1. MANAGEMENT OF SHOCK
Dr. Hanin Osama

2. 1-Management of hypovolemic Shock
ABCs (Air way,Breathing ,Circulation )
Establish 2 large bore IV cannula 16 gauge or larger or a central line (internal jugular and subclavian vein catheterization)
Crystalloids
Normal Saline or Lactate Ringers(Lactated Ringer's solution is a solution that is isotonic with blood and intended for intravenous administration. It may also be given subcutaneously.single dose container.(sodium chloride, soldium lactate, potassium chloride and calcium chloride)
2-3 liters
Packed RBCs
O negative or cross matched
Control any bleeding
Arrange definitive treatment

3. 2-Treatment of Cardiogenic Shock
Goals- Airway stability and improving myocardial pump function
Cardiac monitor, pulse oximetry (Pulse oximeters are non-invasive devices used to measure a patient's blood-oxygen saturation level and pulse rate.)
Supplemental oxygen
IV access
Diuretics
Positive inotropic drugs
IABP (Intra-Aortic Balloon Pump) is utilized if medical therapy is ineffective.
Catheterization if ongoing ischemia
Cardiogenic shock is the exception to the rule that NS (Normal saline)is always given for hypotension NS will exacerbate cardiac shock.

4. Treatment of Cardiogenic Shock
AMI
Aspirin, statin, clopedogril, 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 (percutaneous intervention ) or thrombolytics
Right Ventricle infarct
Fluids and Dobutamine (no NitroGlycerine)
Acute mitral regurgitation or Ventral Septal Defect
Pressors (Dobutamine)

5. 3. Distributive, A. Management of Septic Shock
2 large bore Ivs
NS I/V bolus- 1-2 L wide open (A large volume of fluid or dose of a drug given intravenously and rapidly at one time. intravenous bolus,. a relatively large dose of medication administered into a circulation )
Supplemental oxygen
Empiric antibiotics, based on suspected source, as soon as possible, Broad Spectrum Antibiotics
Cover gram positive and gram negative bacteria
Add additional coverage as indicated e.g. MRSA- Vancomycin, Asplenic- Ceftriaxone for N. meningitidis, H. infuenzae
Vasopressors e.g. dopamine to raise the BP
Bicarbonate if pH < 7.1

6. B-Anaphylactic Shock- Treatment
ABC’s; Angioedema and respiratory compromise require immediate intubation(is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or 4 the purpose of adding & removing fluid)...
IV, cardiac monitor, pulse oximetry
IV Fluids, oxygen
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
Corticosteriods
Epi – the single most important step in treatment

7. Anaphylactic Shock - Treatment
H1 and H2 blockers
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(May be used as an inotropic agent in beta-blocker overdose.)
For patients taking beta blockers and with refractory hypotension.
1 mg IV q (each,every )5 minutes until hypotension resolves
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. B-blk==hypoglycemia
Methylprednisolone causes less fluid retention

8. C-Neurogenic Shock- Treatment
A,B,Cs
Remember c-spine precautions
Fluid resuscitation
Keep MAP(mean arterial pressure ) 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
Methylprednisolone
Used only for blunt spinal cord injury
High dose therapy
Must be started within 8 hours
Controversial- Risk for infection, GI bleed

9. 4. Obstructive Shock Tension pneumothorax
Rx: Needle decompression, chest tube
B. Cardiac tamponade ( In this condition, blood or fluid collects in the pericardium, the sac surrounding the heart. This prevents the heart ventricles from expanding fully.)
Rx: Pericardiocentesis (Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac, the tissue that surrounds the heart)
C. Pulmonary embolism
Rx: Heparin, consider thrombolytics

10. Resuscitation Fluids
Normal Saline, Crystalloids (used as a first line in the treatment of shock)
Blood (in case of bleeding/anemia)
Lactated Ringers
Colloids
Hetastarch
may aggravate bleeding
Dextran
use as plasma expanders
These solutions are not used as often as albumin or hetastarch for plasma expansion, possibly due to concerns related to aggravation of bleeding and anaphylaxis.
Hypertonic Saline
Blood Substitutes

11. Autonomic Drugs in Shock