1. SHOCK

2. DEFINITION
Profound hemodyamic and metabolic disturbance characterized by failure of the circulatory system to maintain adequate perfusion of vital organs

3. Types of Shock Cardiogenic (intracardiac vs extracardiac) Hypovolemic
Distributive
sepsis****
neurogenic (spinal shock)
adrenal insufficiency
anaphylaxis

5. Cardiogenic Shock, intracardiac
Myocardial Injury or Obstruction to Flow
Arrythymias
valvular lesions
AMI
Severe CHF
VSD
Hypertrophic Cardiomyopathy

6. Presentation of Cardiogenic Shock
Pulmonary Edema
JVD
hypotensive
weak pulses
oliguria

7. Cardiogenic Shock, extracardiac (Obstructive)
Pulmonary Embolism
Cardiac Tamponade
Tension Pneumothorax
Presentation will be according to underlying disease process.

8. Hypovolemic Shock
Reduced circulating blood volume with secondary decreased cardiac output
Acute hemorrhage
Vomiting/Diarrhea
Dehydration
Burns
Peritonitis/Pancreatitis

9. Presentation of Hypovolemic Shock
Hypotensive
flat neck veins
clear lungs
cool, cyanotic extremities
evidence of bleeding?
Anticoagulant use
trauma, bruising
oliguria

10. Distributive Shock
Peripheral Vasodilation secondary to disruption of cellular metabolism by the effects of inflammatory mediators.
Gram negative or other overwhelming infection.
Results in decreased Peripheral Vascular Resistance.

11. Distributive Shock: Presentation
Febrile
Tachycardic
clear lungs, evidence of pneumonia
warm extremities
flat neck veins
oliguria

12. Diagnosing Shock Response to fluids Echo/EKG CXR Evidence of infection
Swan-Ganz Catheter?

13. Swan-Ganz Catheter
Utilized to differentiate types of shock and assist in treatment response.
Probably overused by physicians. Studies documenting increased mortality in patients with catheters versus no catheters, although somewhat swayed by selection bias.

14. Swan-Ganz Catheter

16. Swan-Ganz Interpretation

17. Management
Correct underlying disorder if possible and then direct efforts at increasing the blood pressure to increase oxygen delivery to the tissues.
Maintain a mean arterial pressure of 60 (1/3 systolic + 2/3 diastolic)
Keep O2 sats >92%, intubate if neccesary

18. Correction of hypotension
Normal Saline should be administered anytime a patient is hypotensive. If hypotension exists give more NS. ***
If possible give blood as it replaces colloid.
Vasopressors
Inotropic agents for cardiogenic shock
Intra-aortic Balloon Pump for cardiogenic

19. Autonomic Drugs in Shock

20. Management of Cardiogenic Shock
Attempt to correct problem and increase cardiac output by diuresing and providing inotropic support. IABP is utilized if medical therapy is ineffective. Catheterization if ongoing ischemia
Cardiogenic shock is the exception to the rule that NS is always given for hypotension NS will exacerbate cardiac shock.

21. Intra-Aortic Balloon Pump

22. Management of Septic Shock
Early goal directed therapy
Identification of source of infection
Broad Spectrum Antibiotics
IV fluids
Vasopressors
Steroids ??
Recombinant human activated protein C ( Xygris)
Bicarbonate if pH < 7.1

23. Management of Hypovolemic Shock
Correct bleeding abnormality
If PT or PTT elevated then FFP
Aggressive Fluid replacement with 2 large bore IV’s or central line.
Pressors are last line, but commonly required.

24. Addison’s Disease
Deficiency of cortisol and aldosterone production in the adrenal glands
This is suspected when patient is non-responsive to fluids and antibiotics.
Electrolytes may reveal hyponatremia and hyperkalemia
Hydrocortisone 100 mg IV immediately then taper appropriately