1. SHOCK

2. Pretest A patient was in a motorcycle accident. He is confused and hypotensive. What type of shock could he have? a)Hypovolemic b)Cardiogenic c)Distributive d)Obstructive

3. Pretest What statements about early hypovolemic shock are true? a)The patient may be alert and oriented. b)A patient may have a normal blood pressure. c)The patient may have a widened pulse pressure. d)The patient may not have a palpable femoral pulse. e)The patient may be tachycardic.

4. Pretest Which of the following signs might you find on examination in a patient with obstructive shock? a)High JVP b)Crepitations on chest auscultation c)Decreased breath sounds d)Tachycardia e)Subcutaneous emphysema

5. Pretest Which of the following can cause distributive shock? a)Myocardial infarction b)Burn c)Spinal cord injury d)Severe allergy / Anaphylaxis e)Sepsis

6. Pretest A 70 year old man has a history of chest pain with exertion. On examination he has a high JVP, an S3 heart sound, and bilateral pulmonary crepitations. His RR = 30, PR = 115, BP = 90/60. Appropriate treatment includes: a)Give 1 L bolus of NS b)Give oxygen c)Give diuretic (I.e. Lasix) d)Insert chest tubes e)Give drug to reduce systemic vascular resistance

7. Pre-test 30 year old female has postpartum bleeding. She is restless. Vital signs: RR=30, BP=90/60, PR=130. Her weight appears to be 50kg. Appropriate management includes: a)1 - 2 litres of NS immediately b)1 - 2 litres of D5W immediately c)At least 4 litres of NS immediately d)Close monitoring of vital signs and urine output e)Cross-match for blood transfusion as soon as possible f)Find and treat cause of bleeding

8. What Is Shock?

9. Shock Body tissues are not properly perfused (not enough oxygen delivery) Either the body cannot supply enough oxygen, or the cells cannot take up the oxygen Cells become hypoxic and cannot function

10. Pathophysiology of Shock Cardiac Output (CO) is the volume of blood pumped by heart in 1 minute CO = HR X SV HR = Heart rate (beats per minute) SV = Stroke volume (volume of blood ejected through heart per beat)

11. Pathophysiology of Shock Mean Arterial Pressure (MAP) is the average blood pressure in a person MAP (approx) = CO X SVR CO = Cardiac output SVR = Systemic vascular resistance –If either decrease, the BP will decrease

12. Pathophysiology of Shock Not enough blood flow  cells starved for oxygen  Production of lactic acid Lactic acidosis  Na+ floods into cells  cells swell Swelling of mitochondria in cells  stops metabolism  cells die

13. Physiological Response How does the body respond to insufficient perfusion (not enough O2 being delivered to major organs)?

14. Physiological Response Body tries to increase CO and increase SVR to improve BP MAP (BP) = CO X SVR

15. What is the Cardiovascular Response? Heart rate increase Peripheral vasoconstriction Adrenalin release Central vasodilation to improve blood flow to heart, kidneys, brain

16. What is the Renal Response? Increased release of renin-angiotensin Increased Na+ reabsorption by kidneys to improve blood volume Vasoconstriction to increase systemic SVR

17. What is the Neuroendocrine Response? ADH release with increased water absorption by kidneys to improve blood volume

18. What do we need for perfusion?

19. Requirements for Perfusion Functioning pump Intact vascular system Adequate volume Adequate air exchange ** Failure of any one or more causes SHOCK

20. What are the Types of Shock?

21. Hypovolemic Cardiogenic Distributive Obstructive

22. What is Hypovolemic Shock?

23. Loss of blood or plasma –Decreased circulating blood volume within the total vascular capacity –Results in decreased diastolic filling pressures into heart

24. What are causes of Hypovolemic Shock?

25. Hemorrhagic / Bleeding –Trauma Intraabdominal / Retroperitoneal / Intrathoracic / Thighs –GI bleeding –Pregnancy related Non Hemorrhagic –Plasma Loss Dehydration –Vomiting / Diarrhea / Gastroenteritis –Interstitial Fluid Redistribution Peritonitis Severe Pancreatitis Burns Diabetic Ketoacidosis

26. What is Cardiogenic Shock?

27. Poor ventricular function because of loss of myocardial contractility (The heart pump is NOT working well) Results in increased diastolic filling pressures and volumes in the heart

28. What are causes of Cardiogenic Shock?

29. Myocardial Infarction Cardiomyopathy Valvular disease Myocardial contusion –Patient may present with: Congestive Heart Failure Arrhythmias

30. What is Distributive Shock?

31. Loss of vasomotor control resulting in arterial / venous dilatation Characterized (after fluid resuscitation) by increased cardiac output and decreased SVR

32. What are causes of Distributive Shock?

33. Septic Shock –Vasodilation and increased vascular permeability (plasma volume loss) Anaphylactic Shock –Vasodilation Neurogenic Shock / Spinal Cord Injury –Loss of vasomotor control (no vasoconstriction)

34. What is Obstructive Shock?

35. Obstruction to flow in the cardiovascular system –Not due to poor cardiac ventricles – Blood cannot get into heart impairment in diastolic filling –Blood cannot get out of heart Excessive afterload

36. What are causes of Obstructive Shock?

37. Impaired Diastolic Filling (Decreased ventricle preload) –Tension pneumothorax –Cardiac tamponade –Constrictive pericarditis Impaired Systolic Contraction (Increased ventricle afterload) –Pulmonary embolism (large) –Acute pulmonary hypertension

38. Common Effects of Shock on Organs Systemic –Capillary leak, cytokine release CV –Depression of cardiac function, arrhythmia Hematology –DIC, coagulopathy, bone marrow suppression, platelet dysfunction

39. Common Effects of Shock on Organs Hepatic –Elevation of liver enzymes, coagulopathy, hepatic failure Neuroendocrine –Adrenal suppression, insulin resistance Renal –Acute kidney injury, increased creatinine and BUN

40. General Approach Primary Survey –A: Airway –B: BreathingAssess –C: CirculationResuscitate –D: DisabilityMonitor –E: Exposure History and Secondary Survey Continue to monitor / Arrange transport

41. Monitoring Regular and ongoing monitoring is very important –Respiratory rate –Pulse rate –Blood pressure –Temperature –Urine output Minimum urine output in adult is 0.5 ml/kg/hr –Level of consciousness (i.e. Glasgow coma scale)

42. Common Mistakes in Managing Shock Patient assessment is not thorough Symptoms and signs of a serious illness are not recognized Appropriate and urgent care is not provided Patient is not regularly monitored

43. PATIENT HISTORY will usually indicate the cause of the shock

44. Circulation Assess –Inspect: Colour (pale / cyanosis) Temperature of skin Dilated neck veins Dry mucous membranes –Palpate: Pulse rate and character (compare peripheral and central pulse) Capillary refill / Skin turgor Character and location of cardiac apex beat –Auscultate: BP Heart sounds / Extra heart sounds / Murmurs

45. Circulation Remember the signs of heart failure –Tachycardia –Raised JVP (often not seen in infants with heart failure) –Lung crepitations on auscultation –Enlarged liver –… and listen for a heart murmur

46. What are the signs of Early Shock?

47. Early Shock Early shock may have few symptoms or signs in young healthy patients –Healthy cardiovascular system compensates Older patients may show signs and symptoms earlier –Cardiovascular system is less capable to compensate

48. Compensated Shock (Early Shock) EARLY WARNING SIGNS –Anxiousness –Delayed capillary refill –Tachycardia –Increasing RR –BP may be normal –Narrowed pulse pressure

49. Circulation Pulse Pressure –Difference between systolic and diastolic pressure BP: 120/80 = pulse pressure is 120 - 80 = 40 –Young patients can compensate to maintain good cardiac output for quite awhile even when they are going into shock by: –Increasing HR –Maintaining strong ventricular contractions –Vasoconstriction –Narrowed pulse pressure is worrisome Patient maintains normal systolic pressure Patient’s diastolic pressure begins to go up –Be watchful for narrowed pulse pressure because patient may be tachycardic and have normal systolic BP, but suddenly go into shock

50. Early Warning Scoring System (Adult) Patient with a score of 3 in any one area or a total score of 4 or more needs immediate assessment / resuscitation / close monitoring SCORE3210123 Resp rate <1010-1415-2021-30>30 Heart rate <4040-5051-100101-110111-130>130 BP systolic <7071-8081-100101-199>200 CNS SCAVPU Temp <3535-3838-39>39 Urine output (ml/kg/hr) 0< 0.5 SC - Sudden confusion / A - Alert / V - responds to voice / P - responds to pain / U - Unresponsive

51. REMEMBER Closely Monitor –Pulse rate / BP –Urine output –O2 saturation (if available)

52. What are the signs of Late Shock?

53. Decompensated Shock (Late Shock) Decreased consciousness BP drops Weak, thready pulse (may slow) Weak, ineffective respirations (may slow) Irreversible shock –occurs when the body can no longer deliver sufficient oxygen to organs

54. Management of Hypovolemic Shock

55. Estimating Acute Intravascular Volume Losses in Adults Class I Shock = ≤15% volume loss –No change in vital signs Class II Shock = 15%-30% volume loss –HR>100, SBP normal, skin cool/moist Class III Shock = 30%-40% volume loss –HR >>100, SBP < 90, urine output down, patient confused Class IV Shock > 40% volume loss –Patient near death

56. Categories of Hypovolemic Shock (ADULT) 1234 Blood loss(litre) < 0.750.75 - 1.51.5- 2.0> 2.0 Blood loss (% blood volume) < 15%15 - 30%30 - 40%> 40% Resp rate 14-2020 - 3030 - 40> 35 or low Heart rate < 100> 100> 120>140 or low Systolic BP Normal DecreasedDecreased + Diastolic BP NormalRaisedDecreasedDecreased + Pulse Pressure NormalDecreased Capillary refill NormalDelayed Urine output (ml/hr) >3020 - 305 - 15Almost none Mental state NormalAnxious Anxious/ConfusedConfused/Drowsy

57. Estimating Blood Loss Patients with Class I or II shock who stabilize with NS or RL often do not need transfusions Patients with Class III or IV shock usually require transfusions

58. “ Doctor, I Can’t Hear a Blood Pressure!” In patients with shock, BP can be hard to hear Make sure tubing of BP cuff over brachial artery to get accurate reading Quick estimate: if you can feel the… –Femoral pulse, SBP is > 50 mmHg –Carotid pulse, SBP is > 60 mmHg –Brachial pulse, SBP is > 70 mmHg

59. Hypovolemic Shock Estimate Fluid Resuscitation –Circulating blood volume: 70 cc/kg in adult male –Interstitial fluid volume: 2X circulating blood volume Significant amount of IV fluid goes interstitial

60. Estimate Volume Resuscitation (Adult) Estimate volume deficit using vital signs and patient’s weight Replace the estimated volume loss with 3 times that amount of normal saline… to replace intravascular and interstitial loss 60 kg male with HR>100, BP = 110/70 –Normal total circulating volume = 70 cc/kg x 60 kg = 4200 cc –20% fluid deficit based on vital signs –.20 X 4200 cc = 840 cc deficit –840 cc X 3 = 2520 cc NS needed –Patient needs > 2 litres of NS or RL

61. Why Multiply Normal Saline 3 Times? NS or RL are the best fluids to replace lost volume because they are isotonic 2/3 of the NS or RL given goes out of the blood vessels into the interstitial space Must give 3 cc for every 1 cc of fluid deficit

62. Target Vital Signs Goals of fluid resuscitation –Good peripheral perfusion (warm and dry skin, capillary refill < 2 seconds) –Awake and oriented –SBP = 90 or better –Heart rate < 100 –Urine output for adults: 0.5 cc/kg/hr

63. Hypovolemic Shock in Children

64. Estimating Fluid Losses in Children Findings to look for (one point each): –Looks sick, lethargic –Absence of tears –Dry mucus membranes –Capillary refill slow, > 2 seconds 1 = mild (1-4%) dehydration 2 = moderate (5-9%) dehydration 3 or 4 = severely (>10%) dehydrated

65. Fluid Resuscitation in Children After Hx & P/E and labs, start largest IV you can Use NS or RL Give bolus of 20 cc/kg  good improvement means mild dehydration If child needs second bolus of 20 cc/kg to improve, means moderate dehydration No improvement after 2 boluses of 20 cc/kg suggests severe dehydration and/or sepsis

66. Fluid Resuscitation in Children Hypovolemic shock most commonly due to diarrhea/dehydration in children In moderate or severe dehydration, give IV fluid boluses quickly When pulse decreases or capillary refill improves: –Give 70 ml/kg of RL or NS Give over 5 hours in children < 1year Give over 2.5 hours in children 2 - 5 yrs Reassess child every hour Adjust IV drip according to child’s improvement

67. Normal Vital Signs in Children Children should make > 1 ml/ kg/ hr of urine Age HRRRSystolic BP < 6 months90 - 18025-6065 -110 6 months - 2 yrs90 - 17025 - 4090 - 110 2 - 5 yrs90 - 14020 - 3090 - 110 5 - 7 yrs65 - 13018 - 25100 - 120

68. Venous Access Problems Often hard to start IVs in dehydrated children Consider: –External jugular vein –Femoral vein –Intraosseous infusion into proximal medial tibia

69. Management of Cardiogenic Shock

70. Cardiogenic Shock Signs and Symptoms Patients may present with chest pain due to myocardial infarction or have history of cardiovascular disease SBP, cardiac output (CO), oxygen saturation and urine output  LOW Heart rate, respiratory rate  fast Patient may have cool,skin, crepitations, S3 heart sound, high JVP

71. Cardiogenic Shock Management Oxygen: if O2 sat does not improve on oxygen, consider intubation Give fluid cautiously / May need diuretic if congestive heart failure Diagnosis: EKG, CXR, Echo (if possible) High mortality / ?Patient transfer / ? Patient may need pressors

72. Examples of Pressors Low-dose dopamine (<10 mcg/kg/min) –Increases heart rate and contractility and dilates peripheral blood vessels  CO High-dose dopamine (15-20 mcg/kg/min) –increases SVR Dobutamine (2-20 mcg/kg/min) –Increases contractility, but does not increase HR and SVR as much as dopamine Often used together

73. Distributive Shock Problem: severe arterial and venous dilation  SVR Sepsis is most common cause 30-50% mortality, especially children and elderly pts

74. Management of Septic Shock Goals –Improve BP –Correct dehydration –Treat source of infection Give 20ml/kg rapid bolus of NS or RL (1-2 L in adult) Try to identify source of infection Give broad spectrum antibiotics (i.e. ceftriaxone, gentamicin) Transfer early if no improvement to treatment (may need pressors if severe)

75. Management of Anaphylactic Shock Give oxygen Give epineprhine / adrenalin 0.5 mg IM –Repeat every 5 minutes until BP improves Give NS or RL 20 mg/kg IV bolus Give antihistamine –Give IV initially –Continue po for 48 hours May need to administer steroids

76. Obstructive Shock Need to treat the etiology Tension pneumothorax –CXR will confirm –Treatment: Needle decompression / chest tube Cardiac tamponade –Echo will confirm –Treatment: Pericardial tap Pulmonary embolus –CT will confirm –Treatment: Anticoagulation

77. Summary HISTORY will almost always help you to know the type of shock the patient has Be thorough in patient assessment Start resuscitation immediately Continue to monitor Arrange transfer early if no improvement

78. Summary Resuscitate –Hypovolemic shock Large bore IV (16 or 18 gauge) / Start two IV’s Give 2 litres of isotonic fluid quickly Consider giving blood Control hemorrhage / Call surgery –Cardiogenic shock Careful with fluid / Drugs to improve cardiac function / Drugs for pulmonary edema –Distributive shock Septic shock –IV isotonic fluid bolus & IV antibiotics (broad spectrum) Anaphylactic shock –IV isotonic fluid bolus & epinephrine –Obstructive shock Treat cause

79. Summary Hypovolemic shock most common –In young adults and children, SBP is a late indicator of volume statu –Normal Saline or Ringer’s Lactate are acceptable volume resuscitation fluids (isotonic) –Do not use D5W for resuscitation –Look for cause of volume loss while administering fluids –Order blood early

80. Summary Signs of success in hypovolemic shock: –Warm extremities –Good mentation –SBP>90, HR <100 –Urine output 0.5 cc/kg/hour for adults –Urine output 1.0 cc/kg/hr for children –Cause of bleeding / fluid loss found –Therapeutic intervention to treat the cause of bleeding

81. Patient: Khampanh 36 year old male Motorbike accident Complains of chest pain and shortness of breath RR 35 / PR 120 / BP 110/85 / Temp 37 Does this patient have shock? What will you do?

82. Patient: Phoutong 29 year old woman (G5,P4) who delivered baby at home 4 hours ago She continues to bleed from her vagina She is drowsy and pale RR 25 / PR 140 / BP 80/40 / Temp 36.5 Does this patient have shock? What will you do?

83. Patient: Noi 11 month old girl Has been sick for 3 days Agitated and restless RR 50 / HR 165 / Temp 38 Does this patient have shock? What will you do?

84. Give me examples of patients who had shock that you treated Is there anything you could have done differently that may have improved patient care or outcome?

85. Ideas How could you improve management of patients presenting with shock at your health care setting?

86. Post-test A patient was in a motorcycle accident. He is confused and hypotensive. What type of shock could he have? a)Hypovolemic b)Cardiogenic c)Distributive d)Obstructive

87. Post-test What statements about early hypovolemic shock are true? a)The patient may be alert and oriented. b)A patient may have a normal blood pressure. c)The patient may have a widened pulse pressure. d)The patient may not have a palpable femoral pulse. e)The patient may be tachycardic.

88. Post-test Which of the following signs might you find on examination in a patient with obstructive shock? a)High JVP b)Crepitations on chest auscultation c)Decreased breath sounds d)Tachycardia e)Subcutaneous emphysema

89. Post-test Which of the following can cause distributive shock? a)Myocardial infarction b)Burn c)Spinal cord injury d)Severe allergy / Anaphylaxis e)Sepsis

90. Post-test A 70 year old man has a history of chest pain with exertion. On examination he has a high JVP, an S3 heart sound, and bilateral pulmonary crepitations. His RR = 30, PR = 115, BP = 90/60. Appropriate treatment includes: a)Give 1 L bolus of NS b)Give oxygen c)Give diuretic (I.e. Lasix) d)Insert chest tubes e)Give drug to reduce systemic vascular resistance

91. Post-test 30 year old female has postpartum bleeding. She is restless. Vital signs: RR=30, BP=90/60, PR=130. Her weight appears to be 50kg. Appropriate management includes: a)1 - 2 litres of NS immediately b)1 - 2 litres of D5W immediately c)At least 4 litres of NS immediately d)Close monitoring of vital signs and urine output e)Cross-match for blood transfusion as soon as possible f)Find and treat cause of bleeding

92. Questions