Shock Management

Erin Burrell, ACNP-BC

Surgical ICU Nurse
Practitioner

Objectives
Understand the definition of the
three different types of shock
Be able to recognize the different
types of shock in patient scenarios
Understand 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
CO
Imbalance between oxygen delivery and
oxygen consumption which leads to cell
death, end organ damage, multi-system
organ failure,
and
death
Gaieski et al. 2009
(Online
accessed 22 August 2013)
URL: http://lijhs.sandi.net/faculty/rtenenbaum/ap-biologyfolder/Links/Shock.utd.pdf

Three Types of Shock

Cardiogenic
Hypovolemic
Distributive
Septic
Anaphylactic
Neurogenic

Combined

Case Study
Mrs. 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%
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

What kind of shock does this patient

have?
A. Cardiogenic
B. Hypovolemic
C. Distributive

Cardiogenic Shock

Shock caused as a result of cardiac

pump failure
Results in a decrease in CO
SVR is increased in an effort to
compensate to maintain organ perfusion
Causes:
Myocardial Infarction
Arrythmias (Atrial fibrillation, ventricular
tachycardias, bradycardias, etc)
Mechanical abnormalities (valvular defects)
Extracardiac abnormalities (PE, pulm HTN, tension
Medscape Reference. 1994 (Online accessed 22 August 2013)
pneumothorax)
URL: http://emedicine.medscape.com/article/152191treatment#showall

What information do you have to

suggest that Mrs. C has cardiogenic
A.
Hypotension
shock?
B. Evidence of MI
C. Altered Mental
Status
D. All of the above
E. Both A. and B.

Treatment of Cardiogenic
Shock
Correct hypotension:
Fluid resuscitation to correct hypovolemia
Inotropic or Vasopressor support:

Dobutamine
Milrinone
Norepinephrine
Dopamine
Epinephrine

Oxygenation
If MI ASA, Heparin, and Revascularization
If arrthymia correct arrthymia
If extracardiac abnormality reverse or treat
cause

Case Study
Mr. 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?
A. Cardiogenic
B. Hypovolemic
C. Distributive

Hypovolemic Shock
Shock caused by decreased preload
due to intravascular volume loss (1/5
of blood volume)
Results in decreased CO
SVR is typically increased in an effort to
compensate
Causes:
Hemorrhagic trauma, GI bleed, hemorrhagic
pancreatitis, fractures
Fluid loss induced Diarrhea, vomiting, burns
Medscape LLC. 2013 (Online access on 22 August 2013)
URL: http://emedicine.medscape.com/article/760145treatment#2

What information do you have to

suggest that Mr. H has hypovolemic
shock?
A. Recent trauma
B. WBC 12.3
C. Hgb 6.7
D. All of the above
E. Both A. and C.

Treatment of Hypovolemic
Shock

Maximize oxygen delivery

Control further blood loss
Tourniquets
Surgical intervention

Fluid resuscitation
NS fluid boluses
Blood product administration

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

What kind of shock does this patient

have?
A. Cardiogenic
B. Hypovolemic
C. Distributive

Distributive Shock
Shock as a result of severely diminished
SVR
CO is typically increased in an effort to
maintain perfusion
Subtypes:
Septic secondary to an overwhelming infection
Anaphylactic secondary to a life-threatening
allergic reaction
Neurogenic 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-biologyfolder/Links/Shock.utd.pdf

What information do you have to

suggest Mr. S has distributive shock?
A. SpO2 94% on 4
L NC
B. Anastamotic
leak on CT scan
C. WBC 20.1
D. All of the above
E. Both B. and C.

Treatment of Septic Shock

Resuscitate
30cc/kg of NS bolus

Identify Source
Pan cultures
CT scan
Line removal
Foley removal
Surgical exploration

Antibiotics

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
Shock
Remove offending
agent

Establish an airway and return circulation

Pharmacologic support:
Epinephrine reverses peripheral vasodilation,
dilates bronchial airways, increases myocardial
contractility, and suppresses histamine/ leukotriene
release

Antihistamine (benadryl) may help counter

histamine-mediated vasodilation and
bronchoconstriction

Corticosteroids (hydrocortisone) may help shorten

reaction

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

Treatment of Neurogenic
Shock

Establish an airway to maintain

adequate oxygenation and ventilation
Fluid resuscitation for MAP>65mmHg
Inotropic support
Dobutamine
Dopamine

Atropine for severe bradycardia

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

All three types of shock can

occur at the same time to
have a combined shock
picture.

Case Study
Mrs. D is a 71yo F who presented to
ED after a 3 day h/o N&V with inability
to tolerate PO intake. She is now
POD0 s/p exlap, pancretectomy for
necrotizing pancreatitis. She presents
to the Surgical ICU postop.
Vitals: HR 121, BP 82/41, Intubated on
100% FiO2, Fever 102.8
Labs: WBC 1.1, Hgb 8.4, BUN 61,
Creat 2.82, Lactate 3.7

Case Study cont..

The Surgical ICU team places a MAC
with PAC to obtain further data about
the patients hemodynamic status.
PAC numbers: PAP 18/6, CVP 1, PCWP
2, CI 1.7, SVR 615

What type of shock does this patient

have?
A. Cardiogenic
B. Hypovolemic
C. Distributive
D. All of the Above

What information leads you to believe

Mrs. D has a component of cardiogenic
shock?
A. BP 82/41
B. Temp 102.8
C. CI 1.7 L/min
D. Cr 2.82

What information demonstrates a

component of hypovolemic shock?
A. CVP 1 mmHg
B. PCWP 2 mmHg
C. SVR 615
dynes/sec/cm-5
D. PAP 18/6 mmHg
E. Both A. B. and
D.

What information indicates a degree of

distributive shock?
A. PCWP 2 mmHg
B. SVR 615
dynes/sec/cm-5
C. PAP 18.16
mmHg
D. WBC 1.1

Mrs. S is suffering from distributive

septic shock along with cardiogenic
and hypovolemic shock.
A. True
B. False

Case Study cont..

The Surgical ICU team starts by giving Mrs.
S a 2L NS bolus and 1L 5% Albumin bolus
Vitals: HR 114, BP 89/45, Remains
intubated on SIMV/PRVC 60% FiO2, Febrile
101.7
Labs: WBC 3.4, Hgb 7.4, BUN 72, Creat
3.21, Lactate 2.1
Broad spectrum ABX are started
immediately upon arrival
PAC numbers after the initial resuscitation:
PAP 22/10, CVP 9, PCWP 11, CI 1.5, SVR 682

Mrs. S. continues to have a combined

shock of hypovolemic, distributive, and
cardiogenic shock.
A. True
B. False

Mrs. S continues to suffer from

cardiogenic and distributive septic
shock as evidence by the following:
A. CI 1.5 L/min
B. SVR 682
dynes/sec/cm-5
C. Both A. and B.

As an intensivist, what treatment

should be implemented next?
A. More fluid
resuscitation
B. Initiate vasopressor
support
C. Initiate inotropic
support
D. No change in
current therapy

E. Both B. and C.

Case study cont..

After initiating milrinone and
levophed therapy, Mrs. S improves.
Vitals: HR 93, BP 122/61, Intubated
on PS/CPAP 40%, Afebrile. Levophed
at 4mcg/min and Milrinone at
0.375mcg/kg/min
PA numbers: PAP 24/10, CVP 12,
PCWP 14, CI 3.6, SVR 1120

Case study cont..

The Surgical ICU team decides to attempt
to wean vasopressor support first.
Mrs. S is successfully weaned off levophed
support after approximately 12 hours.
Vitals: HR 87, BP 117/58, Intubated on
PS/CPAP 40%, Afebrile. Levophed is off and
Milrinone at 0.375mcg/kg/min
PA numbers: PAP 22/14, CVP 12, PCWP 14,
CI 3.4, SVR 1068

Case Study cont..

After an additional 12 hours, Mrs. S is
successfully weaned off milrinone
support as well.
She is extubated the next day and
progressing well.
On HOD 6, Mrs. S is complaining of a HA
and would prefer not to take narcotics.
Ibuprofen 200mg q6h PRN is added to
HA pain.

Case Study cont..

After approximately 15 min of her first
dose of Ibuprofen, Mrs S starts to
complain of difficult breathing,
flushing, and airway edema.
The bedside RN notices a new onset of
hives around Mrs. Ss neck and mouth.
Vitals: HR 147, BP 54/31, SpO2 91% on
100% NRB, Febrile 102.6.

What kind of shock is Mrs. S

exhibiting?
A. Cardiogenic
B. Hypovolemic
C. Distributive

What would you include in your

treatment plan?
A. Benadryl 25 mg
IV
B. Reintubation
C. Hydrocortisone
100 mg IV
D. Epinephrine 50
mcg IV
E. All of the above

Case Study cont..

Mrs. S is successfully intubated and
administered treatment for her
anaphylaxis. After approximately
12hours, her symptoms have
resolved. She is again extubated and
progressing well.
Mrs. S goes on to rehab and
eventually home!

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

Questions?

References
Dellinger, R et al. Surviving Sepsis Campaign: International
Guidelines for Management of Severe Sepsis and Septic
Shock:2012, 41: 580-637, 2013.
Emergency Medicine. 2009 (Online Accessed on 22 August 2013)
URL: http://emergencymed.wordpress.com/2009/03/11/neurogenicshock/
Gaieski et al. 2009 (Online accessed 22 August 2013)
URL:http://lijhs.sandi.net/faculty/rtenenbaum/ap-biologyfolder/Links/Shock.utd.pdf
Medscape Reference. 1994 (Online accessed 22 August 2013) URL:
http://emedicine.medscape.com/article/152191-treatment#showall
Medscape LLC. 2013 (Online access on 22 August 2013) URL:
http://emedicine.medscape.com/article/760145-treatment#2
Soar, J et al. 2013 (Online Accessed on 22 August 2013) URL:
http://www.resus.org.uk/pages/reaction.pdf