Shock

Differential Diagnosis and Hemodynamic

Monitoring
Andrew Watt
SICU CONFERENCE
Shock
Shock is a Cardiovascular Derangement.
1. Deliver Oxygen and Metabolic Substrates
2. Remove Products of Cellular Metabolism
3. Thermoregulation
Definition:
A physiological state characterized by a significant,
systemic reduction in tissue perfusion, resulting in
decreased tissue oxygen delivery and insufficient
removal of cellular metabolic products, resulting in
tissue injury.
Classification of Shock
Hypovolemic
Septic/Inflammatory
Cardiogenic (Intrinsic, compressive &
Obstructive)
Neurogenic
Anaphylactic

Clinical Markers of Shock
K
l
k
j

Brachial systolic blood pressure: <110mmHg
Sinus tachycardia: >90 beats/min
Respiratory rate: <7 or >29 breaths/min
Urine Output: <0.5cc/kg/hr
Metabolic acidemia: [HCO3]<31mEq/L or base deficit>3mEq/L
Hypoxemia: 0-50yr: <90mmHg; 51-70yr: <80mmHg;
>71yo<70mmHg;
Cutaneous vasoconstriction vs. vasodilation.
Mental Changes: anxiousness, agitation, indifference, lethargy,
obtundation
Etiology & Hemodynamic Changes
in Shock
Etiology of
shock
example CVP CO SVR VO2 sat
preload
hypovolemic low low high low
contractility
cardiogenic high low high low
afterload
distributive
Etiology & Hemodynamic Changes
in Shock (Afterload)
ETIOLOGY
OF SHOCK
EXAMPLE CVP CO SVR VO2 SAT
AFTERLOAD DISTRIBUTIVE
Hyperdynamic Septic
Low/High High Low High
Hypodynamic
Septic
Low/High Low High Low/High
Neurogenic Low Low Low Low
Anaphylactic Low Low Low Low
Hypovolemic Shock
Decreased preload->small ventricular end-diastolic
volumes -> inadequate cardiac generation of pressure
and flow
Causes:
-- bleeding: trauma, GI bleeding, ruptured aneurysms,
hemorrhagic pancreatitis
-- protracted vomiting or diarrhea
-- adrenal insufficiency; diabetes insipidus
-- dehydration
-- third spacing: intestinal obstruction, pancreatitis,
cirrhosis
Hypovolemic Shock
Signs & Symptoms: Hypotension, Tachycardia,
MS change, Oliguria, Deminished Pulses.

Markers: monitor UOP,CVP, BP, HR, Hct, MS,
CO, lactic acid and PCWP

Treatment: ABCs, IVF (crystalloid), Trasfusion
Stem ongoing Blood Loss

Patients on -blockers, w/ spinal shock &
athletes may not be tachycardic
Septic/Inflammatory Shock
Mechanism: release of inflammatory mediators leading to
1. Disruption of the microvascular endothelium
2. Cutaneous arteriolar dilation and sequestration of blood in
cutaneous venules and small veins
Causes:
1. Anaphylaxis, drug, toxin reactions
2. Trauma: crush injuries, major fractures, major burns.
3. infection/sepsis: G(-/+ ) speticemia, pneumonia,
peritonitis, meningitis, cholangitis, pyelonephritis,
necrotic tissue, pancreatitis, wet gangrene, toxic shock
syndrome, etc.
Septic/Inflammatory Shock
Signs: Early warm w/ vasodilation, often adequate urine
output, febrile, tachypneic.
Late-- vasoconstriction, hypotension, oliguria,
altered mental status.

Monitor/findings: Earlyhyperglycemia, respiratory
alkylosis, hemoconcentration,
WBC typically normal or low.
Late Leukocytosis, lactic acidosis
Very Late Disseminated Intravascular
Coagulation & Multi-Organ
System Failure.

Tx : ABCs, IVF, Blood cx, ABX, Drainage (ie abscess)
pressors.

Cardiogenic Shock
Mechanism: Intrinsic abnormality of heart -> inability to
deliver blood into the vasculature with adequate power
Causes:
1. Cardiomyopathies: myocardial ischemia, myocardial infarction,
cardiomyopathy, myocardiditis, myocardial contusion
2. Mechanical: cardiac valvular insufficiency, papillary muscle
rupture, septal defects, aortic stenosis
3. Arrythmias: bradyarrythmias (heart block), tachyarrythmias
(atrial fibrillation, atrial flutter, ventricular fibrillation)
4. Obstructive disorders: PE, tension peneumothorax, pericardial
tamponade, constrictive pericaditis, severe pulmonary
hypertension
Cardiogenic Shock
Characterized by high preload (CVP) with low CO
Signs/SXS: Dyspnea, rales, loud P2 gallop, low BP,
oliguria
Monitor/findings: CXR pulm venous congestion, elevated
CVP, Low CO.
Tx: CHF diuretics & vasodilators +/- pressors.
LV failure pressors, decrease afterload,
intraaortic ballon pump &
ventricular assist device.
Neurogenic Shock

Causes:
1. Spinal cord injury
2. Regional anesthesia
3. Drugs
4. Neurological disorders
Mechanism: Loss of autonomic innervation of the
cardiovascular system (arterioles, venules, small
veins, including the heart)
Neurogenic Shock
Characterized by loss of vascular tone & reflexes.

Signs: Hypotension, Bradycardia, Accompanying
Neurological deficits.

Monitor/findings: hemodynamic instability, test bulbo-
carvernous reflex

Tx: IVF, vasoactive medications if refractory
Monitoring Adjuncts in Shock

Sphyngomanometry

Pulse Oximeter

Arterial Line

Central Venous Line (Cordice, Triple Lumen,
Pulmonary Artery Catheter)
Pulmonary Artery
Catheterization
K
l
k
j



Allows for accurate and continuous hemodynamic monitoring
in shock patients
1. Evaluate Fluid Resuscitation
2. Titration of Vasoactive Medications
3. Allows for Assessment of Cardiovascular
Performance.
4. Monitor the Effects of Changes in Mechanical
Ventilation.
Pulmonary Artery
Catheterization
K
l
k
j


Pulmonary Artery
Catheterization: cardiovascular
performance
K
l
k
j

Central Venous Pressure (CVP):
CVP = right atrial pressure (RAP) = right-ventricular
end-diastolic pressure (RVEDP) (Right Ventricular
Preload)
Pulmonary Capillary Wedge Pressure (PCWP)
PCWP = left atrial pressure (LAP) = left-ventricular
end-diastolic pressure (LVEDP) (Left Ventricular
Preload)
Cardiovascular Performance
K
l
k
j



Cardiac Output (CO) = HR x SV (L/min)
Normal CO = 4 to 8 L/min
Cardiac Index (CI) = CO/BSA (L/min/m
2
)
Normal CI = 2.5-4.2 L/min/m2
Stroke Volume Index (SVI): CI/HR (ml/beat/m
2
)
Normal SVI = 40-85 ml/beat/m2
Systemic Vascular Resistance = MAP CVP / CO x 80
Normal SVR = 900-1600 dynes/sec/cm
-5

Systemic Vascular Resistance Index = MAP CVP / CI x 80
Normal SVRI = 1970-2390 dynes/sec/cm-5

Pulmonary Artery
Catheterization: systemic oxygen
transport
K
l
k
j


Oxygen Delivery (DO
2
) [520-570 mL/min x m
2
]: rate
of oxygen transport in arterial blood
DO
2
= CI x 13.4 x Hb x SaO
2
Oxygen Uptake (VO
2
) [110-160 ml/min x m
2
]: rate of
oxygen taken up from the systemic microcirculation
VO
2
= CI x 13.4 x Hb x (SaO
2
SvO
2
)
Hemodynamic Profiles
K
l
k
j


PCWP CVP CO/CI SVR/I

Hypovolemic
Low Low Low High
Cardiogenic
High High Low High
Inflammatory
Low / N Low/N High Low
Neurogenic
Low Low Low Low
Shock