1. CARDIOGENIC, HYPOVOLEMIC, NEUROGENIC, ANAPHYLACTIC
SHOCK
CARDIOGENIC, HYPOVOLEMIC, NEUROGENIC, ANAPHYLACTIC

2. 1. Summarize the generalized principles of shock and the associated pathophysiological findings.
2. Differentiate the various types of shock (hypovolemic, cardiogenic, anaphylactic, neurogenic); including the causes and pathological findings of each.
3. Identify and apply the appropriate treatment modalities for each form of shock; including pharmacological management.
OBJECTIVES

4. SHOCK OVERVIEW All shock leads to cellular hypoxia (if not corrected)
Cellular hypoxia is due to decreased perfusion or ineffective use of the oxygen provided
Cellular hypoxia causes further systemic damage which can lead to SIRS and MODS (if not corrected)
SHOCK OVERVIEW

5. The priority treatment is to remove/treat the underlying cause
Most forms of shock are caused by either a decreased CO and/or decreased SVR
stroke volume (preload, contractility, afterload)
Systemic vascular resistance (blood viscosity, vessel tone)
Distributive shock refers to all types of shock that cause massive vasodilation
Septic, Neurogenic, Anaphylactic
All forms of shock are progressive. Rate and method of progression depends on the type
Late shock is typically irreversible. EARLY identification and treatment is key.
The priority treatment is to remove/treat the underlying cause

6. Impaired Oxygen Consumption
Anaerobic Metabolism
Disruption of sodium-potassium pump
Cellular edema
Decreased circulatory volume
Lysosomal enzyme release
Activation of inflammatory and clotting cascades
Leads to metabolic acidosis  lactic acid
Causes a continual loop of further cellular destruction
Impaired Oxygen Consumption

7. Impaired Glucose Consumption
Ineffective glucose delivery
Utilize glucose stores within the body
Switch to alternate forms of fuel production
Gluconeogenesis
Ammonia and urea byproduct  toxic accumulation
Impaired Glucose Consumption

8. Compensated
Decompensated
Irreversible
Progression of Shock

9. Types of Shock CARDIOGENIC Causes: Acute myocardial infarction
Endocarditis
Dysrhythmias
Pericardial tamponade
Pulmonary embolism
Types of Shock

10. Cardiogenic Shock Pathophysiology:
Inability of the heart to pump adequate blood to tissues and organs
Persistent Hypotension with adequate intravascular volume
Hypoperfusion  activation of renin-angiotensin, sympathetic nervous system, neurohormonal compensation
Compensation causes increased cardiac demand  further cardiac failure
Cardiogenic Shock

11. Cardiogenic Shock Manifestations: Angina Dyspnea
Feelings of impending doom
Tachycardia
Tachypnea
Hypotension
Jugular venous distention
Pulmonary edema
dysrhythmias
Cardiogenic Shock

12. Cardiogenic Shock Signs of end-organ hypoperfusion: Cyanosis
Skin mottling
Faint, irregular pulses
Low urine output
Cardiogenic Shock

13. Cardiogenic Shock Treatment: Fibrinolytic drugs PCI
Intra-aortic balloon pump
Cardio-supportive drugs
Cardiogenic Shock

15. HYPOVOLEMIC Causes: Hemorrhage (whole blood) Burns (plasma)
Loss of interstitial fluid (emesis, diuresis, diaphoresis)

16. Hypovolemic Shock Pathophysiology:
Hypovolemia  compensatory mechanisms
Catecholamine release  increased heart rate, increased SVR
Interstitial fluid moves to the vascular space
Stored RBCs and plasms are released by the liver and spleen
Activation of renin-angiotensin system
Hypovolemic Shock

17. Hypovolemic Shock Manifestations:
Dependent on amount of fluid/blood loss
Tachycardia
Poor skin turgor
Increased thirst
oliguria
Hypovolemic Shock

19. Hypovolemic Shock Treatment: Crystalloid fluid resuscitation
Blood products (if indicated)
Vasopressors (if hypotension remains s/p fluid resuscitation)
Hypovolemic Shock

21. Neurogenic Shock NEUROGENIC Causes: Spinal cord injuries TBI (medulla)
Insulin reactions
Anesthetic drugs
Severe emotional stress
Neurogenic Shock

22. Neurogenic Shock Pathophysiology:
Massive vasodilation due to an imbalance between sympathetic and parasympathetic stimulation
Low SVR
Relative hypovolemia
Normal ejection fraction
Decreased central venous pressure
Neurogenic Shock

23. Manifestations:
Bradycardia
Hypotension
Neurogenic Shock

24. Neurogenic Shock Treatment: Fluid resuscitation
Vasopressor therapy (if indicated)
Drugs for bradycardia (if indicated)
Neurogenic Shock

26. Anaphylactic Shock ANAPHYLACTIC Causes:
Hypersensitivity reaction to an allergen…
Food allergens
Insect venom
Pollen
Medications
Latex
Anaphylactic Shock

27. Anaphylactic Shock Pathophysiology: Immediate onset
Hypersensitivity reaction leads to massive vasodilation and relative hypovolemia
Immune response to antigen recognition
Production of mast cells, IgE
Rapidly progressive if not treated immediately
Anaphylactic Shock

28. Anaphylactic Shock Manifestations: Difficulty breathing GI cramps
Airway constriction
Hives
Hemolysis
Anxiety
Anaphylactic Shock

29. Anaphylactic Shock Treatment: Remove underlying cause Epinephrine
IV fluid replacement
Corticosteroids
Antihistamines
Anaphylactic Shock

31. Adrenergic Agonists Epinephrine Norepinephrine Dopamine Dobutamine
Albuterol
Adrenergic Agonists

32. Receptor Specificity Alpha 1 Alpha 2 Beta 1 Beta 2
Vasoconstriction of blood vessels
Mydriasis
Alpha 2
Reduction of sympathetic outflow
Relief of pain
Beta 1
Increase cardiac contractility
Increase heart rate
Enhance impulse conduction
Initiate heart beat
Beta 2
Promote bronchodilation
Receptor Specificity

33. Epinephrine Receptor specificity: Chemical class: Therapeutic uses:
a1, a2, b1, b2
Chemical class:
catecholamine
Therapeutic uses:
Delay absorption of local anesthetics
Control superficial bleeding
Initiate heart beat
Promote bronchodilation
Adverse effects:
Hypertensive crisis
Dysrhythmias
Angina
Necrosis of tissue
hyperglycemia
Epinephrine

34. Administration: Topically or injection 0.1% SQ or IM .01% IV EpiPen
Epinephrine auto-injector
0.3ml solution; inject immediately
Report to hospital after use
IM injection to outer thigh
Stored in room temperature
Side effects:
Palpitations, nervousness, headache, n/v

35. Dobutamine Receptor specificity: Chemical class: Uses:
Beta 1
Chemical class:
catecholamine
Uses:
Short term use in severe heart failure; cardiogenic shock
Maintain systemic perfusion
Chemical stress tests
Adverse effects:
Tachycardia
Dysrhythmias
hypertnesion
Administration: IV
Starting dose mcg/kg/min titrate
Dobutamine

36. Dopamine Chemical class: Receptor specificity: Uses: Adverse effects:
catecholamine
Receptor specificity:
dose dependent
Low dose – dopamine receptors
Moderate dose – dopamine and beta 1 receptors
High dose – dopamine, beta 1 and alpha 1 receptors
Uses:
Shock
Heart failure
Adverse effects:
Contraindicated in individuals with tachycardia/dysrhythmias
Angina
Necrosis of tissue
Administration:
2 to 5 mcg/kg/min IV continuous infusion
If extravasation occurs, infiltrate area with phentolamine
Dopamine

37. Albuterol Receptor specificity: Chemical class: Uses:
Beta 2
Chemical class:
Non-catecholamine
Uses:
asthma
Adverse effects: (in large doses)
Tachycardia
Tremor
Albuterol

38. Norepinephrine Receptor specificity: Chemical class: Uses:
Alpha 1, alpha 2, beta 1
Chemical class:
catecholamine
Uses:
Hypotensive states
Cardiac arrest
Adverse effects:
Tachydysrhythmias, angina, hypertension, necrosis of tissue
Administration:
IV infusion only
Norepinephrine