kuliah shock
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SHOCK
MEDICINE FACULTYABDURRAB UNIVERSITY
Global Health Emergency Medicine Teachi ng Modules by GHEM is licensed undera Creative Commons Attribution-NonCommercial-ShareAlike 3 ! "n#orted $icense
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*A T +
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.e%inition o% Shock
/nade0uate #er%usion and o1ygenation o%cells
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.e%inition o% Shock
/nade0uate #er%usion and o1ygenation o%cells leads to)
Cellular dys%unction and damage'rgan dys%unction and damage
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2hy should you care
High mortality - ,!-4!5
Early on the e%%ects o% ', de#rivation onthe cell are E6E S/7$E
Early intervention reduces mortality
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*atho#hysiology
8 ty#es o% shockCardiogenic'bstructiveHy#ovolemic.istributive
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*atho#hysiology) 'vervie&
Tissue #er%usion is determined by Mean Arterial *ressure 9MA*:
MA* ; C' 1 S6
Heart rate Stroke 6olume
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Cardiogenic Shock)*atho#hysiology
Heart %ails to #um# blood out
MA* ; C' 1 S6
H Stroke 6olume
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Cardiogenic Shock)*atho#hysiology
Normal
MA* ; C' 1 S6
Cardiogenic
MA* ; ↓ C' 1 S6 MA* ; ↓ C' 1 ↑ S6↓ MA* ; ↓↓ C' 1 ↑ S6
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Cardiogenic Shock) Causes
↓ MA* ; ↓ CO (HR x Stroke Volume) 1 ↑ S6
.ecreased Contractility 9Myocardial /n%arction< myocarditis<cardiomy#othy< *ost resuscitation syndrome %ollo&ing cardiac arrest:
Mechanical .ys%unction = 9*a#illary muscle ru#ture #ost-M/< Severe Aortic Stenosis< ru#ture o% ventricular aneurysms etc:
Arrhythmia = 9Heart block< ventricular tachycardia< S6T< atrial
%ibrillation etc :
Cardioto1icity 97 blocker and Calcium Channel 7locker 'verdose:
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'bstructive Shock)*atho#hysiology
Heart #um#s &ell< but the out#ut is decreaseddue to an obstruction 9in or out o% the heart:
MA* ; C' 1 S6
H 1 Stroke volume
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'bstructive Shock)*atho#hysiology
Normal
MA* ; C' 1 S6
'bstructive
MA* ; ↓ C' 1 S6 MA* ; ↓ C' 1 ↑ S6↓ MA* ; ↓↓ C' 1 ↑ S6
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'bstructive Shock) Causes
↓ MA* ; ↓ CO ( HR x Stroke Volume) 1 ↑ S6
Heart is &orking but there is a block to the out%lo&Massive #ulmonary embolism
Aortic dissectionCardiac tam#onadeTension #neumothora1
'bstruction o% venous return to heart6ena cava syndrome - eg neo#lasms< granulomatous diseaseSickle cell s#lenic se0uestration
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Hy#ovolemic Shock)*atho#hysiology
Heart #um#s &ell< but not enough bloodvolume to #um#
MA* ; C' 1 S6
H 1 Stroke volume
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Hy#ovolemic Shock)*atho#hysiology
Normal
MA* ; C' 1 S6
Hy#ovolemic
MA* ;↓
C' 1 S6 MA* ; ↓ C' 1 ↑ S6↓ MA* ; ↓↓ C' 1 ↑ S6
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Hy#ovolemic Shock) Causes
↓ MA* ; ↓ CO ( HR x Stroke Volume) 1 ↑ S6
.ecreased /ntravascular volume 9*reload: leads to .ecreasedStroke 6olumeHemorrhagic - trauma< G/ bleed< AAA ru#ture< ecto#ic #regnancyHy#ovolemic - burns< G/ losses< dehydration< third s#acing 9e g#ancreatitis< bo&el obstruction:< Adesonian crisis< .iabetic>etoacidosis
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.istributive Shock)*atho#hysiology
Heart #um#s &ell< but there is #eri#heralvasodilation due to loss o% vessel tone
MA* ; C' 1 S6
H 1 Stroke volume
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.istributive Shock)*atho#hysiology
Normal
MA* ; C' 1 S6
.istributive
MA* ; co 1 ↓ S6
MA* ; ↑ co 1 ↓ S6↓ MA* ; ↑ co 1 ↓↓ S6
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.istributive Shock) Causes
↓ MA* ; ↑ C' 9H 1 S6: 1 ↓ S6
$oss o% 6essel tone/n%lammatory cascade
Se#sis and To1ic Shock Syndrome Ana#hyla1is*ost resuscitation syndrome %ollo&ing cardiac arrest
.ecreased sym#athetic nervous system %unctionNeurogenic - C s#ine or u##er thoracic cord in(uries
To1ins.ue to cellular #oisons -Carbon mono1ide< methemoglobinemia<cyanide.rug overdose 9a+ antagonists:
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To Summari?e
T !e o"S#o$k
I%&ult '# & olo $E""e$t
Com!e%&*t o%
Cardiogenic Heart %ails to #um#blood out
↓ CO BaroRc↑ SVR
'bstructive Heart #um#s &ell< butthe out%lo& is obstructed
↓ CO BaroRc↑ SVR
Hemorrhagic Heart #um#s &ell< but
not enough bloodvolume to #um#
↓ CO 7aro c↑ SVR
.istributive Heart #um#s &ell< butthere is #eri#heralvasodilation
↓ SVR ↑ CO
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'k@it s really not THAT sim#le
MA* ; C' 1 S6
H 1 Stroke volume
*reload A%terload Contractility
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T !e o"S#o$k
I%&ult '# & olo $E""e$t
Com!e%&*t o%
Com!e%&*t o%He*rt R*te
Com!e%&*t o%Co%tr*$t l t
Cardiogenic Heart %ails to#um# bloodout
↓ CO BaroRc↑ SVR
↑ ↑
'bstructive Heart #um#s&ell< but the
out%lo& isobstructed
↓ CO BaroRc↑ SVR
↑ ↑
Hemorrhagic Heart #um#s&ell< but notenough bloodvolume to
#um#
↓ CO 7aro c↑ SVR
↑ ↑
.istributive Heart #um#s&ell< butthere is#eri#heralvasodilation
↓ SVR ↑ CO ↑
No Change -in neurogenic
shock
↑
No Change -in neurogenic
shock
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Additional Com#ensatoryMechanisms
enin-Angiotensin-Aldosterone Mechanism A// com#onents lead to vasoconstriction Aldosterone leads to &ater conservation
A.H leads to &ater retention and thirst
/n%lammatory cascade
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Case +
,8 year old male*reviously healthy$ives in a malaria endemic area 9*NG:7rought in by %riends a%ter a %ight - he &as kickedin the abdomenHe is agitated< and &on t lie %lat on the stretcher H 4,< 7* +,B D,< Sa', 4 5< ,B
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Stages o% Shock
Timeline and #rogression &illde#end on)
-Cause
-*atient Characteristics
-/ntervention
/nsult
*reshock9Com#ensation:
Shock9Com#ensation'ver&helmed:
End organ.amage
.eath
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Case +) Stages o% ShockSt* e '*t#o!# & olo Cl % $*l F %+ % &/nsult S#lenic u#ture -- 7lood
$oss Abdominal tenderness and girth
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Case +) Stages o% ShockSt* e '*t#o!# & olo Cl % $*l F %+ % &/nsult S#lenic u#ture -- 7lood $oss Abdominal tenderness and
girth
*reshock Hemo&t*t $ $om!e%&*t o%MA* ; ↓ CO (↑ HR x ↓ SV ) 1↑ SVR.ecreased C' is com#ensated byincrease in H and S6
MA* is maintainedH &ill be increasedE1tremities &ill be cool dueto vasoconstriction
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Case +) Stages o% ShockSt* e '*t#o!# & olo Cl % $*l F %+ % &/nsult S#lenic u#ture -- 7lood
$oss Abdominal tenderness andgirth
*reshock Hemo&t*t $ $om!e%&*t o%MA* ; ↓ CO (HR x ↓ SV ) 1 ↑ SVR.ecreased C' is com#ensatedby increase in H and S6
MA* is maintainedH &ill be increasedE1tremities &ill be cool due tovasoconstriction
Shock Com#ensatory mechanisms%ail
MA* is reducedTachycardia< dys#nea<restlessness
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Case +) Stages o% ShockSt* e '*t#o!# & olo Cl % $*l F %+ % &/nsult S#lenic u#ture -- 7lood $oss Abdominal tenderness and girth
*reshock Hemo&t*t $ $om!e%&*t o%MA* ; ↓ CO (HR x ↓ SV ) 1 ↑ SVR.ecreased C' is com#ensated
by increase in H and S6
MA* is maintainedH &ill be increasedE1tremities &ill be cool due to
vasoconstriction
Shock Com#ensatory mechanisms%ail
MA* is reducedTachycardia< dys#nea<restlessness
Endorgandys%unction
Cell death and organ %ailure .ecreased renal %unction$iver %ailure.isseminated /ntravascularCoagulo#athy.eath
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/s this Shock
Signs and sym#toms$aboratory %indings
Hemodynamic measures
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Sym#toms and Signs o% Shock
$evel o% consciousness
/nitially may sho& %e& sym#tomsContinuum starts &ith
An1iety AgitationCon%usion and .elirium'btundation and Coma
I% %"*%t&'oor to%eU%"o$u&e+ *,e-e*k $rLet#*r .Com*(Su%ke% or /ul % "o%t*%elle)
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Sym#toms and Signs o% Shock
*ulseTachycardia H F +!! - 2hat are a %e& e1ce#tions
a#id< &eak< thready distal #ulses
es#irationsTachy#neaShallo&< irregular< labored
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7lood *ressureMay be normal.e%inition o% hy#otension
Systolic 4! mmHg
MA* B mmHg8! mmHg dro# systolic 7* %rom %rom baseline
ChildrenSystolic 7* + month ; B! mmHg
Systolic 7* + month - +! years ; D! mmHg I 9, 1 age in years:
/n children hy#otension develo#s l*te0 l*te0 l*teA !re1term %*l e2e%t
Sym#toms and Signs o% Shock
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Sym#toms and Signs o% Shock
SkinCold< clammy 9Cardiogenic< 'bstructive<Hemorrhagic:
2arm 9.istributive shock:Mottled a##earance in children$ook %or #etechia
.ry Mucous membranes$o& urine out#ut ! ml kg hr
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H !o2olem $S#o$k
D &tr /ut 2eS#o$k
C*r+ o e% $S#o$k
O/&tru$t 2eS#o$k
HR /ncreased /ncreased9Normal inNeurogenicshock:
May beincreased ordecreased
/ncreased
3V' $o& $o& High High
B' $o& $o& $o& $o&
SKIN Cold 2arm 9Coldin severeshock:
Cold Cold
CA'REFILL
Slo& Slo& Slo& Slo&
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Em#iric Criteria %or Shock
4 out o" 5 $r ter * #*2e to /e met
/ll a##earance or altered mental status
Heart rate F+!!es#iratory rate F ,, 9or *aC', 3, mmHg:"rine out#ut ! ml kg hr
Arterial hy#otension F ,! minutes duration$actate F 8
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$actate
$actate is increased in Shock
*redictor o% Mortality
Can be used as a guide to resuscitation
Ho&ever it is not necessary< or available inmany settings
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Management o% Shock
History*hysical e1am
$abs'ther investigationsTreat the Shock - Start treatment as soon
as you sus#ect *re-shock or ShockMonitor
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Historical Jeatures
Trauma*regnant
Acute abdominal #ain6omiting or .iarrheaHematoche?ia or hematemesis
Jever Jocus o% in%ectionChest #ain
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*hysical E1am
6itals - H < 7*< Tem#erature< es#iratoryrate< '1ygen SaturationCa#illary blood sugar 2eight in children
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*hysical E1am
/n a #atient &ith normal level o%consciousness - *hysical e1am can bedirected to the history
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*hysical E1am
/n a #atient &ith abnormal level o% consciousness*rimary survey
Cardiovascular 9murmers< K6*< mu%%led heart sounds:
es#iratory e1am 9crackles< &hee?es:< Abdominal e1am
ectal and vaginal e1amSkin and mucous membranes
Neurologic e1amination
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$aboratory Tests
C7C< Electrolytes< Creatinine 7"N< glucoseI - $actateI - Ca#illary blood sugar I - Cardiac En?ymes7lood Cultures - %rom t&o di%%erent sites7eta HCG
I - Cross Match
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'ther investigations
ECG"rinalysis
CLI - EchoI - JAST
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Treatment
St*rt tre*tme%t mme+ *tel
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Stages o% Shock
Early /ntervention can arrest or
reduce the damage
/nsult
*reshock9Com#ensation:
Shock9Com#ensation
'ver&helmed:
End organ.amage
.eath
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Treatment
A7C s to + Air&ay7reathingCirculation*ut the #atient on a monitor i% available
Treat underlying cause
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Treatment) Air&ay and 7reathing
Give o1ygen
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Consider /ntubation/s the cause 0uickly reversible
Generally no need %or intubation
3 reasons to intubate in the setting o% shock/nability to o1ygenate/nability to maintain air&ay2ork o% breathing
Treatment) Air&ay and 7reathing
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Treatment) Circulation
Treat the e*rl signs o% shock 9Cold<clammy .ecreased ca#illary re%illTachycardic Agitated :
.' N'T 2A/T %or hy#otension
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Treatment) Circulation
Start /6 I - Central line 9or /ntraosseous:.o 7lood 2ork I - 7lood Cultures
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Treatment) Circulation
Jluids - ,! ml kg bolus 1 3Normal saline
inger s lactate
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7ack to Case +
,8 year old male*reviously healthy$ives in a malaria endemic area 9*NG:7rought in by %riends a%ter a %ight - he &as kickedin the abdomenHe is agitated< and &on t lie %lat on the stretcher
H 4,< 7* +,B D,< Sa', 4 5< ,B
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Case +
'n e1aminationE1tremely agitatedClammy and coldHeart e1am - normalChest e1am - good air entry
Abdomen - bruised< tender< distended
No other signs o% trauma
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Case +) Management
Hemorrhagic 9Hy#ovolemic Shock: A7C s
Monitors
',/ntubate/6 lines 1 ,< Jluid boluses< Call %or 7lood - ' ty#e7lood &ork including cross match
Treat "nderlying Cause
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Case +) Management
Hemorrhagic 9Hy#ovolemic Shock: A7C s
Monitors',
/ntubate/6 lines 1 ,< Jluid boluses< Call %or 7lood - ' ty#e7lood &ork including cross match
Treat "nderlying CauseGive 7lood
Call the surgeon stat/% the #atient does not res#ond to initial boluses and blood#roducts - take to the '#erating oom
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7lood *roducts
"se blood #roducts i% no im#rovement to %luids* 7C -+! ml kg
'- in child-bearing years and 'I in everyone elseI - *latelets
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Case ,
,3 year old &oman in Addis AbabaHas been %atigued and short o% breath %or a%e& daysShe %ainted and %amily brought her inThey tell you she has a heart #roblem
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Case ,
H +3,< 7* DB 3B< Sa', OO5< 3!< Tem# 3B 3 A##earance - obtundedCardiovascular e1am - S+< S,< irregular<holosytolic murmer< K6* is cm ASA< no edemaChest - bilateral crackles< accessory muscle use
Abdomen - unremarkable
est o% e1am is normal
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Stages o% Shock
2hat stage is she at
/nsult
*reshock9Com#ensation:
Shock9Com#ensation
'ver&helmed:End organ.amage
.eath
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Case ,) Management
Cardiogenic Shock A7C s
Monitors
',/6 and blood &orkECG - Atrial Jibrillation< rate +3! s
Treat "nderlying Cause
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Case ,) Management
Cardiogenic Shock A7C s
Monitors',/6 and blood &ork/ntubateECG - Atrial Jibrillation< rate +3! s
Treat "nderlying Cause
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Case ,) 2hy &ould you intubate
/s the cause 0uickly reversible
3 reasons to intubate in the setting o% shock/nability to o1ygenate/nability to maintain air&ay2ork o% breathing
UNLIKELY
/nability to o1ygenate 9*ulmonary edema<
Sa', OO5:
AccessoryMuscle "se
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Case ,) 2hy /ntubate
Strenuous use o% accessory res#iratorymuscles 9i e &ork o% breathing: can)
/ncrease ', consum#tion by !-+!!5.ecrease cerebral blood %lo& by !5
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Case ,) Management
Cardiogenic Shock A7C s
Monitors',/6 and blood &ork/ntubateECG - Atrial Jibrillation< rate +3! s
Treat "nderlying Cause
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Case ,) Management
Cardiogenic ShockTreat "nderlying Cause
$asi1
Atrial Jibrillation - Cardioversion ate control/notro#es - .obutamine I - Nore#ine#hrine96aso#ressor:$ook %or #reci#itating causes - in%ectious
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6aso#ressors in Cardiogenic Shock
Nore#ine#hrine.o#amine
E#ine#hrine*henyle#hrine
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Case 3
3B year old &oman*edestrian hit by a car
She is brought into the hos#ital , hrs a%teraccidentShort o% breathHas been com#laining o% chest #ain
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Case 3
H +,B< S7* O,< Sa', D!5< 3B< Tem# 3'btunded< Accessory muscle useTrachea is deviated to $e%t
Heart - distant heart soundsChest - decreased air entry on the right< brokenribs< subcutaneous em#hysema
Abdominal e1am - normal A#art %rom bruises and scra#es no other signs o%trauma
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Stages o% Shock
2hat stage is she at
/nsult
*reshock9Com#ensation:
Shock9Com#ensation
'ver&helmed:End organ.amage
.eath
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Case 3) Management
'bstructive Shock A7C s
Monitors',/6/ntubate72
Treat "nderlying Cause
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Case 3) Management
'bstructive Shock A7C s
Monitors',/6/ntubate72
Treat "nderlying CauseNeedle thoracentesisChest tube
CL
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Case 3) Management
'bstructive Shock A7C s
Monitors',/6/ntubate72
Treat "nderlying CauseNee+le t#or*$e%te& &Chest tube
CL
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Case 3) Management
'bstructive Shock A7C s
Monitors',/6/ntubate72
Treat "nderlying CauseNee+le t#or*$e%te& &Chest tube
C6RI%tu/*te " %o re&!o%&e
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Case 3
Pou #er%orm a needle thoracentesis - heara hissing soundChest tube is inserted success%ullyH 4B< 7* +!! DB< Sa', 4B5 on ',< ,BPou resume your clinical duties< and callthe surgeon
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Case 3
+ hr has gone byPou are having lunch
The nurse #uts her head through the doorto tell you about another #atient at triage<and as she is leaving 7y the &ay< that&oman &ith the chest tube< is %eeling not
so good and leaves
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Case 3
Pou are back at the bedsideThe #atient is obtunded again*ale and Clammy
H +3!< 7* OB ,< Sa', 4B5 on ',Chest tube seems to be &orkingTrachea is midlineHeart - NormalChest - Good air entry
Abdomen - decreased bo&el sounds< distended
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Combined Shock
.i%%erent ty#es o% shock can coe1istCan you think o% other e1am#les
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Monitoring
6itals - 7*< H < Sa',Mental Status"rine 'ut#ut 9F +-, ml kg hr:2hen something changes or i% you do notobserve a res#onse to your treatment -re-e1amine the #atient
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Can &e measure cell hy#o1ia
$actate - &e already talked about - a surrogate
6enous '1ygen Saturation - more direct measure
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6enous '1ygen Saturation
Hg carries ',
A #ercentage o% ', is e1tracted by thetissue %or cellular res#iration
"sually the cells e1tract 3!5 o% the ',
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6enous '1ygen Saturation
Svo, ; Mi1ed venous o1ygen saturationMeasured %rom #ulmonary artery by S&an-Gan? catheter
Normal F B 5
Scvo, ; Central venous o1ygen saturationMeasured through central venous cannulation o% S6C or
Atrium - i e Central $ine
Normal F D!5
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*A T ,
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Case 8
8! year old male"Q abdominal #ain< %ever< %atigued %or -B
daysNo #ast medical history
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Case 8
H ++!< 7* +!! D,< Sa', 4B5< T 34 ,< ,B.ro&sy2arm skin
Heart - S+< S,< no MurmersChest - good A E 1 ,
Abdomen - decreased bo&el sound< tender "Q
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Stages o% Shock
2hat stage is he at
/nsult
*reshock9Com#ensation:
Shock9Com#ensation
'ver&helmed:End organ.amage
.eath
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Stages o% Se!& &
S/ S
SE*S/S
SE6E ESE*S/S
SE*T/CSH'C>
M'.S .EATH
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.e%initions o% Se#sis
S &tem $ I%"l*mm*tor Re&!o%&e S %+rome (SIRS) = ,or F o%)-Tem# F 3O or 3B
- F ,!-H F 4! min
-27C F+,
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.e%initions o% Se#sis
Se!& & = S/ S &ith !ro2e% or &u&!e$te+m $ro/ *l &our$e
Se2ere Se!& & = se#sis &ith one or moresigns o% organ dys%unction or hy#o#er%usion
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.e%initions o% Se#sis
Se!t $ o$k 7 Se#sis I e%ractoryhy#otension
-"nres#onsive to initial %luids ,!-8!cc kg =6aso#ressor de#endant
MODS = multi#le organ dys%unction
syndrome-, or more organs
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Stages o% Se#sis
Mortality
D5
+B5
,!5
D!5
S/ S
SE*S/S
SE6E ESE*S/S
SE*T/CSH'C>
M'.S .EATH
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*atho#hysiologyCom#le1 #atho#hysiologic mechanisms
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*atho#hysiology
/n%lammatory Cascade)Humoral< cellular and Neuroendocrine 9TNJ< /$etc:
Endothelial reactionEndothelial #ermeability ; leaking vessels
Coagulation and com#lement systemsMicrovascular %lo& im#airment
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*atho#hysiology
End result ; Global Cellular Hy#o1ia
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Jocus o% /n%ection
Any %ocus o% in%ection can cause se#sisGastrointestinalG"'ralSkin
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isk Jactors %or Se#sis
/n%ants/mmunocom#romised #atients
.iabetesSteroidsH/6Chemothera#y malignancyMalnutrition
Sickle cell disease.isru#ted barriers
Joley< burns< central lines< #rocedures
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7ack to Case 8H ++!< 7* +!! D,< Sa', 4B5< T 34 ,< ,!.ro&sy2arm skinHeart - S+< S,< no MurmersChest - good A E 1 ,
Abdomen - decreased bo&el sound< tender "Q
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Case 8) Management.istributive Shock 9SE*S/S:
A7C sMonitors',/6 %luids ,! cc kg 1 3/ntubate72
Treat "nderlying Cause
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esuscitation in Se#sis
E*rl o*l + re$te+ t#er*! 1 R 2er& et *l NE3M 899:
"sed in #t s &ho have) an in%ection< , or more S/ S< have asystolic 4! a%ter ,!-3!cc ml or have a lactate F 8
Emergency #atients by emergency doctors
esuscitation #rotocol started early - B hrs
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7AC T' '" EQ"AT/'N
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7AC> T' '" EQ"AT/'N
MA* ; C' 1 S6
9H 1 Stroke volume:
*reload A%terload
Contractility
7AC> T' '" EQ"AT/'N
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7AC> T' '" EQ"AT/'N
MA* ; C' 1 S6
9H 1 Stroke volume:
*reload A%terload
Contractility
* l d
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*reload
.e#endent on intravascular volume/% de#leted intravascular volume 9due to increased endothelial#ermeability: - * E$'A. .EC EASES
Can use the C6* as measurement o% #reloadNormal ; O-+, mm Hg
* l d
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*reload
Ho& do you correct decreased #reload 9or intravascularvolume:
Give %luidsivers sho&ed an average o% ; L in %irst B hours
2hat is the end #oint
7AC> T' '" EQ"AT/'N
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7AC> T' '" EQ"AT/'N
MA* ; C' 1 S6
9H 1 Stroke volume:
*reload A%terload
Contractility
A%t l d
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A%terload
A"terlo*+ +eterm %e& t &&ue !er"u& o%
"sing the MA* as a surrogate measure - >ee# bet&een B!-4!mm Hg
/n se#sis a%terload is decreased d t loss o% vessel tone
A%t l d
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A%terload
Ho< +o ou $orre$t +e$re*&e+ *"terlo*+=
"se vaso#ressor agentNore#ine#hrine
Alternative .o#amine or *henyl#ehrine
7AC> T' '" EQ"AT/'N
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7AC> T' '" EQ"AT/'N
MA* ; C' 1 S6
9H 1 Stroke volume:
*reload A%terload
Contractility
Contractility
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Contractility
"se the central venous o1ygen saturation9Scv',: as a surrogate measure
Sho&n to a be a surrogate %or cardiac inde1
>ee# F D!5
Contractility
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Contractility
Ho< to m!ro2e S$2O8 > ?9@=
'#timi?e arterial ', &ith non-rebreather
Ensure a hematocrit F 3! 9Trans%use to reach a hematocrit o% F 3!:
"se /notro#e - .obutamine , ug kg #er minute and titrated 9ma1,!ug kg:
Re&! r*tor Su!!ort - /ntubation 9.on t %orget to sedate and #araly?e:
Suspect infectionD i hi 2h
E DT
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Document source within 2hrs
The high risk pt: Systolic < 90 after bolus
Or Lactate !mmol"l
#b$ within % hr & source control
'() 'rystalloi*
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Document source within 2hrs
The high risk pt: systolic < 90 after bolus
Or Lactate !mmol"l
#b$ within % hr & source control
'() 'rystalloi*
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Document source within 2hrs
The high risk pt: systolic < 90 after bolus
#b$ within % hr #n* source control
MAP (UrineOutput)
,ore flui*s< ./ mm3g
,#) (asopressors
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Case 8) Management
.istributive Shock 9SE*S/S: A7C s
Monitors',/6 %luids ,! cc kg/ntubate72
Treat "nderlying CauseA$et*m %o!#e%
Antibiotics - IVE EARLYSource control - the 8 . s ; .rain< .ebride< .evice removal<.e%initive Control
A ibi i
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Antibiotics
E*rl A%t / ot $&
2ithin 3-Bhrs can reduce mortality - 3!5
2ithin + hr %or those severely sick
.on t &ait %or the cultures = treat em#irically thenchange i% need
'ther treatments %or severe se#sis)
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ther treatments %or severe se#sis)
Glucocorticoids
Glycemic Control Activated #rotein C
Cou#le o% &ords about Steroids in
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se#sis@
Ne< u +el %e& "or t#e m*%* eme%t o"&e!& & *%+ &e!t $ o$k 7 Sur2 2 %Se!& & C*m!* %
Grade ,C = consider steroids %or se#tic shockin #atients &ith 7* that res#onds #oorly to %luidresuscitation and vaso#ressors
Cr t $*l C*re Me+ 899 3*% 5 8 5
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Concluding emarks
>no& ho& to distinguish di%%erent ty#es o%shock and treat accordingly
$ook %or e*rl signs o% shock
SH'C> ; hy#otension
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Concluding emarks
Choose cost e%%ective and high im#actinterventions
Do %ot %ee+ $e%tr*l l %e& *%+ S$2O8 measurements to make an im#act
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Concluding emarks
A7C s to +Can t intubate
Give o1ygen
.evelo# algorithms %or bag valve mask ventilationTreat %ever to decrease res#iratory rate
Treat early &ith %luids - need lots o% it
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Concluding emarks
Monitor the #atient.o not need central venous #ressure andScv',
"se the H < MA*< mental status< urine out#ut$actate clearance
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Concluding emarks
Start antibiotics &ithin an hour.o not &ait %or cultures or blood &ork
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