Shock Management

Objectives
• Understand the definition of the three
different types of shock
• Be able to recognize the different types of
shock in patient scenarios
• Understand and apply treatment guidelines
for the different types of shock
 What is Shock?
• Shock is the “physiologic state characterized
by significant reduction of systemic tissue
perfusion, resulting in decreased tissue
oxygen delivery.”
– Tissue perfusion is dependent on systemic
vascular resistance (SVR) and cardiac output
(COP).
– Imbalance between oxygen delivery and oxygen
consumption which leads to cell death, end organ
damage, multi-system organ failure, and death
 Three Types of Shock
• Cardiogenic
• Hypovolemic
• Distributive
– Septic
– Anaphylactic
– Neurogenic
• Combined
 Cardiogenic Shock
• Shock caused as a result of cardiac pump
failure
– Results in a decrease in COP
– SVR is increased in an effort to compensate to
maintain organ perfusion
– Causes:
• Myocardial Infarction
• Arrythmias (Atrial fibrillation, ventricular tachycardias,
bradycardias, etc)
• Mechanical abnormalities (valvular defects)
• Extracardiac abnormalities (PE, pulm HTN, tension pneumothorax)
Medscape Reference. 1994 (Online accessed 22 August 2013)
URL: http://emedicine.medscape.com/article/152191-treatment#showall
 Treatment of Cardiogenic Shock
• Correct hypotension:
– Fluid resuscitation to correct hypovolemia
– Inotropic or Vasopressor support:
• Dobutamine
• Milrinone
• Norepinephrine
• Dopamine
• Epinephrine
• Oxygenation
• If MI – Aspirin, Heparin, and Revascularization
• If arrthymia – correct arrthymia
• If extracardiac abnormality – reverse or treat cause
 Hypovolemic Shock
• Shock caused by decreased preload due to
intravascular volume loss (1/5 of blood
volume)
– Results in decreased COP
– SVR is typically increased in an effort to
compensate
– Causes:
• Hemorrhagic – trauma, GI bleed, hemorrhagic
pancreatitis, fractures
• Fluid loss induced – Diarrhea, vomiting, burns
Medscape LLC. 2013 (Online access on 22 August 2013)
URL: http://emedicine.medscape.com/article/760145-treatment#2
 Treatment of Hypovolemic Shock
• Maximize oxygen delivery
• Control further blood loss
– Tourniquets
– Surgical intervention
• Fluid resuscitation
– NS fluid boluses
– Blood product administration
 Distributive Shock
• Shock as a result of severely diminished SVR
– COP is typically increased in an effort to maintain
perfusion
– Subtypes:
• Septic – secondary to an overwhelming infection
• Anaphylactic – secondary to a life-threatening allergic
reaction
• Neurogenic – secondary to a sudden loss of the
autonomic nervous system function
Gaieski et al. 2009 (Online accessed 22 August 2013)
URL: http://lijhs.sandi.net/faculty/rtenenbaum/ap-biology-folder/Links/Shock.utd.pdf
 Treatment of Septic Shock
• Resuscitate
– 30cc/kg of NS bolus
• Identify Source
– Pan cultures
– CT scan
– Line removal
– Foley removal
– Surgical exploration
• Antibiotics
Dellinger, R et al. Surviving Sepsis Campaign: International Guidelines for Management
of Severe Sepsis and Septic Shock:2012, 41: 580-637, 2013.
 Treatment of Anaphylactic Shock
• Remove offending agent
• Establish an airway and return circulation
• Pharmacologic support:
– Epinephrine – reverses peripheral vasodilation, dilates bronchial
airways, increases myocardial contractility, and suppresses histamine/
leukotriene release
– Antihistamine (benadryl) – may help counter histamine-mediated
vasodilation and bronchoconstriction
– Corticosteroids (hydrocortisone) – may help shorten reaction
– Bronchodilators
 Treatment of Neurogenic Shock
• Establish an airway to maintain adequate
oxygenation and ventilation
• Fluid resuscitation for MAP>65mmHg
• Inotropic support
– Dobutamine
– Dopamine
• Atropine for severe bradycardia
• High dose methylprednisolone therapy
All three types of shock can occur
at the same time to have a
combined shock picture.
 Summary

Survival and outcomes improve

with early perfusion, adequate
oxygenation, and identification
with appropriate treatment of the
cause of shock.