9 Presentation of Hypovolemic Shock Hypotensiveflat neck veinsclear lungscool, cyanotic extremitiesevidence of bleeding?Anticoagulant usetrauma, bruisingoliguria
10 Distributive ShockPeripheral Vasodilation secondary to disruption of cellular metabolism by the effects of inflammatory mediators.Gram negative or other overwhelming infection.Results in decreased Peripheral Vascular Resistance.
12 Diagnosing Shock Response to fluids Echo/EKG CXR Evidence of infection Swan-Ganz Catheter?
13 Swan-Ganz CatheterUtilized to differentiate types of shock and assist in treatment response.Probably overused by physicians. Studies documenting increased mortality in patients with catheters versus no catheters, although somewhat swayed by selection bias.
17 ManagementCorrect underlying disorder if possible and then direct efforts at increasing the blood pressure to increase oxygen delivery to the tissues.Maintain a mean arterial pressure of 60 (1/3 systolic + 2/3 diastolic)Keep O2 sats >92%, intubate if neccesary
18 Correction of hypotension Normal Saline should be administered anytime a patient is hypotensive. If hypotension exists give more NS. ***If possible give blood as it replaces colloid.VasopressorsInotropic agents for cardiogenic shockIntra-aortic Balloon Pump for cardiogenic
20 Management of Cardiogenic Shock Attempt to correct problem and increase cardiac output by diuresing and providing inotropic support. IABP is utilized if medical therapy is ineffective. Catheterization if ongoing ischemiaCardiogenic shock is the exception to the rule that NS is always given for hypotension NS will exacerbate cardiac shock.
22 Management of Septic Shock Early goal directed therapyIdentification of source of infectionBroad Spectrum AntibioticsIV fluidsVasopressorsSteroids ??Recombinant human activated protein C ( Xygris)Bicarbonate if pH < 7.1
23 Management of Hypovolemic Shock Correct bleeding abnormalityIf PT or PTT elevated then FFPAggressive Fluid replacement with 2 large bore IV’s or central line.Pressors are last line, but commonly required.
24 Addison’s DiseaseDeficiency of cortisol and aldosterone production in the adrenal glandsThis is suspected when patient is non-responsive to fluids and antibiotics.Electrolytes may reveal hyponatremia and hyperkalemiaHydrocortisone 100 mg IV immediately then taper appropriately