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SHOCK
Susan Stroud, MD
U. Of Utah Health Sciences Center
Division of Emergency Services
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Yesterday!!!!!!!!!!!
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Tour Highlights
Definition Categories of shock Recognizing shock Treating shock
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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
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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
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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
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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)
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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
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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
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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
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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
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GOLDEN RULES OF SHOCK GOLDEN RULES OF SHOCK RESUSCITATIONRESUSCITATION
Maintain ventilationMaintain ventilation
Enhance perfusionEnhance perfusion
Treat underlying causeTreat underlying cause
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Classifying Shock Hypovolemic shock -
volume problem
Cardiogenic shock - pump problem
Distributive shock - tubing problem
Obstructive shock - pump function blocked by mechanical obstruction
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CLINICAL ENDPOINTS CLINICAL ENDPOINTS OF SHOCKOF SHOCK
END-STAGE SHOCK
BradycardiaArrythmias
Death
DECREASED BLOOD FLOW TO BRAIN AND HEART
Restless, agitated, confusedHypotensionTachycardiaTachypnea
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Hypovolemic Shock
Hemorrhagic Severe burn GI losses
vomiting and diarrhea
Urinary DKA, diabetes insipidus
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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
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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
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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.
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WHAT DO WE DO NEXT?
Maintain ventilationMaintain ventilation
Enhance perfusionEnhance perfusion
Treat underlying causeTreat underlying cause
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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
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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?
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Hemothorax
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Hypovolemic Resuscitation
Give Oxygen Assist Breathing if needed Maximize Circulation by
giving IV fluids or blood Stop the bleeding and
repair the damage
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Have you saved the patient?
FAST exam to look for intra-abdominal free fluid
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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
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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
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WHAT DO WE DO NEXT?
Maintain ventilationMaintain ventilation
Enhance perfusionEnhance perfusion
Treat underlying causeTreat underlying cause
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What studies or labs can help you immediately?
EKG CXR Frequent vital signs and continuous cardiac and
oxygen monitoring
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EKG
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Chest X-ray
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Cardiogenic Resuscitation
Maximize oxygenation Stabilize breathing Maximize circulation Treat her heart -
nitroglycerin, aspirin, beta-blocker, CATH LAB or thrombolysis
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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
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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
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WHAT DO WE DO NEXT?
Maintain ventilationMaintain ventilation
Enhance perfusionEnhance perfusion
Treat underlying causeTreat underlying cause
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What studies or labs can help you immediately?
Xrays FAST exam Frequent vital signs and continuous cardiac and
oxygen monitoring
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Xrays from the trauma bay
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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!
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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
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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%
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WHAT DO WE DO NEXT?
Maintain ventilationMaintain ventilation
Enhance perfusionEnhance perfusion
Treat underlying causeTreat underlying cause
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What studies or labs can help you immediately?
Frequent vital signs and continuous cardiac and oxygen monitoring
Examine patient for clinical signs of anaphylaxis
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Clinical Exam
Patient is covered in hives, is speaking in two word sentences, has loud wheezing sounds with respirations
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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)
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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
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“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
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WHAT DO WE DO NEXT?
Maintain ventilationMaintain ventilation
Enhance perfusionEnhance perfusion
Treat underlying causeTreat underlying cause
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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
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Treating septic shock
Maximize Oxygenation Assist Breathing if needed Maximize Circulation
IV Fluids, pressors
Start Antibiotics Consider surgical
intervention if needed
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PRINCIPLES OF RESUSCITATIONPRINCIPLES OF RESUSCITATION
Maintain ventilationMaintain ventilation
Enhance perfusionEnhance perfusion
Treat underlying causeTreat underlying cause
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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
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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)
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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
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Case Study
Vital Signs on Arrival: Pulse 55 bpm BP 81/39 RR 33 Temp 35.3 R Sa02 83% on RA
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WHAT DO WE DO NEXT?
Maintain ventilationMaintain ventilation
Enhance perfusionEnhance perfusion
Treat underlying causeTreat underlying cause
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What studies or labs can help you immediately?
CXR EKG Frequent vital signs and continuous cardiac and
oxygen monitoring
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Case Study - EKG
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Case Study - Old EKG
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Case Study - CXR
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Case Study Interventions
Interventions!
Airway - O2 BP - fluids vs. pressors HR - inappropriate bradycardia (?) RR - O2 and CXR
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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
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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!