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Shock 2004.05.01.. MECHANISM/DESCRIPTION Supply of blood flow to tissues inadequate to meet the demands of the tissues Nutrient requirements are not fulfilled.

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Presentation on theme: "Shock 2004.05.01.. MECHANISM/DESCRIPTION Supply of blood flow to tissues inadequate to meet the demands of the tissues Nutrient requirements are not fulfilled."— Presentation transcript:

1 Shock

2 MECHANISM/DESCRIPTION Supply of blood flow to tissues inadequate to meet the demands of the tissues Nutrient requirements are not fulfilled Toxic metabolites are not removed Nutrient requirements are not fulfilled Toxic metabolites are not removed Main components of blood flow Cardiac output Blood volume Peripheral resistance of arteriolar and venous system (systemic vascular resistance) Cardiac output Blood volume Peripheral resistance of arteriolar and venous system (systemic vascular resistance) Clinical shock is usually accompanied by hypotension, i.e., a mean arterial pressure <60 mmHg in previously normotensive persons

3 Clinical Presentation SIGNS AND SYMPTOMS MECHANISM/DESCRIPTIONETIOLOGIES

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5  Generalized shock  Generalized shock  Hypotension Decreased peripheral pulses Tachycardia Tachypnea Decreased urine output Diaphoresis Anxiety Obtundation Lethargy

6  Hypovolemic shock  Hypovolemic shock  Cold and clammy extremities Pallor Flattened neck veins Decreased capillary refill Narrowed pulse pressure

7  Cardiogenic shock  Cardiogenic shock  Chest pain/pressure Dyspnea Orthopnea Jugular venous distention Cool, clammy, sweaty extremities Rales Wheezes Dullness at lung bases S3 gallop

8  Septic shock  Septic shock  Warm flushed extremities Strong pulses Hyperthermia Hypothermia Purpura or petechial rash

9  Anaphylactic shock  Warm flushed extremities Urticaria Stridor Throat tightness Hoarseness Wheezing

10 Neurogenic shock Neurogenic shock Flaccid paralysis Loss of rectal tone Hypotension with bradycardia

11 Major Categories of Shock

12  Hypovolemic shock  Hypovolemic shock  Decreased Blood volume  Suspect hemorrhage if acute onset Severe dehydration if progressive onset and elevated HCT, BUN, and creatinine Decrease in central venous pressure (CVP) Resultant decrease in cardiac output leads to compensatory increase of the systemic vascular resistance (SVR) in an attempt to normalize perfusion pressure

13 Obstructive (cardiogenic) shock Obstructive (cardiogenic) shock Decreased Cardiac output Venous congestion with increase in CVP Increase in SVR Causes of decreased cardiac output: Cardiac dysfunction with reduced contractility Obstruction to inflow of blood to the heart Obstruction to outflow of blood to the heart Decreased Cardiac output Venous congestion with increase in CVP Increase in SVR Causes of decreased cardiac output: Cardiac dysfunction with reduced contractility Obstruction to inflow of blood to the heart Obstruction to outflow of blood to the heart

14  Vasogenic shock  Vasogenic shock  Decrease in vascular resistance secondary to excessive immunologic response to infection or antigen Reflexive increase in cardiac output Decreased central venous pressure

15 Septic shock Septic shock An initial infectious insult overwhelms the immune system Biochemical messengers (leukotrienes, histamines, prostaglandins) cause vessel dilatation Capillary endothelium becomes disrupted and the vessels leak Drop in total vascular resistance leads to inadequate tissue perfusion Secondarily, decreased cardiac output resulting in cold septic shock An initial infectious insult overwhelms the immune system Biochemical messengers (leukotrienes, histamines, prostaglandins) cause vessel dilatation Capillary endothelium becomes disrupted and the vessels leak Drop in total vascular resistance leads to inadequate tissue perfusion Secondarily, decreased cardiac output resulting in cold septic shock

16  Neurogenic shock  Spinal chord insults disrupts sympathetic stimulation to vessels Loss of sympathetic tone causes arteriodilation and vasodilatation Lesions proximal to T4 disrupt sympathetic, spares vagal innervation causing bradycardia

17  Anaphylactic shock  Anaphylactic shock  An antigen stimulates the allergic reaction Mast cells degranulate Histamine release along with autocoids stimulate an anaphylaxis cascade Vascular smooth muscle relaxes Capillary endothelium leaks Drop in total vascular resistance leads to inadequate tissue perfusion

18 Pharmacologic agents may cause shock through smooth muscle dilation or myocardial depression. myocardial depression.

19 Diagnosis

20 ESSENTIAL WORKUP Identify type or types of shock present Identify type or types of shock present Identify underlying cause of shock Identify underlying cause of shock

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23 LABORATORY TESTS Hemoglobin/hematocrit Low hemoglobin and hematocrit — hemorrhage Very high hematocrit — dehydration Poor marker with acute hemorrhage Hemoglobin/hematocrit Low hemoglobin and hematocrit — hemorrhage Very high hematocrit — dehydration Poor marker with acute hemorrhage White blood cell count High — nonspecific marker of infection Low — neutropenic infection White blood cell count High — nonspecific marker of infection Low — neutropenic infection

24 Electrolytes Low CO 2 — acidosis Increased BUN (GI hemorrhage) Increased Na, K, Cl, BUN/CR (dehydration) Electrolytes Low CO 2 — acidosis Increased BUN (GI hemorrhage) Increased Na, K, Cl, BUN/CR (dehydration) Blood glucose High (DKA or septic shock) Blood glucose High (DKA or septic shock) PT/PTT Increased in DIC, septic shock, and liver disease PT/PTT Increased in DIC, septic shock, and liver disease Cardiac enzymes Cardiac enzymes

25 Urinalysis High glucose/ketones (DKA or septic shock ) WBCs and bacteria when uroseptic Urinalysis High glucose/ketones (DKA or septic shock ) WBCs and bacteria when uroseptic Beta-HCG Women of childbearing age at risk for a ruptured ectopic pregnancy Beta-HCG Women of childbearing age at risk for a ruptured ectopic pregnancy Lactic acid level Anaerobic metabolism of lactic acids when organ demands exceed nutrient supply Good surrogate marker of shock state Lactic acid level Anaerobic metabolism of lactic acids when organ demands exceed nutrient supply Good surrogate marker of shock state

26 IMAGING/SPECIAL TESTS EKG Assess for ischemia and other disorders of cardiac muscle Electrical alternans with cardiac tamponade Right heart strain with pulmonary embolism EKG Assess for ischemia and other disorders of cardiac muscle Electrical alternans with cardiac tamponade Right heart strain with pulmonary embolism Chest x-ray Chest x-ray Pneumonia Pulmonary edema Pneumothorax Hemothorax Pulmonary infarction Traumatic injuries Pneumonia Pulmonary edema Pneumothorax Hemothorax Pulmonary infarction Traumatic injuries

27 Echocardiography Echocardiography Tamponade Wall motion abnormalities (myocardial ischemia) LV collapse (pulmonary embolus) Aortic dissection Tamponade Wall motion abnormalities (myocardial ischemia) LV collapse (pulmonary embolus) Aortic dissection Abdominal ultrasound Use to assess for intraperitoneal hemorrhage Ectopic pregnancy Abdominal ultrasound Use to assess for intraperitoneal hemorrhage Ectopic pregnancy CT abdomen CT abdomen Requires that the patient first be stabilized In the setting of abdominal trauma and in search for suspicion of abdominal catastrophes and trauma Requires that the patient first be stabilized In the setting of abdominal trauma and in search for suspicion of abdominal catastrophes and trauma

28 Treatment

29 INITIAL STABILIZATION ABCs ABCs Large-bore IV access Large-bore IV access When possible central venous access and monitoring When possible central venous access and monitoring Fluid resuscitation in noncardiogenic shock patients Fluid resuscitation in noncardiogenic shock patients Control bleeding with temporary measures Control bleeding with temporary measures Direct pressure Long bone traction External fixation of pelvis Direct pressure Long bone traction External fixation of pelvis

30 FURTHER TREATMENT Hypovolemic Shock Identify source of volume depletion Identify source of volume depletion Aggressive fluid resuscitation keeping SBP >100 mm Hg until definitive treatment 2 – 3 L crystalloid initially Aggressive fluid resuscitation keeping SBP >100 mm Hg until definitive treatment 2 – 3 L crystalloid initially Transfuse packed red blood cells (O- negative if type specific unavailable) if 2 – 3 crystalloids do not correct pressure Transfuse packed red blood cells (O- negative if type specific unavailable) if 2 – 3 crystalloids do not correct pressure

31 Identify source of bleeding and rapidly move toward definitive treatment Identify source of bleeding and rapidly move toward definitive treatment Dopamine and epinephrine in refractory shock after maximal fluid and blood product resuscitation with delayed hemorrhage control Dopamine and epinephrine in refractory shock after maximal fluid and blood product resuscitation with delayed hemorrhage control Thoracotomy and aortic cross-clamping in refractory shock with penetrating torso trauma Thoracotomy and aortic cross-clamping in refractory shock with penetrating torso trauma

32 Cardiogenic Shock Cardiogenic Shock Ease work of breathing with intubation Ease work of breathing with intubation A PCWP of 15 to 20 mmHg should be the initial goal A PCWP of 15 to 20 mmHg should be the initial goal Insult specific therapy (e.g., thrombolytics for MI, pericardiocentesis for pericardial tamponade) Insult specific therapy (e.g., thrombolytics for MI, pericardiocentesis for pericardial tamponade) Treat dysrhythmias Treat dysrhythmias

33 Septic Shock Septic Shock Aggressive volume expansion with a crystalloid solution to a PCWP of approximately 15 mmHg Aggressive volume expansion with a crystalloid solution to a PCWP of approximately 15 mmHg Titrate fluid to urine output >30 cc/h Titrate fluid to urine output >30 cc/h Blood product transfusion to maintain Hct 30 – 35% Blood product transfusion to maintain Hct 30 – 35% Early antimicrobial therapy Early antimicrobial therapy Inotropic support as needed Dopamine infusion or Norepinephrine infusion Inotropic support as needed Dopamine infusion or Norepinephrine infusion

34 Anaphylactic Shock Anaphylactic Shock Intubation for airway compromise Intubation for airway compromise H-1 blockers (diphenhydramine) H-1 blockers (diphenhydramine) H-2 blockers (cimetidine) H-2 blockers (cimetidine) Corticosteroids (hydrocortisone or methylprednisolone) Corticosteroids (hydrocortisone or methylprednisolone) Nebulized β2-antagonists for bronchospasm Nebulized β2-antagonists for bronchospasm Epinephrine Subcutaneous in noncritical settings Epinephrine Subcutaneous in noncritical settings Intravenous drip for immediate life threats or refractory hypotension Intravenous drip for immediate life threats or refractory hypotension

35 Pharmacologic Shock Pharmacologic Shock Supportive therapy Supportive therapy Decontamination of overdoses with charcoal Decontamination of overdoses with charcoal Inotropic agents as needed Inotropic agents as needed Drug specific antidotes Drug specific antidotes

36 Neurogenic Shock Neurogenic Shock Supportive therapy Supportive therapy Traction and fracture stabilization Traction and fracture stabilization Corticosteroids Corticosteroids

37 MEDICATIONS

38 Albuterol 2.5 mg/2.5 cc nebulizer PRN Albuterol 2.5 mg/2.5 cc nebulizer PRN Calcium gluconate 100 – 1,000 mg i.v. Calcium gluconate 100 – 1,000 mg i.v. Cimetidine 300 mg i.v. Cimetidine 300 mg i.v. Diphenhydramine 50 – 100 mg i.v. over 3 minutes Diphenhydramine 50 – 100 mg i.v. over 3 minutes Dobutamine 5 – 40 μg/kg/min i.v. Dopaminergic 1 – 3 μg/kg/min i.v. Beta effects 3 – 10 μg/kg/min i.v. Alpha/beta effects 10 – 20 μg/kg/min i.v. Alpha effects 20 μg/kg/min i.v. Dobutamine 5 – 40 μg/kg/min i.v. Dopaminergic 1 – 3 μg/kg/min i.v. Beta effects 3 – 10 μg/kg/min i.v. Alpha/beta effects 10 – 20 μg/kg/min i.v. Alpha effects 20 μg/kg/min i.v.

39 Epinephrine 1 – 4 μg/min i.v. infusion SQ/IM 1: – 0.3 mg repeat q 5 – 20 min × 3 PRN IV 1:100, mL over 10 min i.v. Epinephrine 1 – 4 μg/min i.v. infusion SQ/IM 1: – 0.3 mg repeat q 5 – 20 min × 3 PRN IV 1:100, mL over 10 min i.v. Glucagon 1 – 5 mg i.v. bolus initial, then 1 – 20 mg/h infusion Glucagon 1 – 5 mg i.v. bolus initial, then 1 – 20 mg/h infusion Hydrocortisone 5 – 10 mg/kg i.v. Hydrocortisone 5 – 10 mg/kg i.v. Methylprednisolone 1 – 2 mg/kg i.v. Methylprednisolone 1 – 2 mg/kg i.v. Naloxone 0.01 mg/kg initial, titrate to effect Naloxone 0.01 mg/kg initial, titrate to effect Norepinephrine start 2 – 4 μg/min i.v., titrate up to 1 – 2 μg/kg/min i.v. Norepinephrine start 2 – 4 μg/min i.v., titrate up to 1 – 2 μg/kg/min i.v. Phenylephrine 40 – 180 μg/kg/min i.v Phenylephrine 40 – 180 μg/kg/min i.v

40 ADJUNCTIVE THERAPIES POSITIONING POSITIONING IABP IABP PNEUMATIC ANTISHOCK GARMENT (PASG) PNEUMATIC ANTISHOCK GARMENT (PASG) REWARMING REWARMING


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