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SHOCK
BY
ARUN.M
KVM COLLEGE
DEFINITION
• Profound hemodyamic and metabolic
disturbance characterized by failure of the
circulatory system to maintain adequate
perfusion of vital organs
Types of Shock
• Cardiogenic (intracardiac vs extracardiac)
• Hypovolemic
• Distributive
– sepsis****
– neurogenic (spinal shock)
– adrenal insufficiency
– anaphylaxis
SHOCK
Cardiogenic Shock, intracardiac
• Myocardial Injury or Obstruction to Flow
– Arrythymias
– valvular lesions
– AMI
– Severe CHF
– VSD
– Hypertrophic Cardiomyopathy
Presentation of Cardiogenic
Shock
• Pulmonary Edema
• JVD
• hypotensive
• weak pulses
• oliguria
Cardiogenic Shock, extracardiac
(Obstructive)
• Pulmonary Embolism
• Cardiac Tamponade
• Tension Pneumothorax
• Presentation will be according to underlying
disease process.
Hypovolemic Shock
• Reduced circulating blood volume with
secondary decreased cardiac output
– Acute hemorrhage
– Vomiting/Diarrhea
– Dehydration
– Burns
– Peritonitis/Pancreatitis
Presentation of Hypovolemic
Shock
• Hypotensive
• flat neck veins
• clear lungs
• cool, cyanotic extremities
• evidence of bleeding?
– Anticoagulant use
– trauma, bruising
• oliguria
Distributive Shock
• Peripheral 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.
Distributive Shock: Presentation
• Febrile
• Tachycardic
• clear lungs, evidence of pneumonia
• warm extremities
• flat neck veins
• oliguria
Diagnosing Shock
• Response to fluids
• Echo/EKG
• CXR
• Evidence of infection
• Swan-Ganz Catheter?
Swan-Ganz Catheter
• Utilized 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.
Swan-Ganz Catheter
SHOCK
Swan-Ganz Interpretation
Etiology CO PCWP SVR
cardiogenic decreased increased increased
hypovolemic decreased decreased increased
distributive increased decreased decreased
obstructive decreased Increased increased
Management
• Correct 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
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.
• Vasopressors
• Inotropic agents for cardiogenic shock
• Intra-aortic Balloon Pump for cardiogenic
Autonomic Drugs in Shock
Drug Indication Dose MOA Principal actions
Dopamine Renal perfusion 2-5 mcg/kg/min Dopaminergic Renal a. dilation
hypotension 5-10 mcg/kg/min β1 &
dopaminergic
+ inotrope
Hypotension >10 mcg/kg/min α1 vasoconstriction
Dobutamine Cardiogenic shock 2.5-25 mcg/kg/min Selective β1 + inotrope
Norepinephrine Hypotension 2-4 mcg/min α1 & β1 Vasoconstriction
Phenylephrine Hypotension 40-180 mcg/min Selective α1 Vasoconstriction
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 ischemia
• Cardiogenic shock is the exception to the
rule that NS is always given for
hypotension NS will exacerbate cardiac
shock.
Intra-Aortic Balloon Pump
Management of Septic Shock
• Early goal directed therapy
• Identification of source of infection
• Broad Spectrum Antibiotics
• IV fluids
• Vasopressors
• Steroids ??
• Recombinant human activated protein C ( Xygris)
• Bicarbonate if pH < 7.1
Management of Hypovolemic
Shock
• Correct bleeding abnormality
• If PT or PTT elevated then FFP
• Aggressive Fluid replacement with 2 large
bore IV’s or central line.
• Pressors are last line, but commonly
required.
Addison’s Disease
• Deficiency of cortisol and aldosterone
production in the adrenal glands
• This is suspected when patient is non-
responsive to fluids and antibiotics.
• Electrolytes may reveal hyponatremia and
hyperkalemia
• Hydrocortisone 100 mg IV immediately
then taper appropriately

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SHOCK

  • 2. DEFINITION • Profound hemodyamic and metabolic disturbance characterized by failure of the circulatory system to maintain adequate perfusion of vital organs
  • 3. Types of Shock • Cardiogenic (intracardiac vs extracardiac) • Hypovolemic • Distributive – sepsis**** – neurogenic (spinal shock) – adrenal insufficiency – anaphylaxis
  • 5. Cardiogenic Shock, intracardiac • Myocardial Injury or Obstruction to Flow – Arrythymias – valvular lesions – AMI – Severe CHF – VSD – Hypertrophic Cardiomyopathy
  • 6. Presentation of Cardiogenic Shock • Pulmonary Edema • JVD • hypotensive • weak pulses • oliguria
  • 7. Cardiogenic Shock, extracardiac (Obstructive) • Pulmonary Embolism • Cardiac Tamponade • Tension Pneumothorax • Presentation will be according to underlying disease process.
  • 8. Hypovolemic Shock • Reduced circulating blood volume with secondary decreased cardiac output – Acute hemorrhage – Vomiting/Diarrhea – Dehydration – Burns – Peritonitis/Pancreatitis
  • 9. Presentation of Hypovolemic Shock • Hypotensive • flat neck veins • clear lungs • cool, cyanotic extremities • evidence of bleeding? – Anticoagulant use – trauma, bruising • oliguria
  • 10. Distributive Shock • Peripheral 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.
  • 11. Distributive Shock: Presentation • Febrile • Tachycardic • clear lungs, evidence of pneumonia • warm extremities • flat neck veins • oliguria
  • 12. Diagnosing Shock • Response to fluids • Echo/EKG • CXR • Evidence of infection • Swan-Ganz Catheter?
  • 13. Swan-Ganz Catheter • Utilized 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.
  • 16. Swan-Ganz Interpretation Etiology CO PCWP SVR cardiogenic decreased increased increased hypovolemic decreased decreased increased distributive increased decreased decreased obstructive decreased Increased increased
  • 17. Management • Correct 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. • Vasopressors • Inotropic agents for cardiogenic shock • Intra-aortic Balloon Pump for cardiogenic
  • 19. Autonomic Drugs in Shock Drug Indication Dose MOA Principal actions Dopamine Renal perfusion 2-5 mcg/kg/min Dopaminergic Renal a. dilation hypotension 5-10 mcg/kg/min β1 & dopaminergic + inotrope Hypotension >10 mcg/kg/min α1 vasoconstriction Dobutamine Cardiogenic shock 2.5-25 mcg/kg/min Selective β1 + inotrope Norepinephrine Hypotension 2-4 mcg/min α1 & β1 Vasoconstriction Phenylephrine Hypotension 40-180 mcg/min Selective α1 Vasoconstriction
  • 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 ischemia • Cardiogenic 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 therapy • Identification of source of infection • Broad Spectrum Antibiotics • IV fluids • Vasopressors • Steroids ?? • Recombinant human activated protein C ( Xygris) • Bicarbonate if pH < 7.1
  • 23. Management of Hypovolemic Shock • Correct bleeding abnormality • If PT or PTT elevated then FFP • Aggressive Fluid replacement with 2 large bore IV’s or central line. • Pressors are last line, but commonly required.
  • 24. Addison’s Disease • Deficiency of cortisol and aldosterone production in the adrenal glands • This is suspected when patient is non- responsive to fluids and antibiotics. • Electrolytes may reveal hyponatremia and hyperkalemia • Hydrocortisone 100 mg IV immediately then taper appropriately