Shock ManagementAhmad ALI

ObjectivesUnderstand the definition of the three different types of shockBe able to recognize the different types of shock in patient scenariosUnderstand and apply treatment guidelines for the different types of shock

What is Shock?Shock is the physiologic state characterized by significant reduction of systemic tissue perfusion, resulting in decreased tissue oxygen delivery. Tissue perfusion is dependent on SVR and COImbalance between oxygen delivery and oxygen consumption which leads to cell death, end organ damage, multi-system organ failure, and deathGaieski et al. 2009 (Online accessed 22 August 2013) URL: http://lijhs.sandi.net/faculty/rtenenbaum/ap-biology-folder/Links/Shock.utd.pdf

Gaieski et al. 2009 (Online accessed 22 August 2013) URL: http://lijhs.sandi.net/faculty/rtenenbaum/ap-biology-folder/Links/Shock.utd.pdf

Three Types of ShockCardiogenicHypovolemicDistributiveSepticAnaphylacticNeurogenicCombined

Case StudyMrs. C is a 61yo F who presents to ED complaining of fatigue and SOB. She has significant PMHx: DM, obesity, HTN. Husband also states she has become slightly confused.Vitals: HR 46, BP 68/32, RR 23, SpO2 95% , 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

What kind of shock does this patient have?CardiogenicHypovolemicDistributive

Cardiogenic ShockShock caused as a result of cardiac pump failureResults in a decrease in COSVR is increased in an effort to compensate to maintain organ perfusionCauses: Myocardial InfarctionArrythmias (Atrial fibrillation, ventricular tachycardias, bradycardias, etc)Mechanical abnormalities (valvular defects)Extracardiac abnormalities (PE, HTN, tension pneumothorax)Medscape Reference. 1994 (Online accessed 22 August 2013) URL: http://emedicine.medscape.com/article/152191-treatment#showall

Medscape Reference. 1994 (Online accessed 22 August 2013) URL: http://emedicine.medscape.com/article/152191-treatment#showall

What information do you have to suggest that Mrs. C has cardiogenic shock?

HypotensionEvidence of MIAltered Mental StatusAll of the aboveBoth A. and B.

Treatment of Cardiogenic ShockCorrect hypotension:Fluid resuscitation to correct hypovolemiaInotropic or Vasopressor support:DobutamineMilrinoneNorepinephrineDopamineEpinephrineOxygenationIf MI MONA, Heparin, and RevascularizationIf arrthymia correct arrthymia If extracardiac abnormality reverse or treat cause

Case StudyMr. H is a 18yo M who presents to ED after suffering a MCC into a tree. He was unhelmeted and has an obvious left femur fx. He was intubated for a GCS of 8 in the field and given 1L NS en route for hypotension.Vitals: HR 145, BP 71/38, Intubated with SpO2 100%, Afebrile.Labs: WBC 12.3, Hgb 6.7, Plts 72, INR 2.1.Traumagram shows Grade III liver lac.

What kind of shock does this patient have?CardiogenicHypovolemicDistributive

Hypovolemic ShockShock caused by decreased preload due to intravascular volume loss (1/5 of blood volume)Results in decreased COSVR is typically increased in an effort to compensateCauses:Hemorrhagic trauma, GI bleed, hemorrhagic pancreatitis, fracturesFluid loss induced Diarrhea, vomiting, burnsMedscape LLC. 2013 (Online access on 22 August 2013) URL: http://emedicine.medscape.com/article/760145-treatment#2

Medscape LLC. 2013 (Online access on 22 August 2013) URL: http://emedicine.medscape.com/article/760145-treatment#2

What information do you have to suggest that Mr. H has hypovolemic shock?Recent traumaWBC 12.3Hgb 6.7All of the aboveBoth A. and C.

Treatment of Hypovolemic ShockMaximize oxygen deliveryControl further blood lossTourniquetsSurgical interventionFluid resuscitationNS fluid bolusesBlood product administration

Case StudyMr. S is a 59yo M presents to ED with worsening abdominal pain and N&VHe is POD#8 s/p ex-lap, SBR with primary anastamosis for chronic SBO at OSHVitals: HR 128, BP 78/45, RR28, SpO2 94% on 4L NC, Fever 103.1Labs: WBC 20.1, Hgb 9.5, BUN 34, Creat 2.1CT scan of ABD shows anastamotic leak

What kind of shock does this patient have?CardiogenicHypovolemicDistributive

Distributive ShockShock as a result of severely diminished SVRCO is typically increased in an effort to maintain perfusionSubtypes:Septic secondary to an overwhelming infectionAnaphylactic secondary to a life-threatening allergic reactionNeurogenic secondary to a sudden loss of the autonomic nervous system function Gaieski et al. 2009 (Online accessed 22 August 2013) URL: http://lijhs.sandi.net/faculty/rtenenbaum/ap-biology-folder/Links/Shock.utd.pdf

Gaieski et al. 2009 (Online accessed 22 August 2013) URL: http://lijhs.sandi.net/faculty/rtenenbaum/ap-biology-folder/Links/Shock.utd.pdf

What information do you have to suggest Mr. S has distributive shock?

SpO2 94% on 4 L NCAnastamotic leak on CT scanWBC 20.1All of the aboveBoth B. and C.

Treatment of Septic ShockResuscitate30cc/kg of NS bolusIdentify SourcePan culturesCT scanLine removalFoley removalSurgical explorationAntibioticsDellinger, R et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock:2012, 41: 580-637, 2013.

Dellinger, R et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock:2012, 41: 580-637, 2013.

Treatment of Anaphylactic ShockRemove offending agentEstablish an airway and return circulationPharmacologic support:Epinephrine reverses peripheral vasodilation, dilates bronchial airways, increases myocardial contractility, and suppresses histamine/ leukotriene releaseAntihistamine (benadryl) may help counter histamine-mediated vasodilation and bronchoconstrictionCorticosteroids (hydrocortisone) may help shorten reactionBronchodilatorsSoar, J et al. 2013 (Online Accessed on 22 August 2013) URL: http://www.resus.org.uk/pages/reaction.pdf

Soar, J et al. 2013 (Online Accessed on 22 August 2013) URL: http://www.resus.org.uk/pages/reaction.pdf

Treatment of Neurogenic ShockEstablish an airway to maintain adequate oxygenation and ventilationFluid resuscitation for MAP>65mmHgInotropic supportDobutamineDopamineAtropine for severe bradycardiaHigh dose methyl prednisolone therapy Emergency Medicine. 2009 (Online Accessed on 22 August 2013) URL: http://emergencymed.wordpress.com/2009/03/11/neurogenic-shock/

Emergency Medicine. 2009 (Online Accessed on 22 August 2013) URL: http://emergencymed.wordpress.com/2009/03/11/neurogenic-shock/

All three types of shock can occur at the same time to have a combined shock picture.

Summary

Survival and outcomes improve with early perfusion, adequate oxygenation, and identification with appropriate treatment of the cause of shock.

Questions?