1. D. P. Laporta MD SMBD-JGH Dept of Adult Critical Care

2. SHOCK - OUTLINE b DEFINITION b CAUSES b EFFECTS OF INEFFECTIVE TREATMENT b ASSESSMENT b CLINICAL APPROACH

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10. SHOCK CASES 1. post Cardiac Surgery - same day - 1 week postop 2. in MVA victim 3. In young male with Crohn ’s disease found febrile in shock 4. In drug addict, hospital worker

11. SHOCK - b DEFINITION b CAUSES b EFFECTS OF INEFFECTIVE TREATMENT b ASSESSMENT b CLINICAL APPROACH

12. A profound disturbance of the circulation and metabolism, leading to and metabolism, leading to inadequate perfusion of vital organs, necessary to maintain homeostasis necessary to maintain homeostasis DEFINITION

14. SHOCK - b DEFINITION b CAUSES b EFFECTS OF INEFFECTIVE TREATMENT b ASSESSMENT b CLINICAL APPROACH

15. HYPOPERFUSED STATES RVLV Arterial (resistance) Venous (capacitance) PVR EF End-Diastolic Volume SVR

16. Hypovolemic BP 60/30 HR 140/min CVP 0 Lactate 10

17. Cardiogenic BP 70/50 HR 130/min CVP 18 Lactate 12

18. Obstructive BP 70/50 HR 140/min CVP 15 Lactate 12 VTED OAD DLD

19. Distributive BP 70/40 HR 140/min CVP 5 Lactate 12

21. SHOCK - b DEFINITION b CAUSES b EFFECTS OF INEFFECTIVE TREATMENT b ASSESSMENT b MEASUREMENT b CLINICAL APPROACH

22. EFFECTS OF INEFFECTIVE TREATMENT MISERY !!! INFECTION

23. SHOCK - b DEFINITION b CAUSES b EFFECTS OF INEFFECTIVE TREATMENT b ASSESSMENT b MEASUREMENT b CLINICAL APPROACH

26. SHOCK: asssessment b Class 1&2 vs 3&4 b needs blood or crystalloid ?

30. hypercarbia is a universal indicator of critically reduced tissue perfusion. Sublingual capnometry: A new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock Max Harry Weil MD, PhD, FCCM - CCM 1999

31. Sublingual capnometry: A new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock

32. Sublingual capnometry: A new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock

33. Sublingual capnometry: A new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock P SL CO 2 provides a prompt indication of the reversal of tissue hypercarbia when circulatory shock is reversed

34. SHOCK - b DEFINITION b CAUSES b EFFECTS OF IEFFECTIVE TREATMENT b MEASUREMENT b CLINICAL APPROACH

35. SHOCK: an EMERGENCY !!! GOAL: RAPIDLY RESTORE TISSUE PERFUSION Recognize it !!! Immediate stabilization: ABCImmediate stabilization: ABC ……. SHOTGUN approach ……. SHOTGUN approach ICU & Surgical consultation ICU & Surgical consultation Treat the causeTreat the cause

36. Management priorities in hypoperfused states BP potency: Dopamine...NE…Vasopressin/Phenylephrine