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1. Pharmacotherapy
of Shock
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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03/02/14
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2. Introduction
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Review the current view on
etiology, pathophysiology and
management of shock with
emphasis on pharmacotherapy.
Daniel Game, M.D.
O. D. Polk, Jr., M.D.
Wayne Davis, M.D.
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3. Topics of Discussion
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Pathophysiology of Shock
Types of Circulatory Shock
Management of Shock
Inotropic Agents
 Vasodilators
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4. Shock
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Term “choc” – French for “push” or
impact was first published in 1743
by the physician LeDran
Belief – symptoms arose from fear
or some other form of altered
cerebral function
Crile in 1899 showed that
replacement of blood volume
decreased mortality experimentally
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5. Determinants of Shock
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Inadequate tissue perfusion
Sustained loss of effective circulatory
blood volume
Breakdown of cellular metabolism
and microcirculatory homeostasis
Hypoperfusion of peripheral tissue
that leads to a diminutive
transcapillary exchange function
Disproportion between VO2 and DO2
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6. Hemodynamic States of
Shock
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Hyperdynamic State
Hypodynamic State
Related to:
Cardiac Output (CO)
 Systemic Vascular Resistance
(SVR)
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7. Pathophysiology of
Shock
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Shock develops with inadequate
capillary perfusion by decreased
Cardiac Output following heart
attack (cardiogenic shock) or
blood/volume loss (hypovolemic
shock)
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8. Mediators of Shock
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Toxins
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Oligo- and polypeptides
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Arachidonic acid metabolites
Varia
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Complement Factors
Opiods
TNF, Interleukins
Fatty Acid Derivatives
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Endotoxins
Calcium
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9. Main Classes of Shock
Hypovolemic Shock
 Distributive Shock
 Cardiogenic Shock
 Obstructive Shock
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10. Hypovolemic Shock
Hemorrhagic/Traumatic
 Dehydrative
 Burn
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11. Distributive Shock
Septic
 Anaphylactic/
Anaphylactoid
 Neurogenic
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12. Obstructive Shock
Pulmonary Embolism
 Cardiac Tamponade
 Pneumothorax
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13. Question
Which one of the folowing is the most common cause of severe
Lactic acidosis (blood lactate concentration >5 mmol/L)?
a.
b.
c.
d.
e.
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Ethanol intoxication
Severe liver disease
Circulatory shock
Ischemic bowel
Acute asthma
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14. Management of Shock
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Shock begins when DO2 to the
cells is inadequate to meet
metabolic demand
The major therapeutic goals in
shock therefore are sufficient
tissue perfusion and oxygenation
Early diagnosis remains a major
problem
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15. Pulmonary Artery
Catheter Waveforms
Right Atrium Right Ventricle Pulmonary Artery
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PCWP
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16. Hemodynamic Characteristics in
Different Types of Shock
Type
Preload
CO
PVR
SVR
Hemmorrhagic
Anaphylactic
/
Cardiogenic
Septic
(Hyperdynamic)
Septic
(Hypodynamic)
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17. Question
The wavefrom shown in this figure was observed while
attempting to advance a pulmonary arterial catheter, with the
Balloon inflated, from the proximal pulmonatry artery to a
“wedged” position.
Which one of the following best explains the terminal
portion of the depicted waveform?
W
a. Pulmonary hypertension
h
b. Mitral regurgitation
i
c. Severe left ventricular dysfunction
c
d. Obstruction of the catheter tip
h
e. Pericardial www.indiandentalacademy.com
tamponade
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18. Inotropic Agents and
Vasodilators
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Vasoactive drugs are an important
pharmacologic defense in the
treatment of shock.
May be required to support BP in the
early stages of shock.
These agents may be needed to:
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Enhance CO through the use of inotropic
agents
Increase SVR through the use of
vasopressors
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19. Effects of Inotropic
1
Agents and Vasodilators
Drug
Epinephrine
Receptor
CO
SVR
α1 ,β1, (β2)
Norepinephrine α1, β1
Dose Range
0.02 – 0.5
0-
0.05 – 0.5
Dopamine
β2, DR, (α)
2 -12
Dobutamine
β1 , β2
2 - 12
Dopexamine
β1, β2, DR
Vasopressin
Angiotensin III
Amrinone
PDI
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00-
0.9 - 5
5 - 20
5 -10
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(µg/kg/min)
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20. Effects of Inotropic
2
Agents and Vasodilators
Drug
CO
SVR
Dose Range
Nifedipine
0-
0.5 - 10
Nitroglycerin
0-
3-5
Nitroprusside
0-
0.5 - 5
Prostacyclin
10 - 40
(µg/kg/min)
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21. Dopamine
An endogenous precursor of norepinephrine with
multiple dose-related effects
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Low Dose (0.5 - 3 mg/kg/min)
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Positive inotropic effects
High Dose (>20 mg/kg/min)
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Enhanced blood flow to renal and
splanchnic beds
Moderate Dose (5 -10 mg/kg/min)

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β2 and dopaminergic (DR) effects
α-actions (vasoconstriction)
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22. Question
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23. Reference
Pharmacotherapy of Shock. In: The Pharmacologic
Approach to the Critically Ill Patient, 3rd ed. Williams
& Wilkins,1994, pp 1104 – 1121.
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24. Thank you
For more details please visit
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