1. Good Morning! February 18, 2011

2. Types of Shock Hypovolemic ▫Inadequate blood volume Distributive ▫Inappropriately distributed blood volume and flow Cardiogenic ▫Insufficient CO caused by poor myocardial function Obstructive ▫Obstructed flow (into or out of the heart)

4. Septic Shock February 18, 2011

5. Shock: Defined Critical condition ▫Inadequate delivery of oxygen to the tissues to meet metabolic demand ▫Often characterized by inadequate perfusion

6. Shock Consequences ▫Tissue hypoxia ▫Anaerobic metabolism  Accumulation of lactic acid, carbon dioxide ▫Irreversible cell damage ▫Death  Acute: cardiovascular collapse  Delayed: multiple-organ system failure

7. Severity of Shock Compensated vs Decompensated??? DECOMPENSATED = HYPOTENSIVE

8. Severity of Shock Compensatory mechanisms: ▫Tachycardia ▫Increased contractility ▫Increased SVR Failure of compensatory mechanisms results in hypotension (decompensated shock)

9. Keep in Mind Severe shock ▫Low BP ▫Normal BP Automated BP devices are not reliable with weak/absent distal pulses

10. Assessment General Appearance ▫Ill, listless, decreased response to environment Airway ▫Associated with level of consciousness

11. Assessment Breathing ▫Quiet tachypnea  metabolic acidosis ▫Nasal flaring/retractions  intrinsic respiratory distress  Cardiogenic or obstructive shock ▫Pulse oximetry  Unreliable with poor perfusion

12. Assessment Circulation ▫Skin: mottled, pale, diaphoretic, cyanotic ▫Heart: murmur, gallop, distant ▫Lungs: crackles ▫Extremities: prolonged cap refill, diminished pulses ▫End-organ function: brain, kidneys

13. Circulation Tachycardia ▫Early sign of shock Hypotension ▫Late and often sudden sign of decompensation ▫May progress quickly to cardiac arrest Cap Refill ▫Extremity above level of heart ▫Context of other signs

14. Questions What volume of fluid should you bolus? ▫How fast? ▫What is to goal fluid administration w/in first hour? Warm vs Cold: What is the difference? ▫How does treatment vary?

15. Questions How does volume resuscitation differ for: ▫Cardiogenic shock? ▫Tamponade? ▫Pulmonary Embolism? When should you consider hydrocortisone?

16. See Septic Shock Flowchart