1. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management

2. Suggested Reading Current Diagnosis and Treatment: Surgery
Chapter 12. Shock & Acute Pulmonary Failure in Surgical Patients
Schwartz's Principles of Surgery, 9e
Chapter 5. Shock
Current Diagnosis & Treatment: Surgery, Thirteenth Edition
Edited by Gerard M. Doherty
Copyright © 2010 by The McGraw-Hill Companies, Inc.
Schwartz's Principles of Surgery, 9e F. Charles Brunicardi, Dana K. Andersen, Timothy R. Billiar, David L. Dunn, John G. Hunter, Jeffrey B. Matthews, Raphael E. Pollock
Copyright © 2010, 2005, 1999, 1994, 1989, 1984, 1979, 1974, 1969 by The McGraw-Hill Companies, Inc.

3. ? What is shock? Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What is shock?

4. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What are the four principle types of shock (Excluding anaphylactic shock)?

5. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What physical examination findings will help determine the type of shock present?

6. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 32 year-old man was driving drunk and without his seatbelt fastened when he was involved in a single-vehicle automobile collision.

7. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 32 year-old man was driving drunk and without his seatbelt fastened when he was involved in a single-vehicle automobile collision.
When attended by EMT personnel, no information was available about the time of the accident. He was found agitated and complaining of abdominal pain. His airway was patent. At the scene, he was breathing at 20 per minute with a blood pressure of 90/60 and a pulse of 130. He was placed in a hard cervical collar and on a back board and transported to your emergency room. Upon arrival his vital signs are the same, with a temperature of 36°C. His abdomen is markedly distended. His hands and feet are cold, his legs mottled. A nasogastic tube reveals green liquid. A urinary catheter reveals dark yellow urine. His hemoglobin is 12. His abdominal lavage reveals gross blood.

8. ? What type of shock does this patient exhibit?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What type of shock does this patient exhibit?

9. ? How do you explain the patient’s normal hemoglobin value?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
How do you explain the patient’s normal hemoglobin value?

10. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What are the normal physiologic mechanisms to compensate for blood loss?

11. ? Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What would be the effect of this type of shock on the following physiologic measurements (low, normal, high)?
Cardiac Output
Systemic Vascular Resistance
Central Venous Pressure
Pulmonary Capillary Occlusion Pressure (“Wedge Pressure”)
Oxygen Delivery
Mixed Venous Oxygen Saturation
Oxygen Consumption

12. ? What acid/base disturbances might be expected?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What acid/base disturbances might be expected?

13. ? What is the single most important treatment for this type of shock?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What is the single most important treatment for this type of shock?

14. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
How would you manage the patient until the primary goal is accomplished?

15. ? What is the role of vasopressors in hypovolemic shock?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What is the role of vasopressors in hypovolemic shock?

16. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 55 year-old man with stable angina undergoes an uneventful sigmoid resection for diverticular disease.

17. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 55 year-old man with stable angina undergoes an uneventful sigmoid resection for diverticular disease.
The patient’s angina occurs twice a week while walking uphill and is treated with nitoglycerin. On postoperative day four he develops severe substernal chest pain, sudden hypotension (85/45), tachycardia (120), and becomes agitated. Physical exam reveals body mottling, cold hands and feet, distended neck veins and an S3 gallop. ECG demonstrates elevated ST-T wave segments in all of the anterior leads.

18. ? What type of shock does this patient exhibit?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What type of shock does this patient exhibit?

19. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What are the normal physiologic mechanisms to compensate for this type of shock?

20. ? Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What would be the effect of this type of shock on the following physiologic measurements (low, normal, high)?
Cardiac Output
Systemic Vascular Resistance
Central Venous Pressure
Pulmonary Capillary Occlusion Pressure (“Wedge Pressure”)
Oxygen Delivery
Mixed Venous Oxygen Saturation
Oxygen Consumption

21. ? What acid/base disturbances might be expected?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What acid/base disturbances might be expected?

22. ? What are the potential causes for this type of shock?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What are the potential causes for this type of shock?

23. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
How would you manage this patient’s shock for each of the previously listed causes?

24. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 35 year-old man dove into three feet of water at a swimming pool, did not emerge and was rescued by friends who performed CPR.

25. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 35 year-old man dove into three feet of water at a swimming pool, did not emerge and was rescued by friends who performed CPR.
When the EMTs arrived they found the patient to have blood pressure of 80/50, pulse 60, and no spontaneous respirations, although he was opening his eyes. They began ambu bag assistance of respiration and placed a hard cervical collar. He was placed on a back board and transported to your emergency room. Upon arrival he has the same vital signs with warm hands and feet and pink extremities. He is unable to move any of his extremities. His anal sphincter tone is lax and he has no deep tendon reflexes in his extremities.

26. ? What type of shock does this patient exhibit?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What type of shock does this patient exhibit?

27. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What is the significance of the patient’s lack of anal sphincter tone and loss of reflexes?

28. ? What are the physiologic causes for the patient’s hypotension?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What are the physiologic causes for the patient’s hypotension?

29. ? What acid/base disturbances might be expected?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What acid/base disturbances might be expected?

30. ? Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What would be the effect of this type of shock on the following physiologic measurements (low, normal, high)?
Cardiac Output
Systemic Vascular Resistance
Central Venous Pressure
Pulmonary Capillary Occlusion Pressure (“Wedge Pressure”)
Oxygen Delivery
Mixed Venous Oxygen Saturation
Oxygen Consumption

31. ? How would you manage this patient’s shock?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
How would you manage this patient’s shock?

32. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 65 year-old man with known coronary artery disease is admitted with acute left lower quadrant pain of six hours duration.

33. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 65 year-old man with known coronary artery disease is admitted with acute left lower quadrant pain of six hours duration.
The patient had a myocardial infarction three years earlier and is currently taking beta-blockers. His blood pressure is 90/50, pulse 120, respiration 18, temperature 39°C. He is flushed with warm hands and warm feet, his legs are pink. Physical examination reveals findings consistent with peritonitis in the left lower quadrant.

34. ? What type of shock does this patient exhibit?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What type of shock does this patient exhibit?

35. ? What is responsible for the pathophysiology of this condition?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What is responsible for the pathophysiology of this condition?

36. ? What is the consequences of this condition?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What is the consequences of this condition?

37. ? Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What would be the effect of this type of shock on the following physiologic measurements (low, normal, high)?
Cardiac Output
Systemic Vascular Resistance
Central Venous Pressure
Pulmonary Capillary Occlusion Pressure (“Wedge Pressure”)
Oxygen Delivery
Mixed Venous Oxygen Saturation
Oxygen Consumption

38. ? What acid/base disturbances might be expected?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
What acid/base disturbances might be expected?

39. Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
Given the effects of this condition on Oxygen delivery, what is the explanation for this acid base disturbance?

40. ? How would you manage this patient’s shock?
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management ?
How would you manage this patient’s shock?

41. ?