Shock

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Shock

• Tad Kim, M.D.
• UF Surgery
• tad.kim_at_surgery.ufl.edu
• (c) 682-3793 (p) 413-3222

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Overview

• Definitions
• Initial Assessment ABC
• Stages of Shock
• Physiologic Determinants of Shock
• Types of Shock
• Common Features of Shock
• H P / Work-up
• Case scenarios and Management
• Take Home Points

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Definitions

• Shock is a physiologic state characterized by
  systemic reduction in tissue perfusion, resulting
  in decreased tissue oxygen delivery
• Hypotension is not a requirement
• Poor tissue perfusion

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Initial Assesment - ABC

• Airway
• Does pt have mental status to protect airway?
• GCS less than eight means intubate
• Airway is compromised in anaphylaxis
• Breathing
• If pt is conversing with you, A B are fine
• Place patient on oxygen
• Circulation
• Vitals (HR, BP)
• 2 large bore (16g) IV, start fluids (careful if
  cardiogenic shock), put on continuous monitor

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ABC DE

• In a trauma, perform ABCDE, not just ABC
• Deficit or Disability
• Assess for obvious neurologic deficit
• Moving all four extremities? Pupils?
• Glascow Coma Scale (M6, V5, E4)
• Exposure
• Remove all clothing on trauma patients

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Stages / Spectrum of Shock

• Preshock aka compensated/warm shock
• Body is able to compensate for ?perfusion
• Up to 10 reduction in blood volume
• Tachycardia to ?cardiac output perfusion
• Shock
• Compensatory mechanisms overwhelmed
• See signs/symptoms of organ dysfunction
• 20-25 reduction in blood volume
• End-organ dysfunction
• Leading to irreversible organ damage/death

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Physiologic Determinants

• Global tissue perfusion is determined by
• Cardiac output (CO)
• CO Heart rate (HR) times Stroke Volume (SV)
• SV function of Preload, Afterload,
  Contractility
• Systemic vascular resistance (SVR)
• Variables Length, Inverse of Diameter, Viscosity

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Types of Shock

• Hypovolemic shock from ?preload
• Hemorrhage
• Fluid Loss (Vomiting, Diarrhea, Burns)
• Cardiogenic shock pump failure or ?SV
• MI, arrhythmia, aortic stenosis, mitral regurg
• Extracardiac obstructive causes such as PE,
  tension pneumothorax, tamponade
• Distributive (vasodilatory) shock - ?SVR
• Septic, anaphylactic, and neurogenic shock
• Pancreatitis, burns, multi-trauma via activation
  of the inflammatory response

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Common Features of Shock

• Hypotension (not an absolute requirement)
• SBP lt 90mm Hg, not seen in preshock
• Cool, clammy skin
• Vasoconstrictive mechanisms to redirect blood
  from periphery to vital organs
• Exception is warm skin in early distrib. shock
• Oliguria (?kidney perfusion)
• Altered mental status (?brain perfusion)
• Metabolic acidosis

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HP / Work-up

• History to determine etiology
• Bleeding (recent surgery, trauma, GI bleed)
• Allergies or prior anaphylaxis
• Sx consistent with pancreatitis, EtOH history
• Hx of CAD, MI, current chest pain/diaphoresis
• Physical examination
• Mucous membranes, JVD, lung sounds, cardiac exam,
  abdomen, rectal (blood), neuro exam, skin (cold
  clammy or warm)
• Labs/Tests directed toward suspected dxs

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Case 1

• 55yo male otherwise healthy who is fresh post-op
  from a colon resection for CA
• Called for tachycardia, hypotension, altered
  mental status, and abd distension
• On exam pale, dry mucous membranes, disoriented,
  abdomen is tender and tense
• UOP is 15mL over past hour
• What else do you want to know?
• What is the most likely diagnosis?

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Case 1

• The one thing you want to know Hct (Hgb)
• Dx Hemorrhagic (hypovolemic) shock
• Management
• ABC (need intubation? IV access?)
• Wide open fluids and TC 6 units PRBC
• Send coags when sending for CBC
• Make sure its not an MI (chest pain, EKG)
• Give blood prepare for re-exploration in OR

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Case 2

• 75yo male PMH CAD, PVD, DM who is post-op from
  AAA repair complains of crushing substernal chest
  pain
• Stat 12-lead EKG shows ST elevation in 2
  contiguous leads
• What do you do?
• What is the diagnosis?

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Case 2

• ABC, get good access, continuous monitor
• Dx Acute ST elevation MI
• Treatment MONA
• Oxygen, Aspirin, Nitroglycerin, Morphine
• Beta-blockade (no heparin or tPA due to surg)
• Plavix GP IIb/IIIa inhibitor (i.e.
  eptifibatide)
• Stat cardiology consult for cardiac cath

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Case 2, continued

• Cath reveals critical stenosis of left main s/p
  balloon angioplasty
• 24 hrs later, in ICU intubated
• Vitals 80/50
• On exam cool, clammy extremities
• Echocardiogram severe LV dysfunction
• What is the diagnosis management?

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Case 2, continued

• Dx Cardiogenic shock 2ndary to STEMI
• Management
• Ventilator support (remember, ABC)
• Aspirin, Heparin (maintain coronary patency)
• Inotropes and Vasopressors
• Pulmonary artery catheter to optimize volume
  status and cardiac function
• May need intra-aortic balloon pump

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Case 3

• 60yo male heavy drinker brought in by EMS with
  nausea, vomiting, severe epigastric pain
  radiating to the back
• Tachycardic, hypotensive
• Altered mentation, dry mucous membranes, minimal
  UOP after Foley
• What is the most likely diagnosis?
• Differential diagnosis?
• How do you manage this patient?

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Case 3

• Acute pancreatitis
• DDx of acute abdomen Perforated viscus, acute
  mesenteric ischemia, cholecystitis, SBO, Ruptured
  AAA, MI
• Hypovolemic shock from vomiting and Distributive
  shock from the inflammation vasodilation,
  vasopermeability (3rd-space)
• These pts require heavy, heavy fluid resus
• Treatment Push heavy fluids, NPO, NGT
• Can feed post-pyloric, consider CT scan

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Case 4

• 55yo male also post-op from colon resection for
  CA, epidural placed for post-operative pain
  control
• Called by nurse for hypotension and bradycardia
• Abdomen soft, no pallor, altered mentation
• Hct is 38
• Most likely diagnosis?

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Case 4

• Neurogenic shock 2ndary to epidural
• Differentiated from hypovolemic due to
  bradycardia
• Treatment is
• IVF
• Turn down or turn off epidural
• If BP does not respond, then alpha-agonist such
  as phenylephrine until above measures stabilize
  patient, then wean the vasopressor

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Case 5

• 25yo male presents with diffuse abdominal pain of
  1day duration, started initially as epigastric
  pain after a meal. Takes ibuprofen 3x a day.
• Vitals hypotensive, tachycardic
• Tense abdomen, involuntary guarding, altered
  mental status, oliguric
• What is the diagnosis management?

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Case 5

• Septic shock 2ndary to perf duodenal ulcer
• This patient has diffuse peritonitis
• Management
• ABC, IV resuscitation (requires heavy fluids)
• Broad-spectrum IV antibiotics
• Emergent OR for ex-lap, washout repair
• If pt does not respond to fluids, may need
  vasopressors (norepinephrine, dopamine)
• Have beta-agonist effects to help pump function
  as well as alpha-agonist for periph
  vasoconstriction

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Take Home Points

• Shock poor tissue perfusion/oxygenation
• Know difference btw compensated/uncomp shock
• 3 types are based on physiology of shock
• Hypovolemic due to decreased preload
• Cardiogenic due to decreased SV or CO
• Distributive due to decreased SVR
• Know the common signs a/w shock
• Oliguria, AMS, cool/clammy skin, acidosis
• Work-up management starts with ABC
• Aggressive resuscitation except if cardiogenic
• Vasopressors if hypotensive despite fluids