MANAGEMENT OF SHOCK Dr. Hanin Osama

1-Management of hypovolemic Shock ABCs (Air way,Breathing ,Circulation ) Establish 2 large bore IV cannula 16 gauge or larger or a central line (internal jugular and subclavian vein catheterization) Crystalloids Normal Saline or Lactate Ringers(Lactated Ringer's solution is a solution that is isotonic with blood and intended for intravenous administration. It may also be given subcutaneously.single dose container.(sodium chloride, soldium lactate, potassium chloride and calcium chloride) 2-3 liters Packed RBCs O negative or cross matched Control any bleeding Arrange definitive treatment

2-Treatment of Cardiogenic Shock Goals- Airway stability and improving myocardial pump function Cardiac monitor, pulse oximetry (Pulse oximeters are non-invasive devices used to measure a patient's blood-oxygen saturation level and pulse rate.) Supplemental oxygen IV access Diuretics Positive inotropic drugs IABP (Intra-Aortic Balloon Pump) is utilized if medical therapy is ineffective. Catheterization if ongoing ischemia Cardiogenic shock is the exception to the rule that NS (Normal saline)is always given for hypotension NS will exacerbate cardiac shock.

Treatment of Cardiogenic Shock AMI Aspirin, statin, clopedogril, morphine, heparin If no pulmonary edema, IV fluid challenge If pulmonary edema Dopamine – will ↑ HR and thus cardiac work Dobutamine – May drop blood pressure Combination therapy may be more effective PCI (percutaneous intervention ) or thrombolytics Right Ventricle infarct Fluids and Dobutamine (no NitroGlycerine) Acute mitral regurgitation or Ventral Septal Defect Pressors (Dobutamine)

3. Distributive, A. Management of Septic Shock 2 large bore Ivs NS I/V bolus- 1-2 L wide open (A large volume of fluid or dose of a drug given intravenously and rapidly at one time. intravenous bolus,. a relatively large dose of medication administered into a circulation ) Supplemental oxygen Empiric antibiotics, based on suspected source, as soon as possible, Broad Spectrum Antibiotics Cover gram positive and gram negative bacteria Add additional coverage as indicated e.g. MRSA- Vancomycin, Asplenic- Ceftriaxone for N. meningitidis, H. infuenzae Vasopressors e.g. dopamine to raise the BP Bicarbonate if pH < 7.1

B-Anaphylactic Shock- Treatment ABC’s; Angioedema and respiratory compromise require immediate intubation(is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or 4 the purpose of adding & removing fluid)... IV, cardiac monitor, pulse oximetry IV Fluids, oxygen Epinephrine 0.3 mg IM of 1:1000 (epi-pen) Repeat every 5-10 min as needed Caution with patients taking beta blockers- can cause severe hypertension due to unopposed alpha stimulation For CV collapse, 1 mg IV of 1:10,000 If refractory, start IV drip Corticosteriods Epi – the single most important step in treatment

Anaphylactic Shock - Treatment H1 and H2 blockers H1 blocker- Diphenhydramine 25-50 mg IV H2 blocker- Ranitidine 50 mg IV Bronchodilators; Albuterol nebulizer, Atrovent nebulizer, Magnesium sulfate 2 g IV over 20 minutes Glucagon(May be used as an inotropic agent in beta-blocker overdose.) For patients taking beta blockers and with refractory hypotension. 1 mg IV q (each,every )5 minutes until hypotension resolves All patients who receive epinephrine should be observed for 4-6 hours If symptom free, discharge home If on beta blockers or h/o severe reaction in past, consider admission. B-blk==hypoglycemia Methylprednisolone causes less fluid retention

C-Neurogenic Shock- Treatment A,B,Cs Remember c-spine precautions Fluid resuscitation Keep MAP(mean arterial pressure ) at 85-90 mm Hg for first 7 days Thought to minimize secondary cord injury If crystalloid is insufficient use vasopressors Search for other causes of hypotension For bradycardia Atropine Pacemaker Methylprednisolone Used only for blunt spinal cord injury High dose therapy Must be started within 8 hours Controversial- Risk for infection, GI bleed

4. Obstructive Shock Tension pneumothorax Rx: Needle decompression, chest tube B. Cardiac tamponade ( In this condition, blood or fluid collects in the pericardium, the sac surrounding the heart. This prevents the heart ventricles from expanding fully.) Rx: Pericardiocentesis (Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac, the tissue that surrounds the heart) C. Pulmonary embolism Rx: Heparin, consider thrombolytics

Resuscitation Fluids Normal Saline, Crystalloids (used as a first line in the treatment of shock) Blood (in case of bleeding/anemia) Lactated Ringers Colloids Hetastarch may aggravate bleeding Dextran use as plasma expanders These solutions are not used as often as albumin or hetastarch for plasma expansion, possibly due to concerns related to aggravation of bleeding and anaphylaxis. Hypertonic Saline Blood Substitutes

Autonomic Drugs in Shock