dobutamine
Norepinephrine
Epinephrine
Amrinone
Slide 115
Dopamine
SIDE EFFECTS
tachycardia
> 20 g/kg/min to norepinephrine
Slide 116
Dobutamine
-agonist
5 - 20 g/kg/min
Slide 117
Norepinephrine
Slide 118
Epinephrine
dose 1 - 10 g/min
Slide 119
Amrinone
Slide 120
vasopressin
V1 vascular smooth muscle receptor
vasoconstriction
0.01-0.04 units/min
Risk: coronary, mesenteric ischemia,
hyponatremia, skin necrosis
Slide 121
Calcium Sensitisation by
Levosimendan
Clinical trials
status
Slide 122
Endpoints?
Swan-guided resuscitation
C.I. 4.5, DO2I 670, VO2I 166
Gastric pH
Slide 123
Dont forget...
Shock: rude unhinging of the
machinery of life.
-Samuel D. Gross, 1872
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Slide 124