1 / 24

Shock

Shock. Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D. Shock: Definitions. Shock = inadequate tissue perfusion Tissue perfusion is determined by: Cardiac output (CO) = HR x SV SV = function of preload, afterload, contractility Systemic vascular resistance (SVR). Shock: Types.

ganesa
Download Presentation

Shock

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Shock Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D.

  2. Shock: Definitions Shock = inadequate tissue perfusion Tissue perfusion is determined by: Cardiac output (CO) = HR x SV SV = function of preload, afterload, contractility Systemic vascular resistance (SVR)

  3. Shock: Types • Hypovolemic • Septic (high CO, low SVRI) • Cardiogenic (high CVP) • Neurogenic • Anaphylactic • Adrenal insufficiency

  4. Shock Types & Physiology

  5. Hypovolemic Shock • CNS response to hypovolemia • Rapid: peripheral vasoconstriction, increased cardiac activity • Sustained: arterial vasoconstriction, Na/water retention, increased cortisol • 2/2 hemorrhage or fluid loss • Classes of hemorrhage: I: 15% II: 30% = tachycardia III: 40% = decreased SBP, confusion IV: >40% = lethargy, no UOP Tx: stop source / fluids / blood

  6. Septic Shock • SIRS = T >38C or <36C, HR >90, RR >20, PaCO2 <32mmHg, WBC >12 or <4 • Sepsis = SIRS + focus of infection • Severe sepsis = sepsis + MSOF • Septic shock = sepsis + refractory hypotension • Remember: septic shock is a/w high CO • Tx: fluids, antibiotics

  7. Cardiogenic Shock • Cardiogenic shock 2/2 cardiac disease or cardiac compression • Cardiac disease: MI, arrhythmia, valve dysfunction, increased PVR or SVR, increased ventricular resistance • Cardiac compression: tension PTX, cardiac tamponade, positive pressure ventilation • Look for Beck’s triad in tamponade (hypotension, JVD, muffled heart sounds) • Tx: fluids, tx underlying cause (relieve PTX, pericardiocentesis, change ventilator settings)

  8. Neurogenic Shock • Shock 2/2 spinal cord injury, regional anesthesia, autonomic blockade • Mechanism: loss of vasomotor control, expansion of venous capacitance bed • Signs: warm skin, normal or low HR, normal CO, low SVR • Tx: Fluids / pressors / +- steroids

  9. Hypoadrenal • Unresponsive to fluids or pressors • Tx: steroids

  10. Shock: Signs • Pale, cool skin • Change in MS, lethargy • Decreased UOP • Hypotension, tachycardia, tachypnea

  11. Shock: Evaluation Airway: includes brief evaluation of mental status Breathing Circulation: includes placement of adequate IV access Disability: identification of gross neurologic injury Exposure: ensures complete exam History: OPQRST, review PMHx, PSHx, ALL, SHx PE: complete Labs: include ABG (pH, base deficit, lactate)

  12. Case 1 55y M post-op day 0 s/p colectomy Called for tachycardia, hypotension, altered mental status, abdominal distension, decreased UOP PE: pale, disoriented, abdomen tense, TTP, w/rebound tenderness, UOP 15mL/hr What is your diagnosis? What additional information should you obtain? What is the plan?

  13. Case 1: Continued Dx: hemorrhagic shock Additional information: CBC, coags, T&C Management ABC (intubate, IV access) Resuscitate (isotonic IVF) Prepare for take-back

  14. Case 2 75y M h/o CAD, PVD, DM, POD 1 s/p AAA repair c/o nausea What do you need to think about? What is the plan?

  15. Case 2: Continued Dx: MI Plan: ABC MONA, beta-blockade Cardiology consult for catheterization Labs/x-rays: cardiac enzymes Q8H x3 sets w/EKG, chemstick, BMP, CXR/KUB

  16. Case 2: Continued Cath w/critical stenosis of left main s/p balloon angioplasty PE: intubated, 80/50, UOP 10mL/hr Echo: severe LV dysfunction What is the diagnosis? What is the plan?

  17. Case 2: Continued Dx: Post-myocardial infarction (cardiogenic) shock Plan: ABC Pressor support as needed Placement of Swan-Ganz catheter +/- Intra-aortic balloon pump, cardiac assist device Heparin (maintain coronary patency)

  18. Case 3 60y M h/o chronic ETOH use presents to ED w/ N/V and epigastric pain radiating to the back PE: tachycardic, hypotensive, confused What is the working diagnosis? What is the plan?

  19. Case 3: Continued Dx: Hypovolemic shock 2/2 acute pancreatitis Plan: ABC (intubate, IV acess, NGT, Foley, DHT) Resuscitate Labs: chemstick, ABG, BMP, LFT, amylase/lipase, CBC, coags Studies: CXR, CT A/P

  20. Case 4 55y M POD 0 s/p colectomy, w/epidural placed for post-op pain control Called by nurse for hypotension and bradycardia PE: AAOx3, abdomen ND, NT Recent post-op labs: HCT 35 What is your working diagnosis?

  21. Case 4: Continued DX: Neurogenic shock 2/2 epidural Treatment is: IVF Turn down or turn off epidural If BP does not respond to IVF, initiate pressor support w/alpha-agonist such as phenylephrine

  22. Case 5 25y M p/w diffuse abdominal pain. PMHx PUD. PE: febrile, tachycardic, hypotensive, lethargic, rigid abdomen w/ involuntary guarding What is your working diagnosis? What is your plan?

  23. Case 5 Dx: septic shock 2/2 duodenal perforation Plan: ABC Broad-spectrum IV antibiotics Emergent OR for ex-lap, washout & repair

  24. Shock: Take Home Points Shock = inadequate tissue perfusion Types of shock: hypovolemic, septic, cardiogenic, neurogenic, anaphylactic Signs of shock: altered MS, tachycardia, hypotension, tachypnea, low UOP Always start with ABCs Resuscitation begins with fluid (exception - cardiogenic shock)

More Related