1. Shock
Monica Patel 1076

2. Outline Definition Types of Shocks Risk Factors Signs and Symptoms
Diagnosis
Treatment and Management
Case Study
References

3. Pathophysiology of Shock
Systemic hypoperfusion (decreased blood flow) due to reduction in either cardiac output or the effective circulating blood volume
Impaired tissue perfusion occurs when an imbalance develops between cellular oxygen supply and cellular oxygen demand
Often accompanies severe injury or illness
Can lead to other conditions such as lack of oxygen in the body’s tissues (hypoxia), heart attack (cardiac arrest), or organ damage.

4. Clinical Features of Shock
Hypotension (Hypovolemic and Cardiogenic)
With a weak, rapid pulse
Oliguria (decreased kidney perfusion)
Altered mental status (decreased brain perfusion)
Tachypnea
Tachycardia
Cool, clammy, cyanotic skin
Vasoconstrictive mechanisms to redirect blood from periphery to vital organs

5. Stages of Shock
Nonprogressive phase: compensated stage, normal mechanisms will cause recovery. (baroreceptor reflexes, angiotensin secretion by the kidneys, vasopressin-constriction of peripheral arteries and veins).
Progressive phase: the phase characterized by tissue hypoperfusion and worsening circulatory and metabolic abnormalities including lactic acidosis leading to metabolic acidosis.
Irreversible phase: the phase during which damage is so severe that, even if perfusion is restored, survival is not possible.

6. Types of Shocks Cardiogenic shock Hypovolemic Shock Distributive shock
Blood pump problem
Hypovolemic Shock
Blood volume problem
Distributive shock
Septic Shock
Blood vessel problem

7. Other Type of Shock: Neurogenic Shock Anaphylactic Shock
Distributive type of shock resulting in hypotension with bradycardia
Anaphylactic Shock
Serious allergic reaction

8. Cardiogenic Shock
Low cardiac output due to outflow obstruction or myocardial pump failure
Inability of the heart to maintain adequate tissue perfusion secondary to impaired pump function or failure
Most commonly the result of a heart attack
Other causes: valve disease, arrhythmias, tamponade, cardiomyopathies

9. Risk Factors Previous history of myocardial infarction
Plaque buildup in the coronary arteries
Long-term valvular disease

10. Clinical Presentation
Cool skin
Tachypnea
Hypotension
Fatigue
Altered mental status
Narrowed pulse pressure
Rales, murmur

11. Diagnosis Physical examination (pulse and blood pressure)
Confirm the following tests:
Blood pressure measurement
Blood tests
Electrocardiogram
Echocardiography: heart activity and blood flow
Swan-Ganz Catheter: pulmonary catheter to observe pumping activity of the heart

12. Treatment and Management
Correct hypotension:
Fluid resuscitation to correct hypovolemia
Vasoactive agents:
Dopamine-will increase heart rate and cardiac work
Dobutamine-may drop blood pressure
Norepinephrine
Epinephrine

13. Treatment Continued: Oxygenation Optimizing pump function:
Morphine as needed (decreases preload, anxiety)
If Myocardial infarction:
Heparin and revascularization
If arrhythmia-correct arrhythmia
If extracardiac abnormality:
Reverse or treat cause

14. Hypovolemic Shock Most common type of shock
Life threatening condition that results when you lose more than 20% of your body’s blood or fluid supply. The severe fluid loss makes it impossible for the heart to pump sufficient blood to your body.
Resulting in decreased cardiac output
Causes:
Vomiting, diarrhea, bowel obstruction, burns
GI bleeding, trauma,
Can cause organ failure
This condition requires immediate emergency medical attention for survival

15. Risk Factors
Losing about 1/5 or more of the normal amount of blood in your body causes hypovolemic shock.
Excessive blood loss due to:
Bleeding from cuts
Bleeding from other injuries
Internal bleeding, such as in the GI tract

16. Clinical Presentation
Tachycardia and tachypnea
Weak, thready pulses
Hypotension
Cool and clammy skin
Mental status changes
Decreased urine output (dark and concentrated)

17. Diagnosis
In addition to physical symptoms the following testing methods can be done to confirm:
Blood testing to check for electrolyte imbalances and kidney function
CT scan or an ultrasound to visualize body organs
Echocardiogram to measure heart rhythm
Endoscopy to examine esophagus and other GI organs
Right heart catherization to check how blood is circulating
Urinary catherization to measure the amount of urine in the bladder

18. Treatment and Management
Pre-hospital care:
External bleeding should be controlled by direct pressure
Immobilization patient (if trauma is involved)
Securing adequate airway
Ensuring ventilation
Maximizing circulation
Medications to increase the heart’s pumping abilities (dobutamine, epinephrine, norepinephrine)
**delay in any of the above can be harmful to the patient and can lead to death

19. Septic Shock
Systemic inflammation response syndrome (SIRS) secondary to a documented infection.
Response is a state of acute circulatory failure involving persistent arterial hypotension despite adequate fluid resuscitation or by tissue hypoperfusion unexplained by other causes.

20. Risk Factors
Risk factors: certain groups of people are more at risk. Why? They have weaker immune systems.
Newborn babie, elderly people, pregnant women, people with long-term health conditions (diabetes, cirrhosis, or kidney failure), people with lowered immune systems (people with HIV or AIDS or receiving chemotherapy)
Traumatic wounds
Use of invasive catheters
Drug therapy

21. Signs and Symptoms Hyperthermia (Early state) Hypothermia (late stage)
Tachycardia
Wide pule pressure
Decreased blood pressure

22. Diagnosis Important points for diagnosis:
Identify subtle presentations
Screen patient for evidence of tissue hypoperfusion, such as cool or clammy skin, and elevated shock index (heart rate to systolic blood pressure > 0.9)
A lactic acid level higher than 4 mm/dL has been used as an entry criterion for early goal-directed therapy (EGDT) and an indicator of severe tissue hypoperfusion

23. Treatment Hospitalization is required
Adequate antibiotic therapy is required (as early as possible)
Resuscitate the patient using supportive measures to correct hypoxia, hypotension, and impaired tissue oxygenation (hypoperfusion)
Identify the source of infection, and treat with antimicrobial therapy, surgery, or both.
Antibiotics

24. Treatment Continued
Antibiotics- Survival correlates with how quickly the correct drug was given
Cover gram positive and gram negative bacteria
Zosyn grams IV and ceftriaxone 1 gram IV or
Imipenem 1 gram IV
Add additional coverage as indicated
Pseudomonas- Gentamicin or Cefepime
MRSA- Vancomycin
Intra-abdominal or head/neck anaerobic infections- Clindamycin or Metronidazole
Asplenic- Ceftriaxone for N. meningitidis, H. infuenzae
Neutropenic – Cefepime or Imipenem

25. Case Study
Mrs. S is a 65 year old obese female who presents to ED complaining “crushing” substernal chest pain, tachycardia, cool, clammy extremities. History of myocardial infarction is present. Husband also states she has become slightly confused.
Vitals: HR 46, BP 68/32, RR 23, SpO2 95% on RA, Afebrile.
Labs: WBC 8.1, Hgb 12.1, BUN 12, Creat 1.0, Troponin 3.1, BG 121.
EKG shows ST elevation in II, III, aVF

26. What kind of shock does the patient have?????
A. Cardiogenic
B. Hypovolemic
C. Septic

27. Cardiogenic Shock!!!!

28. References
Robbins, Stanley L., Vinay Kumar, and Ramzi S. Cotran. “Shock.” Robbins and Cotran Pathologic Basis of Disease. 8th ed. Philadelphia, PA: Saunders/Elsevier, Print.
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