2 Outline Definition Types of Shocks Risk Factors Signs and Symptoms DiagnosisTreatment and ManagementCase StudyReferences
3 Pathophysiology of Shock Systemic hypoperfusion (decreased blood flow) due to reduction in either cardiac output or the effective circulating blood volumeImpaired tissue perfusion occurs when an imbalance develops between cellular oxygen supply and cellular oxygen demandOften accompanies severe injury or illnessCan lead to other conditions such as lack of oxygen in the body’s tissues (hypoxia), heart attack (cardiac arrest), or organ damage.
4 Clinical Features of Shock Hypotension (Hypovolemic and Cardiogenic)With a weak, rapid pulseOliguria (decreased kidney perfusion)Altered mental status (decreased brain perfusion)TachypneaTachycardiaCool, clammy, cyanotic skinVasoconstrictive mechanisms to redirect blood from periphery to vital organs
5 Stages of ShockNonprogressive phase: compensated stage, normal mechanisms will cause recovery. (baroreceptor reflexes, angiotensin secretion by the kidneys, vasopressin-constriction of peripheral arteries and veins).Progressive phase: the phase characterized by tissue hypoperfusion and worsening circulatory and metabolic abnormalities including lactic acidosis leading to metabolic acidosis.Irreversible phase: the phase during which damage is so severe that, even if perfusion is restored, survival is not possible.
6 Types of Shocks Cardiogenic shock Hypovolemic Shock Distributive shock Blood pump problemHypovolemic ShockBlood volume problemDistributive shockSeptic ShockBlood vessel problem
7 Other Type of Shock: Neurogenic Shock Anaphylactic Shock Distributive type of shock resulting in hypotension with bradycardiaAnaphylactic ShockSerious allergic reaction
8 Cardiogenic ShockLow cardiac output due to outflow obstruction or myocardial pump failureInability of the heart to maintain adequate tissue perfusion secondary to impaired pump function or failureMost commonly the result of a heart attackOther causes: valve disease, arrhythmias, tamponade, cardiomyopathies
9 Risk Factors Previous history of myocardial infarction Plaque buildup in the coronary arteriesLong-term valvular disease
11 Diagnosis Physical examination (pulse and blood pressure) Confirm the following tests:Blood pressure measurementBlood testsElectrocardiogramEchocardiography: heart activity and blood flowSwan-Ganz Catheter: pulmonary catheter to observe pumping activity of the heart
12 Treatment and Management Correct hypotension:Fluid resuscitation to correct hypovolemiaVasoactive agents:Dopamine-will increase heart rate and cardiac workDobutamine-may drop blood pressureNorepinephrineEpinephrine
13 Treatment Continued: Oxygenation Optimizing pump function: Morphine as needed (decreases preload, anxiety)If Myocardial infarction:Heparin and revascularizationIf arrhythmia-correct arrhythmiaIf extracardiac abnormality:Reverse or treat cause
14 Hypovolemic Shock Most common type of shock Life threatening condition that results when you lose more than 20% of your body’s blood or fluid supply. The severe fluid loss makes it impossible for the heart to pump sufficient blood to your body.Resulting in decreased cardiac outputCauses:Vomiting, diarrhea, bowel obstruction, burnsGI bleeding, trauma,Can cause organ failureThis condition requires immediate emergency medical attention for survival
15 Risk FactorsLosing about 1/5 or more of the normal amount of blood in your body causes hypovolemic shock.Excessive blood loss due to:Bleeding from cutsBleeding from other injuriesInternal bleeding, such as in the GI tract
16 Clinical Presentation Tachycardia and tachypneaWeak, thready pulsesHypotensionCool and clammy skinMental status changesDecreased urine output (dark and concentrated)
17 DiagnosisIn addition to physical symptoms the following testing methods can be done to confirm:Blood testing to check for electrolyte imbalances and kidney functionCT scan or an ultrasound to visualize body organsEchocardiogram to measure heart rhythmEndoscopy to examine esophagus and other GI organsRight heart catherization to check how blood is circulatingUrinary catherization to measure the amount of urine in the bladder
18 Treatment and Management Pre-hospital care:External bleeding should be controlled by direct pressureImmobilization patient (if trauma is involved)Securing adequate airwayEnsuring ventilationMaximizing circulationMedications to increase the heart’s pumping abilities (dobutamine, epinephrine, norepinephrine)**delay in any of the above can be harmful to the patient and can lead to death
19 Septic ShockSystemic inflammation response syndrome (SIRS) secondary to a documented infection.Response is a state of acute circulatory failure involving persistent arterial hypotension despite adequate fluid resuscitation or by tissue hypoperfusion unexplained by other causes.
20 Risk FactorsRisk factors: certain groups of people are more at risk. Why? They have weaker immune systems.Newborn babie, elderly people, pregnant women, people with long-term health conditions (diabetes, cirrhosis, or kidney failure), people with lowered immune systems (people with HIV or AIDS or receiving chemotherapy)Traumatic woundsUse of invasive cathetersDrug therapy
22 Diagnosis Important points for diagnosis: Identify subtle presentationsScreen patient for evidence of tissue hypoperfusion, such as cool or clammy skin, and elevated shock index (heart rate to systolic blood pressure > 0.9)A lactic acid level higher than 4 mm/dL has been used as an entry criterion for early goal-directed therapy (EGDT) and an indicator of severe tissue hypoperfusion
23 Treatment Hospitalization is required Adequate antibiotic therapy is required (as early as possible)Resuscitate the patient using supportive measures to correct hypoxia, hypotension, and impaired tissue oxygenation (hypoperfusion)Identify the source of infection, and treat with antimicrobial therapy, surgery, or both.Antibiotics
24 Treatment ContinuedAntibiotics- Survival correlates with how quickly the correct drug was givenCover gram positive and gram negative bacteriaZosyn grams IV and ceftriaxone 1 gram IV orImipenem 1 gram IVAdd additional coverage as indicatedPseudomonas- Gentamicin or CefepimeMRSA- VancomycinIntra-abdominal or head/neck anaerobic infections- Clindamycin or MetronidazoleAsplenic- Ceftriaxone for N. meningitidis, H. infuenzaeNeutropenic – Cefepime or Imipenem
25 Case StudyMrs. S is a 65 year old obese female who presents to ED complaining “crushing” substernal chest pain, tachycardia, cool, clammy extremities. History of myocardial infarction is present. Husband also states she has become slightly confused.Vitals: HR 46, BP 68/32, RR 23, SpO2 95% on RA, Afebrile.Labs: WBC 8.1, Hgb 12.1, BUN 12, Creat 1.0, Troponin 3.1, BG 121.EKG shows ST elevation in II, III, aVF
26 What kind of shock does the patient have????? A. CardiogenicB. HypovolemicC. Septic
28 ReferencesRobbins, Stanley L., Vinay Kumar, and Ramzi S. Cotran. “Shock.” Robbins and Cotran Pathologic Basis of Disease. 8th ed. Philadelphia, PA: Saunders/Elsevier, Print.Medscape Reference (Online accessed 20 June 2014) URL:Medscape LLC (Online access on 20 June 2014) URL: