1. Shock Dr. Mohammad Al-Adaileh M.B.B.S, MRCSI
Fellow of Thoracic surgery
Department of Surgery
Faculty of Medicine
Jordan University Hospital
University of Jordan
Extra information were added to the slide

2. Objectives Definition Approach to the hypotensive patient Types
Specific treatments

3. Definition of Shock
Inadequate oxygen delivery to meet metabolic demands
Results in global tissue hypoperfusion and metabolic acidosis
Shock can occur with a normal blood pressure and hypotension can occur without shock

4. Types of Shock
Cardiogenic: causes: Ischemic heart disease, vasoconstruction
Hypovolemic: The most common one
Distributive shock: Vasodilatation in periphery (limbs), (decrease resistance) and vasoconstruction in an important areas (increase resistance in the central parts)
Septic:
Anaphylactic
Neurogenical: Loss of sympathetic response
Obstructive: Ex. Neumo thorex: air in plural cavity that compress the major vesseles

5. What Type of Shock is This?
68 yo M with hx of HTN and DM presents to the ER with abrupt onset of diffuse abdominal pain with radiation to his low back. The pt is hypotensive, tachycardic, afebrile, with cool but dry skin
Types of Shock
Hypovolemic
Septic
Cardiogenic
Anaphylactic
Neurogenic
Obstructive
Hypovolemic Shock

6. Hypovolemic Shock

7. Hypovolemic Shock Non-hemorrhagic Hemorrhagic Vomiting Diarrhea
Bowel obstruction, pancreatitis (due to effect of what so called third spacing which mean moving of fluid from intravascular third spacing)
Burns (also third spacing)
Neglect, environmental (dehydration)
Hemorrhagic
GI bleed
Trauma
Massive hemoptysis
AAA rupture (Abdominal Aortic Aneurysm rapture), any abdominal pain radiating to the lower back especially in elderly pts)
Ectopic pregnancy, post-partum bleeding

8. Notes:
Crystalloid: Normal saline and Ringer's lactate
Pulse pressure = systolic - diastolic

9. Hypovolemic Shock ABCs Establish 2 large bore IVs or a central line
Crystalloids
Normal Saline or Lactate Ringers (give 20ml/kg) Exam question
Up to 3 liters
PRBCs (Colloids)
O negative or cross matched (except female in child bearing age, we give her O- )
Control any bleeding
Arrange definitive treatment

10. Cardiogenic Shock Pump Failure Causes: acute MI CHF
obstruction arrhythmias

11. Treatment of Cardiogenic Shock
Goals- (1)Airway stability and improving myocardial pump functionthough two large pore cannulas fluid supply & we give Dobutamine to increase the contractility
Cardiac monitor, pulse oximetry
Supplemental oxygen, IV access
Intubation will decrease preload and result in hypotension
Be prepared to give fluid bolus

12. Treatment of Cardiogenic Shock
AMIمش مهم
Aspirin, beta blocker, 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 or thrombolytics
RV infarct
Fluids and Dobutamine (no NTG)
Acute mitral regurgitation or VSD
Pressors (Dobutamine and Nitroprusside)

13. Obstructive Shock Causes Signs Cardiac Tamponade Tension Pneumothorax
Massive Pulmonary Embolus
Signs
 cardiac output
 PAOP
 SVR”Systemic Vascular Resistance-cold dry skin like in Hypovolemic Shock and Cardiogenic Shock

14. Anaphalactic Shock as part of disributive shock

15. Anaphylactic Shock
Anaphylaxis – a severe systemic hypersensitivity reaction characterized by multisystem involvement
IgE mediated
Anaphylactoid reaction – clinically indistinguishable from anaphylaxis, do not require a sensitizing exposure
Not IgE mediated

16. Anaphylactic Shock What are some symptoms of anaphylaxis?
First- Pruritus, flushing, urticaria appear
Next- Throat fullness, anxiety, chest tightness, shortness of breath and lightheadedness
Finally- Altered mental status, respiratory distress and circulatory collapse

17. Anaphylactic Shock Risk factors for fatal anaphylaxis
Poorly controlled asthma
Previous anaphylaxis
Reoccurrence ratesمش مهمه
40-60% for insect stings
20-40% for radiocontrast agents
10-20% for penicillin
Most common causes
Antibiotics # 1
Insects
Food

18. Anaphylactic Shock
Mild, localized urticaria can progress to full anaphylaxis
Symptoms usually begin within 60 minutes of exposure
Faster the onset of symptoms = more severe reaction
Biphasic phenomenon occurs in up to 20% of patients
Symptoms return 3-4 hours after initial reaction has cleared
A “lump in my throat” and “hoarseness” heralds life-threatening laryngeal edema

19. Anaphylactic Shock- Diagnosis مش مهمة
Clinical diagnosis
Defined by airway compromise, hypotension, or involvement of cutaneous, respiratory, or GI systems
Look for exposure to drug, food, or insect
Labs have no role

20. Anaphylactic Shock- Treatment
ABC’s
Angioedema and respiratory compromise require immediate intubation
IV, cardiac monitor, pulse oximetry
IVFs, oxygen
Epinephrine
Second line
Corticosteriods
H1 and H2 blockers
Epi – the single most important step in treatment

21. Anaphylactic Shock- Treatment
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

22. Anaphylactic Shock - Treatment
Corticosteroids
Methylprednisolone 125 mg IV
Prednisone 60 mg PO
Antihistamines
H1 blocker- Diphenhydramine mg IV
H2 blocker- Ranitidine 50 mg IV
Bronchodilators
Albuterol nebulizer
Atrovent nebulizer
Magnesium sulfate 2 g IV over 20 minutes
Glucagon
For patients taking beta blockers and with refractory hypotension
1 mg IV q5 minutes until hypotension resolves
Methylprednisolone causes less fluid retention

23. Anaphylactic Shock - Disposition
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

24. What Type of Shock is This?مهم
A 41 yo M presents to the ER after an MVC complaining of decreased sensation below his waist and is now hypotensive, bradycardic, with warm extremities“في البدايه فقط“
Types of Shock
Hypovolemic
Septic
Cardiogenic
Anaphylactic
Neurogenic
Obstructive
Neurogenic

25. Neurogenic Shock

26. Neurogenic Shock Occurs after acute spinal cord injury
Sympathetic outflow is disrupted leaving unopposed vagal tone
Results in hypotension and bradycardia
Spinal shock- temporary loss of spinal reflex activity below a total or near total spinal cord injury (not the same as neurogenic shock, the terms are not interchangeable)

27. Neurogenic Shock Loss of sympathetic tone results in warm and dry skin
Shock usually lasts from 1 to 3 weeks
Any injury above T1 can disrupt the entire sympathetic system
Higher injuries = worse paralysis

28. Neurogenic Shock- Treatment
A,B,Cs
Remember c-spine precautions
Fluid resuscitation
Keep MAP at 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

29. Neurogenic Shock- Treatment
Methylprednisolone
Used only for blunt spinal cord injury
High dose therapy for 23 hours
Must be started within 8 hours
Controversial- Risk for infection, GI bleed

30. What Type of Shock is This?
A 24 yo M presents to the ED after an MVC c/o chest pain and difficulty breathing. On PE, you note the pt to be tachycardic, hypotensive, hypoxic, and with decreased breath sounds on left
Types of Shock
Hypovolemic
Septic
Cardiogenic
Anaphylactic
Neurogenic
Obstructive
Obstructive

31. Obstructive Shock

32. Obstructive Shock Tension pneumothorax
Air trapped in pleural space with 1 way valve, air/pressure builds up
Mediastinum shifted impeding venous return
Chest pain, SOB, decreased breath sounds
No tests needed!
Rx: Needle decompression, chest tube

33. Obstructive Shock Cardiac tamponade
Blood in pericardial sac prevents venous return to and contraction of heart
Related to trauma, pericarditis, MI
Beck’s triad: hypotension, muffled heart sounds, JVD“Jugular vein distention “
Diagnosis: large heart CXR, echo
Rx: Pericardiocentisis

34. Obstructive Shock Pulmonary embolism
Virscow triad: hypercoaguable, venous injury, venostasis
Signs: Tachypnea, tachycardia, hypoxia
Low risk: D-dimer
Higher risk: CT chest or VQ scan
Rx: Heparin, consider thrombolytics

35. Septic Shock Definitions in Sepsis
Systemic inflammatory response syndrome (SRIS); two of:
Hyperthermia (> 38 0 C).
Tachycardia (> 90/ min no β-blockers) or tachypnea (20/min.
White cell count > 12X109/liter or < 12X109/liter)
Sepsis is SIRS with a documented infection
Severe sepsis or septic syndrome is sepsis with evidence of one or more organ failure (respiratory (ARDS), cardiovascular, renal (ATN) or CNS).
If hypotention occure either with sepsis or severe sepsis we call it septic shock

36. Treatment

38. The End
Any Questions?