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Shock

Definition
SHOCK: inadequate organ
perfusion to meet the tissues
oxygenation demand.

Three major types of shock

Hypovolemic shock
Decreased intravascular volume resulting
form loss of blood, plasma, or fluids and
electrolytes
Cardiogenic shock
Pump failure due to myocardial damage or
massive obstruction of outflow tracts
Distributive shock
Reduction of vascular resistance form
Sepsis
Anaphylaxis
Systemic inflammatory response syndrome
(SIRS)

Cardiogenic Shock

Cardiogenic Shock
Diminished cardiac output
leading to impaired tissue
perfusion
Most extreme form of pump
failure

Cardiogenic Shock
Occurs

in about 15% of acute MI


patients
Usually occurs when 40% or more
of the left ventricular muscle mass
infarcts
Mortality is 85% or more with
treatment

Etiologies

Acute myocardial
infarction/ischemia
LV failure
Papillary
muscle/chordal
rupture- severe MR
Ventricular free wall
rupture with subacute
tamponade

Other conditions complicating large


MIs
Hemorrhage
Infection
Excess negative inotropic or
vasodilator medications
Prior valvular heart disease
Hyperglycemia/ketoacidosis
Post-cardiac arrest
Post-cardiotomy
Refractory sustained
tachyarrhythmias
Acute fulminant myocarditis
End-stage
cardiomyopathyHypertrophic
cardiomyopathy with severe
outflow obstruction
Aortic dissection with aortic
insufficiency or tamponade
Pulmonary embolu
Severe valvular heart diseaseCritical aortic or mitral stenosis,
Acute severe aortic or MR

Pathophysiology

Characteristics of Cardiogenic Shock


Low cardiac output
Peripheral vasoconstriction
Left sided heart failure leads to pulmonary

venous congestion and pulmonary edema

Right sided heart failure leads to systemic

venous congestion and peripheral edema

It is essential to distinguish a cardiogenic from a hypovolemic


shock!
Both forms are associated with reduced cardiac out put, and increased peripheral
vascular resistance, however:

Cardiogenic shock:
jugular venous distention (high
CVP)

Hypovolemic shock: collapsed


capacitance veins (low CVP)

Signs/Symptoms
Confusion,

restlessness,
anxiety, stupor, coma
Cool, clammy skin
Pallor
Weak or absent extremity
pulses
Tachycardia
Slow or absent capillary refill

Signs/Symptoms
BP

< 90 systolic or > 30mmHg


below normal

BP is NOT the same as perfusion


Shock can be present with a
normal BP
Evaluate signs of peripheral
perfusion in addition to BP

Cardiogenic Shock
Treatment

Priorities:

Rate
Rhythm
BP (Volume, Pump/Vascular tone)

Correct

major disorders of
rate, rhythm before directly
treating BP

Goals of Management
Improve

oxygenation and
peripheral perfusion
Avoid increasing cardiac
workload

myocardial oxygen demand

Management
Primary

assessment & Focused

Hx
Identify source of problem
Acute pulmonary edema
Volume problem
Pump problem
Rate problem

Acute Pulmonary Edema


First line

interventions

IV/O2/ECG Monitor
If BP > 90-100 mm Hg:
furosemide

0.5 1.0 mg/kg slow IV (or


twice patients single daily dose up to
120 mg)
Morphine 2 10 mg slow IV
Nitroglycerin 0.4 mg SL

If BP < 90 mm Hg:
Vasopressors

based on SBP

Volume Problem
IV/O2/ECG Monitor
Fluid

challenge until rales or if


evidence of anterior wall AMI
Vasopressors based on SBP

Pump Problem
IV/O2/ECG

Monitor
SBP <70 mmHg:

norepinephrine 0.5 30 mcg/min IV


inf

SBP

70 100 mm Hg & shock

SBP

> 100 mm Hg w/o shock

dopamine 5 15 mcg/kg/min IV inf


dobutamine 2 20 mcg/kg/min IV inf

Management
If

rate/rhythm adequate, treat


BP

Consider fluid challenge of 250cc


LR over 10-15 minutes if relative
or absolute hypovolemia possible,
including RVF and NO
pulmonary edema
Avoid use of vasopressors until
volume deficits corrected or
pulmonary edema presents

BP Treatment Review
If

rate, rhythm, volume


adequate, treat BP with
vasopressors:
Norepinephrine, or
Dopamine

Norepinephrine
0.5 - 30 mcg/min

Inotropic and vasoconstrictive

properties
Can be used if systolic BP < 70
If systolic BP > 70, use dopamine
instead
DO NOT use until hypovolemia
corrected
DO NOT allow infiltration

Dopamine
2 - 20 mcg/kg/min

Place 200 mg/250cc of D5W


Begin at 5 mcg/kg/min
In 2 - 10 mcg/kg/min range, effects dominate
> 20 mcg/kg/min effects dominate
Use lowest dose that produces good perfusion

Use as initial vasopressor if BP

systolic

70-100

If dopamine infusion rate is > 20 mcg/kg/min


use norepinephrine

Dopamine
May

cause tachycardia, ectopy,


nausea
DO NOT use until hypovolemia is
corrected

Distributive Shock

Distributive Shock
Reduced

peripheral vascular
tone leads to pooling of blood in
extremities poor venous
return
Physical exam depends on stage
Early: Warm extremities, wide pulse
pressure, low diastolic pressure
Late: perfusion pressure falls and
acidosis develops

Distributive Shock

Sepsis
Due to gram negative or gram positive
bacteria
Anaphylaxis
Due to previous sensitization to an
allergen
Neurogenic
Due to traumatic spinal cord injury
Effects of epidural or spinal anesthetics
Reflex parasymapthetic stimulation

Bacteremia, SIRS, Sepsis


Bacteremia:

an identifiable organism
cultured from the blood
Systemic Inflammatory Response
Syndrome (SIRS): sepsis without
organism identified. Meet at least 2 of
criteria:
Hypo or hyperthermia
Tachycardia or bradycardia
Tachypnea
Leukocytosis or leukopenia
Sepsis:

SIRS from a systemic illness


(bacterial, viral, protozoal)

Pathogenesis of Septic Shock


(vasodilatory shock)

Sepsis is defined as a systemic inflammatory


response to a bacterial infection with bacteriemia
(though blood cultures can be negative)
Severe sepsis is defined by additional end-organ
dysfunction (mortality rate: 25-30%)
Septic shock is defined as sepsis with hypotension
despite fluid resuscitation and evidence of
inadequate tissue perfusion (40-70%)

NEJM 2004, Vol. 351;2 pp 159-169

The syndrome of septic shock is


characterized by

Systemic vasodilation (hypotension)

Diminished myocardial contractility

Widespread endothelial injury and


activation leading to fluid leakage
(capillary leak) resulting in acute
respiratory distress syndrome (ARDS)
Activation of the coagulation cascade (DIC)

Septic Shock

Early Warm Shock


CO and SVR and
wide pulse pressure
Signs: warm
extremities,
flushing, bounding
pulses, HR,
confusion
Hypocarbia,
elevated lactate,
hyperglycemia

Late Cold Shock


Uncompensated
shock with drop in
CO
Signs: cyanosis,
cold, clammy skin,
thready pulse,
shallow respiration
Metabolic acidosis,
hypoxia,
coagulopathy,
hypoglycemia

S/S of Septic Shock


Increased

to low blood

pressure
High fever, no fever,
hypothermic
Skin flushed, Pale, Cyanotic
Difficulty breathing and
altered lung sounds

TX of Septic Shock
Airway

control
Administer oxygen
IV of crystalloid solution
Dopamine for blood pressure
support
Monitor other vitals

Anaphylatic Shock
Severe

immune response to foreign


substance
S/S most often occur within
minutes but can take up to hours
to occur
The faster the reaction develops
the more severe it is likely to be
Death will occur if not treated
promptly

S/S of Anaphylactic Shock


Skin

- Flushing
- Itching
- Hives
-Swelling
-Cyanosis

S/S of Anaphylactic Shock


Respiratory

System
- Breathing difficulty
- Sneezing, Coughing
- Wheezing, Stridor
- Laryngeal edema
- Laryngospasm

S/S of Anaphylactic Shock


Cardiovascular

System

- Vasodilation
- Increased heart rate
- Decreased blood pressure

S/S of Anaphylactic Shock


Gastrointestinal

System
- Nausea, vomiting
- Abdominal cramping
- Diarrhea

TX for Anaphylactic Shock


Airway protection which may include

Endotracheal Intubation
Establish IV with crystalloid solution
Pharmacological interventions:
Epinephrine, Antihistamines(Benadryl),
Corticosteroids(dexamethasone),
Vasopressors(dopamine, Epinephrine), and
inhaled beta agonist(albuterol)