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Approach to a case of Hypotension and Shock
Introductory Lecture Series
Department of Medicine
Dr C Khati
Shock is an Emergency
Assessment and resuscitation go hand in hand because time is critical
Learning Objectives
• To learn definition and meanings of related terms
• To be able to list the steps in pathogenesis of shock
• To be able to list the 3 major categories of shock, and 3 others
• To be able to enumerate common causes of shock in each of the 3 major categories
Learning Objectives
• To comprehend that more than one mechanisms may operate in a given patient
• To list steps in rapid initial assessment
• To enumerate broad steps in resuscitation of shock
Definitions and Meanings
• Stroke Volume (SV): Amount of blood pumped out with each systole. Pulse pressure correlates well with SV
• Heart Rate (HR): Number of ventricular contractions per minute
• Cardiac Output(CO): Amount of blood pumped out in each minute.
CO = SV X HR
Definitions and Meanings
• Stroke Volume (SV): Amount of blood pumped out with each systole. Pulse pressure correlates well with SV
• Heart Rate (HR): Number of ventricular contractions per minute
• Cardiac Output(CO): Amount of blood pumped out in each minute.
CO = SV X HR
Definitions and Meanings
• Stroke Volume (SV): Amount of blood pumped out with each systole. Pulse pressure correlates well with SV
• Heart Rate (HR): Number of ventricular contractions per minute
• Cardiac Output(CO): Amount of blood pumped out in each minute.
CO = SV X HR
Definitions and Meanings
• Stroke Volume (SV): Amount of blood pumped out with each systole. Pulse pressure correlates well with SV
• Heart Rate (HR): Number of ventricular contractions per minute
• Cardiac Output(CO): Amount of blood pumped out in each minute.
CO = SV X HR
Definitions and Meanings
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
Definitions and Meanings
Pulse Pressure (PP): SBP – DBP correlates well with Stroke Volume .
Mean Arterial Pressure (MAP): DBP + 1/3 PP
Definition and Meanings
• Hypotension is diagnosed if blood pressure falls below 90/50 mmHg in adults.
• Hypotension may also be diagnosed if an individual has a sudden drop in SBP of 30 - 40 mmHg or more from their baseline, or
• An orthostatic (postural) drop in DBP of 15 mm Hg
Definition and Meanings
• Hypotension is diagnosed if blood pressure falls below 90/50 mmHg in adults.
• Hypotension may also be diagnosed if an individual has a sudden drop in SBP of 30 - 40 mmHg or more from their baseline, or
• An orthostatic (postural) drop in DBP of 15 mm Hg
Definition and Meanings
• Hypotension is diagnosed if blood pressure falls below 90/50 mmHg in adults.
• Hypotension may also be diagnosed if an individual has a sudden drop in SBP of 30 - 40 mmHg or more from their baseline, or
• An orthostatic (postural) drop in DBP of 15 mm Hg
Remember
Hypotension is a late manifestation of shock
Definitions and Meanings
• The Jugular Venous Pressure (JVP) is an observed pressure over the jugular veins
• The Central Venous Pressure (CVP) is a measured pressure in the right atrium by means of a catheter attached to a manometer
Definitions and Meanings
• The Jugular Venous Pressure (JVP) is an observed pressure over the jugular veins
• The Central Venous Pressure (CVP) is a measured pressure in the right atrium by means of a catheter attached to a manometer
Definitions and Meanings
• The Jugular Venous Pressure (JVP) is an observed pressure over the jugular veins
• The Central Venous Pressure (CVP) is a measured pressure in the right atrium by means of a catheter attached to a manometer
Definitions and Meanings
Capillary Nail Refill Test• Pressure is applied to the nail bed until it turns white
(blanching). Then pressure is removed.• Time taken for return of pink colour to the nail is
considered (capillary refill).
• Blanch time > 2 seconds is a delayed response.–Dehydration– Shock– Peripheral vascular disease (PVD)– Hypothermia
Definitions and Meanings
Capillary Nail Refill Test• Pressure is applied to the nail bed until it turns
white (blanching). Then pressure is removed.• Time taken for return of pink colour to the nail is
considered (capillary refill).• Blanch time > 2 seconds is a delayed response.
–Dehydration– Shock–Peripheral vascular disease (PVD)–Hypothermia
Definitions and MeaningsShock or circulatory failure is the clinical syndrome that
results from generalized inadequate tissue perfusion lasting for some time. Where oxygen delivery fails to meet metabolic requirements of the tissues.
It is defined by the presence of multisystem, end organ hypo perfusion causing cellular injury.
Cellular injury further compromises perfusion through functional and structural changes in the microvasculature through mediators
Thus, setting up a vicious cycle.
Definitions and MeaningsShock or circulatory failure is the clinical syndrome that
results from generalized inadequate tissue perfusion lasting for some time. Where oxygen delivery fails to meet metabolic requirements of the tissues.
It is defined by the presence of multisystem, end organ hypo perfusion causing cellular injury.
Cellular injury further compromises perfusion through functional and structural changes in the microvasculature through mediators
Thus, setting up a vicious cycle.
Definitions and MeaningsShock or circulatory failure is the clinical syndrome that
results from generalized inadequate tissue perfusion lasting for some time. Where oxygen delivery fails to meet metabolic requirements of the tissues.
It is defined by the presence of multisystem, end organ hypo perfusion causing cellular injury.
Cellular injury further compromises perfusion through functional and structural changes in the microvasculature through mediators
Thus, setting up a vicious cycle.
Hypoperfusion
Demand supply
mismatch
Cellular Dysfunction
Release of mediators
Structural and functional changes in
microvasculature
Hypoperfusion
Demand supply
mismatch
Cellular Dysfunction
Release of mediators
Structural and functional changes in
microvasculature
Hypoperfusion
Demand supply
mismatch
Cellular Dysfunction
Release of mediators
Structural and functional changes in
microvasculature
Hypoperfusion
Demand supply
mismatch
Cellular Dysfunction
Release of mediators
Structural and functional changes in
microvasculature
Definition and Meanings
• Early Shock
• No significant organ failure
• Late Shock
• Multi-organ failure. > 80% mortality
Definition and Meanings
• Early Shock
• No significant organ failure
• Late Shock
• Multi-organ failure. > 80% mortality
Definition and Meanings
• Early Shock
• No significant organ failure
• Late Shock
• Multi-organ failure. > 80% mortality
Definitions and Meanings
• Systemic Vascular Resistance (SVR): An index of arteriolar constriction throughout the body
• Calculated by dividing the blood pressure by the cardiac output. MAP/ CO = SVR
• Pulmonary Vascular Resistance (PVR): An index of arteriolar constriction in the pulmonary circulation
Definitions and Meanings
• Systemic Vascular Resistance (SVR): An index of arteriolar constriction throughout the body
• Calculated by dividing the blood pressure by the cardiac output. MAP/ CO = SVR
• Pulmonary Vascular Resistance (PVR): An index of arteriolar constriction in the pulmonary circulation
Definitions and Meanings
• Systemic Vascular Resistance (SVR): An index of arteriolar constriction throughout the body
• Calculated by dividing the blood pressure by the cardiac output. MAP/ CO = SVR
• Pulmonary Vascular Resistance (PVR): An index of arteriolar constriction in the pulmonary circulation
Definitions and Meanings
• Systemic Vascular Resistance (SVR): An index of arteriolar constriction throughout the body
• Calculated by dividing the blood pressure by the cardiac output. MAP/ CO = SVR
• Pulmonary Vascular Resistance (PVR): An index of arteriolar constriction in the pulmonary circulation
Pathogenesis of Shock
MAP = CO X SVR
Pathogenesis of Shock
MAP = CO X SVR
or
MAP/ CO = SVR
Pathogenesis of Shock
MAP= CO X SVRMAP- Mean Arterial Pressure (Measurable:DBP +1/3 PP)
Pathogenesis of Shock
MAP= CO X SVRMAP- Mean Arterial Pressure -Measurable (DBP + 1/3 PP)
CO- Cardiac Output -Inferable (Pulse Pressure =SBP- DBP)
Pathogenesis of Shock
MAP= CO X SVRMAP- Mean Arterial Pressure (Measurable: SBP + DBP/ 2)
CO- Cardiac Output (Inferable; Pulse Pressure= SBP- DBP)
SVR-Systemic Vascular Resistance: (can be calculated)
Pathogenesis of Shock
• Diminished Cardiac Output
Is the Heart full or empty?
Pathogenesis of Shock
• Diminished Cardiac Output
• Heart Full (Cardiogenic)
• Heart Empty (Hypovolemic)
Pathogenesis of Shock
• Diminished Cardiac Output
• Heart Full (Cardiogenic)
• Heart Empty (Hypovolemic)
• Increased Cardiac Output
Pathogenesis of Shock
Diminished Cardiac Output
MAP/ CO = SVR
• Narrow Pulse Pressure (PP correlates well with SV)
• Low volume pulse
• Cool extremities
• Delayed capillary refill
Pathogenesis of Shock
Increased Cardiac Output
MAP/ CO = SVR
• Wide Pulse Pressure (esp. low DBP)
• Bounding pulse
• Warm extremities
• Rapid capillary refill
Pathogenesis of Shock ( CO)
MAP = CO X SVR
or
MAP/ CO = SVR
• If an hypotensive patient has high CO, it can be inferred that reduced BP is a result of decreased SVR
Pathogenesis of Shock ( CO)
MAP = CO X SVR
or
MAP/ CO = SVR
• If a hypotensive patient has high CO, it can be inferred that reduced BP is a result of decreased SVR
Pathogenesis of Shock ( CO)
• Low Intravascular and Cardiac Volume
• Increased Intravascular and Cardiac Volume
Is the Heart full or empty?
Pathogenesis of Shock ( CO)
Low Intravascular and Cardiac Volume
• Hemorrhage
• Volume Losses (vomiting, diarrhea, Polyuria)
• JVP/ CVP is reduced
• What do you think the other findings will be?
Pathogenesis of Shock ( CO)
Low Intravascular and Cardiac Volume
• Hemorrhage
• Volume Losses (vomiting, diarrhea, Polyuria)
• JVP/ CVP is reduced
• What do you think the other findings will be?
Pathogenesis of Shock( CO)
Increased Intravascular and Cardiac Volume
• Increased JVP/ CVP
• Extremity edema
• S3/ S4 gallops
• Basal crepitations
• X Ray – Cardiomegaly
– Widened vascular pedicles, Kerley B Lines
– Pulmonary edema
Common Categories of Shock
1. Cardiogenic
2. Hypovolemic
3. High CO with decreased SVR (Warm Shock)
4. Neurogenic- Major brain or spinal injury-
5. Hypoadrenal- Refractory Shock
6. Obstructive- Tamponade, Pulmonary Embolism, Tension Pneumothorax
Common Categories of Shock
1. Cardiogenic
2. Hypovolemic
3. High CO with decreased SVR (Warm Shock)
4. Neurogenic- Major brain or spinal injury-
5. Hypoadrenal- Refractory Shock
6. Obstructive- Tamponade, Pulmonary Embolism, Tension Pneumothorax
Basic Changes in Each Category
Cardiogenic Hypovolemic High CO with decreased SVR
CO Low Low High
Basic Changes in Each Category
Cardiogenic Hypovolemic High CO with decreased SVR
CO Low Low High
SVR High High Low/ High (late)
Basic Changes in Each Category
Cardiogenic Hypovolemic High CO with decreased SVR
CO Low Low High
SVR High High Low/ High (late)
MAP Low Low Normal/ Low
Basic Changes in Each Category
Cardiogenic Hypovolemic High CO with decreased SVR
CO Low Low High
SVR High High Low/ High (late)
MAP Low Low Normal/ Low
CVP High Low Low/ High (late)
Basic Changes in Each Category
Cardiogenic Hypovolemic High CO with decreased SVR
CO Low Low High
SVR High High Low/ High (late)
MAP Low Low Normal/ Low
CVP High Low Low/ High (late)
Venous Oxygen saturation
Low Low High
Common Causes of ShockCardiogenic Hypovolemic High CO with
decreased SVR
MI GI Losses SIRS
Arrhythmias Heat stroke Sepsis
Myocarditis Hemorrhage Pancreatitis
Anaphylaxis
Tamponade Trauma Thyrotoxicosis (storm)
Injuries Burns Burns
AV Shunts
Liver Failure
Steps in rapid initial assessment
• Confirm shock and assess severity
• Assess category of shock
• Low CO or high CO
(Heart empty or full)
• Start resuscitation simultaneously
Steps in rapid initial assessment
• Confirm shock and assess severity
• Assess category of shock
• Low CO or high CO
(Heart empty or full)
• Start resuscitation simultaneously
Steps in rapid initial assessment
• Confirm shock and assess severity
• Assess category of shock
• Low CO or high CO
(Heart empty or full)
• Start resuscitation simultaneously
Goal of Resuscitation ?
• Re establish adequate tissue perfusion to prevent or minimize end- organ injury
Goal of Resuscitation
• Re establish adequate tissue perfusion to prevent or minimize end- organ injury
Resuscitation is different in each category
Cardiogenic Hypovolemic High CO with decreased SVR
Treatment for Ischemia
IV Fluids Antibiotics
Ionotropes Colloids EGDT*
After load reduction
Low dose steroids
Activated Protein C
Steps in rapid initial assessment
• Patient and clinical situation assessment• Vitals and quick examination to assess category
of shock-• Core temperature• Cold or warm peripheries• Pulse- bounding or low volume• Capillary filling- slow/ rapid• Raised JVP, S3 and basal crepts in cardiogenic• Respiration• Urine Output
Steps in rapid initial assessment
• Patient and clinical situation assessment• Vitals and quick examination to assess
category of shock-
–Core temperature
–Cold or warm peripheries
–Pulse- bounding or low volume
–Capillary filling- slow/ rapid
–Raised JVP, S3 and basal crepts in cardiogenic
–Respiration
–Urine Output
Terms in Assessment/ Treatment
• APACHE II Score- Acute Physiology and Chronic Health Evaluation II (with points for age and co-morbidity)
• Glasgow Coma Score
• ACLS- Advanced Cardiac Life Support
• Old acronym- ABC (still valid)
General Features of Shock
• Hypotension (SBP < 100)
• Tachycardia (>100)
• Cold clammy skin (Low CO)
• Rapid shallow respiration
• Drowsiness, confusion and irritability
• Oliguria (<30ml/hr)
• Elevated / reduced CVP
• Multi- organ failure
Steps in Resuscitation
• Airway and Respiration
• Circulation
• Early Goal Directed Therapy (EGDT)
• Multisystem organ support
32 year old young lady, on NSAIDS
• Dyspepsia X 5 days
• Dark tarry stools X 2 days
• Profound weakness X 2 days
• Syncope this morning
• Cold clammy and sweating, Poor capp refill
• BP 70/50 mm Hg lying; 60/ 35 mm standing
• Pulse 140/ min, thready
• Resp- 36/ min
• Pallor
40 year busy doctor, HT
• Chest Pain X 1 Hour
• Sweating, palpitations and breathlessness
• Restless, sweating, cold and clammy
• BP 100/76 mm, Pulse 110/ min, low volume
• Resp- 26/ min, prefers to be propped up
• Poor capillary refill
• JVP/ CVP raised
45 year old diabetic male
• Fever, cough and rusty sputum X 2 days
• Weakness X 1 day
• No urine X12 hours
• Temp- 40 degrees C, warm extremities
• Pulse 120/ min, good volume
• BP 108/30 mm, Resp rate 40/ min
• Cyanosis +, JVP not raised
• Capp refill good
Take Home Messages
• Shock is an Emergency. Assessment and resuscitation go hand in hand because time is critical
• Hypotension is a late feature of shock. Do not wait for hypotension before starting treatment
• Clinical setting and simple examination of MAP, pulse pressure, heart rate, JVP and nail cappillarybed refill can give vital clues. Tachypnea and sweating should also make you alert.
Take Home Messages
• Urine output is a good indicator of renal (tissue) perfusion
• Goal of resucitatation is to re establish adequate tissue perfusion to prevent or minimize end-organ injury