shock susan stroud, md u. of utah health sciences center division of emergency services

SHOCK

Susan Stroud, MD

U. Of Utah Health Sciences Center

Division of Emergency Services

Yesterday!!!!!!!!!!!

Tour Highlights

Definition Categories of shock Recognizing shock Treating shock

Who described Shock?

LeDran coined the term “choc” to describe the clinical characteristics observed following severe gunshot trauma in 1773

Shock - “a rude unhinging of the machinery of life”

Samuel Gross 1872

What is shock?

The clinical manifestation of cellular disorganization

A physiological state that results in inadequate organ perfusion and tissue oxygenation

A transition state between illness and death

PathogenesisLow Cardiac

Output or Vasodilatation

Decreased perfusionMajor End-Organ

Dysfunction

MicrocirculatoryFailure

Endothelial Damage

Cellular membraneInjury

Compensated hypotension

Decompensatedhypotension

Cellular Death?

Potentially reversibleshock Irreversible shock

Stage I. Stage II. Stage III.

Pathophysiology of Shock ok

CARDIAC OUTPUT =CARDIAC OUTPUT = HR X SVHR X SV

Sympathetic n. systemSympathetic n. systemCatecholamineCatecholamine releaserelease

Increase EDV via:Increase EDV via:Activation of Renin-Activation of Renin-Angiotensin SystemAngiotensin System

VenoconstrictionVenoconstrictionArteriolar constrictionArteriolar constriction

Renal reabsorptionRenal reabsorption

Increased contractilityIncreased contractilityPeripheral Peripheral

vasoconstrictionvasoconstriction

Limited to 180 beats/min Limited to 180 beats/min before decreased CO due before decreased CO due

to decreased diastolic to decreased diastolic filling timefilling time

(30 seconds)

(10 min)

(1 - 48 hrs)

The cycle of compensation and decompensation

Hypoperfusion Compensatory Mechanisms FAILURE

Myocardial Perfusion and Cardiac Output decrease

Tissue Hypoperfusion leads to anaerobic metabolism and lactic acidosis

Acidosis produces vasodilatation and worsening hypotension

Altered Mental StatusDiminished peripheral pulseOliguria

Multi-systemOrgan Failure

DEATH

Clinical pathophysiology of Shock

An abnormality of Heart Rate An abnormality of Stroke Volume An abnormality of Peripheral Resistance A failure of any of these to compensate for an

abnormality of the others

Vital signs are vital to recognizing shock

The Crucial Factor: OXYGEN

End organs are dependent on the circulatory system for an adequate supply of oxygen

If oxygen supply becomes limited, the body will work to preserve heart and brain function by sacrificing other systems

TREATMENT OF SHOCKTREATMENT OF SHOCKENHANCING PERFUSION/OXYGEN DELIVERYENHANCING PERFUSION/OXYGEN DELIVERY

Oxygen delivery = HR X SV X Hb X S0Oxygen delivery = HR X SV X Hb X S02 2 X 1.34 + Hb X paOX 1.34 + Hb X paO22

Cardiac Cardiac outputoutput Arterial OArterial O22

contentcontent

FluidsFluids TransfuseTransfuse Partially Partially dependent on dependent on

FIOFIO22 and and pulmonary pulmonary

statusstatus

InotropesInotropes

GOLDEN RULES OF SHOCK GOLDEN RULES OF SHOCK RESUSCITATIONRESUSCITATION

Maintain ventilationMaintain ventilation

Enhance perfusionEnhance perfusion

Treat underlying causeTreat underlying cause

Classifying Shock Hypovolemic shock -

volume problem

Cardiogenic shock - pump problem

Distributive shock - tubing problem

Obstructive shock - pump function blocked by mechanical obstruction

CLINICAL ENDPOINTS CLINICAL ENDPOINTS OF SHOCKOF SHOCK

END-STAGE SHOCK

BradycardiaArrythmias

Death

DECREASED BLOOD FLOW TO BRAIN AND HEART

Restless, agitated, confusedHypotensionTachycardiaTachypnea

Hypovolemic Shock

Hemorrhagic Severe burn GI losses

vomiting and diarrhea

Urinary DKA, diabetes insipidus

Hypovolemic Shock

CLASS I II III IV

BVL < 15% 15 - 30% 30 - 40% > 40%

AMOUNT 750 cc 750 - 1500 cc 1500 - 2000 cc > 2000 cc

PULSE Minimal increase

> 100 Marked increase Marked increase

BP No change Narrowed pulse pressure

Consistent decrease in SBP

Decreased SBP and narrowed pulse pressure or no DBP

RESP No change Mild tachypnea Marked tachypnea Marked tachypnea

OTHER None Anxiety, fright, hostility

Significant change in mental status

Decreased level of consciousness, minimal urine output, skin is cold and pale

TX Replace fluid loss

2L NS IV 2 L NS IV, usually requires blood transfusion

Rapid transfusion of blood and NS, requires immediate intervention to stop hemorrhage

Trauma Ringdown

Radio report: We’re on our way with a 25 year old male in a head on MVA. He has sustained obvious chest and abdominal trauma and has a GCS of 13.

Current VS are: HR 125 RR 28 BP 100/50 T 36.0 Sa02 93% on NRBM

Trauma Exam

Patient is agitated and confused. His R chest wall appears to be deformed.

His abdomen is rigid, and appears to be getting larger.

WHAT DO WE DO NEXT?

Maintain ventilationMaintain ventilation

Enhance perfusionEnhance perfusion

Treat underlying causeTreat underlying cause

What studies or labs can help you immediately?

Think in terms of the ABC’s

Chest X-ray (B for breathing) FAST exam (C for circulation) Frequent vital signs and continuous cardiac and

oxygen monitoring

Chest X-ray

What do you see on this chest xray?

Does it explain any of this patients vital signs?

What should you do about it?

Hemothorax

Hypovolemic Resuscitation

Give Oxygen Assist Breathing if needed Maximize Circulation by

giving IV fluids or blood Stop the bleeding and

repair the damage

Have you saved the patient?

FAST exam to look for intra-abdominal free fluid

Cardiogenic Shock

Cardinal elements are hypotension (SBP < 90) and hypoperfusion with pulmonary congestion

Mortality is 50 - 80% before reperfusion therapy and cath lab availability

Acute myocardial ischemia is most common cause

Cardiac Case

65 yr old female, c/o crushing chest pain, SOB, nausea, diaphoresis for three hours

VS are: BP 90/40 RR 28 T 36.5 Sa02 90% HR 115

WHAT DO WE DO NEXT?

Maintain ventilationMaintain ventilation

Enhance perfusionEnhance perfusion

Treat underlying causeTreat underlying cause

What studies or labs can help you immediately?

EKG CXR Frequent vital signs and continuous cardiac and

oxygen monitoring

EKG

Chest X-ray

Cardiogenic Resuscitation

Maximize oxygenation Stabilize breathing Maximize circulation Treat her heart -

nitroglycerin, aspirin, beta-blocker, CATH LAB or thrombolysis

Neurogenic Shock

Usually the result of spinal cord injury

Loss of sympathetic tone and decreased vasomotor tone can result in hypotension and bradycardia

Patients may remain alert, warm, and dry despite the hypotension

More Trauma

29 yo male, PVA while crossing the street, awake, complaining of severe back pain, and inability to move or feel his legs

VS are: HR 45 RR 25 BP 100/45 Sa02 98% T 34.0

WHAT DO WE DO NEXT?

Maintain ventilationMaintain ventilation

Enhance perfusionEnhance perfusion

Treat underlying causeTreat underlying cause

What studies or labs can help you immediately?

Xrays FAST exam Frequent vital signs and continuous cardiac and

oxygen monitoring

Xrays from the trauma bay

Neurogenic Resuscitation

Adequate oxygenation Assess breathing Maximize circulation

IV fluids or blood Pressors if necessary

Support heart rate if needed atropine

Prepare for the OR and call a neurosurgeon now!

Anaphylactic Shock

An IgE mediated event that triggers massive release of immune response mediators

Results in widespread peripheral vasodilation, bronchial smooth muscle contraction, and local vascular dilatation

Attack of the Killer Bees

40 yo male, living in Golden Gate park, set up his tent next to a bee hive and now reports multiple stings

VS are: RR 30 HR 130 BP 90/45 T 36.5 Sa02 92%

WHAT DO WE DO NEXT?

Maintain ventilationMaintain ventilation

Enhance perfusionEnhance perfusion

Treat underlying causeTreat underlying cause

What studies or labs can help you immediately?

Frequent vital signs and continuous cardiac and oxygen monitoring

Examine patient for clinical signs of anaphylaxis

Clinical Exam

Patient is covered in hives, is speaking in two word sentences, has loud wheezing sounds with respirations

Anaphylactic resuscitation

Maximize Oxygenation Assist Breathing if needed

Bronchodilators Consider intubation

Stabilize circulation IV fluids, epinephrine,

pressors

Stabilize immune system reaction Steroids, histamine blockers

(benadryl and H2 blocker)

Septic Shock

A blood borne infection widely disseminated to many areas of the body

Common features are high fever, vasodilation (especially in affected tissues)

Sludging of the blood, and RBC agglutination resulting in DIC

“I don’t feel right” 35 yo male, reports “I’m

dope-sick” c/o fever, chills, fatigue, sweating for one day. Last used heroin yesterday. Also c/o leg pain at site of last injection

VS are: BP 80/40 T 41.0 RR 26 Sa02 95% HR 130

WHAT DO WE DO NEXT?

Maintain ventilationMaintain ventilation

Enhance perfusionEnhance perfusion

Treat underlying causeTreat underlying cause

What studies or labs can help you immediately?

CXR, UA Frequent vital signs and continuous cardiac and

oxygen monitoring Examine patient for clinical signs of sepsis Echocardiogram

Treating septic shock

Maximize Oxygenation Assist Breathing if needed Maximize Circulation

IV Fluids, pressors

Start Antibiotics Consider surgical

intervention if needed

PRINCIPLES OF RESUSCITATIONPRINCIPLES OF RESUSCITATION

Maintain ventilationMaintain ventilation

Enhance perfusionEnhance perfusion

Treat underlying causeTreat underlying cause

TREATMENT OF SHOCKTREATMENT OF SHOCKENHANCING PERFUSION/OXYGEN DELIVERYENHANCING PERFUSION/OXYGEN DELIVERY

Oxygen delivery = HR X SV X Hb X S0Oxygen delivery = HR X SV X Hb X S02 2 X 1.34 + Hb X paOX 1.34 + Hb X paO22

Cardiac Cardiac outputoutput Arterial OArterial O22

contentcontent

FluidsFluids TransfuseTransfuse Partially Partially dependent on dependent on

FIOFIO22 and and pulmonary pulmonary

statusstatus

InotropesInotropes

Which Pressor should I choose?

Hypovolemic shock Fluids and Blood

Cardiogenic shock Dobutamine - 1 agonist

Increases squeeze and heart rate

Neurogenic shock Fluids - look for another type of

shock if it is persistent

Anaphylactic shock Fluids and epinephrine

Septic shock Neosynephrine - alpha agonist

Increases SVR by arteriolar constriction

Levophed - alpha and beta agonists

Dopamine Low Dose - increases renal blood

supply Medium Dose - beta effects (increases

heart rate and squeeze) High Dose - alpha effects (arteriolar

constriction)

Final Case

82 yr old female with cc: Chest pain and SOB

D/C’d this AM from an outside hospital after one month stay 2nd to complicated CABG

Today became increasingly weak and SOB, with DOE and substernal chest pain and coughing

Case Study

Vital Signs on Arrival: Pulse 55 bpm BP 81/39 RR 33 Temp 35.3 R Sa02 83% on RA

WHAT DO WE DO NEXT?

Maintain ventilationMaintain ventilation

Enhance perfusionEnhance perfusion

Treat underlying causeTreat underlying cause

What studies or labs can help you immediately?

CXR EKG Frequent vital signs and continuous cardiac and

oxygen monitoring

Case Study - EKG

Case Study - Old EKG

Case Study - CXR

Case Study Interventions

Interventions!

Airway - O2 BP - fluids vs. pressors HR - inappropriate bradycardia (?) RR - O2 and CXR

Case Study - Outcome

Echo - LV aneurysm Blood Cultures - MRSA Dx: Hospital acquired MRSA pneumonia Dispo: Pt was treated in the ICU with antibiotics

for one week, recovered well, and returned home to her family

Take Home Message

All shock can be approached using the ABC’s to maximize cardiac output

It is possible to have more than one kind of shock

It is not always possible or necessary to have much information to begin proper resuscitation of a patient

My cats are REALLY CUTE!