Shock

1
Shock

• Tad Kim, M.D.
• Connie Lee, M.D.
• Michael Hong, M.D.

2
Shock Definitions

• Shock inadequate tissue perfusion
• Tissue perfusion is determined by
• Cardiac output (CO) HR x SV
• SV function of preload, afterload,
  contractility
• Systemic vascular resistance (SVR)

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Shock Types

• Hypovolemic
• Septic (high CO, low SVRI)
• Cardiogenic (high CVP)
• Neurogenic
• Anaphylactic
• Adrenal insufficiency

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Shock Types Physiology
Shock CVP/PCWP CO SVRI
Hemorrhagic ? ? ?
Septic either ? ?
Cardiogenic ? ? ?
Neurogenic ? ? ?
Hypoadrenal either ? ?
Anaphylactic ? ? ?
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Hypovolemic Shock

• CNS response to hypovolemia
• Rapid peripheral vasoconstriction, increased
  cardiac activity
• Sustained arterial vasoconstriction, Na/water
  retention, increased cortisol
• 2/2 hemorrhage or fluid loss
• Classes of hemorrhage
• I 15
• II 30 tachycardia
• III 40 decreased SBP, confusion
• IV gt40 lethargy, no UOP
• Tx stop source / fluids / blood

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Septic Shock

• SIRS T gt38C or lt36C, HR gt90, RR gt20, PaCO2
  lt32mmHg, WBC gt12 or lt4
• Sepsis SIRS focus of infection
• Severe sepsis sepsis MSOF
• Septic shock sepsis refractory hypotension
• Remember septic shock is a/w high CO
• Tx fluids, antibiotics

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Cardiogenic Shock

• Cardiogenic shock 2/2 cardiac disease or cardiac
  compression
• Cardiac disease MI, arrhythmia, valve
  dysfunction, increased PVR or SVR, increased
  ventricular resistance
• Cardiac compression tension PTX, cardiac
  tamponade, positive pressure ventilation
• Look for Becks triad in tamponade (hypotension,
  JVD, muffled heart sounds)
• Tx fluids, tx underlying cause (relieve PTX,
  pericardiocentesis, change ventilator settings)

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Neurogenic Shock

• Shock 2/2 spinal cord injury, regional
  anesthesia, autonomic blockade
• Mechanism loss of vasomotor control, expansion
  of venous capacitance bed
• Signs warm skin, normal or low HR, normal CO,
  low SVR
• Tx Fluids / pressors / - steroids

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Hypoadrenal

• Unresponsive to fluids or pressors
• Tx steroids

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Shock Signs

• Pale, cool skin
• Change in MS, lethargy
• Decreased UOP
• Hypotension, tachycardia, tachypnea

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Shock Evaluation

• Airway includes brief evaluation of mental
  status
• Breathing
• Circulation includes placement of adequate IV
  access
• Disability identification of gross neurologic
  injury
• Exposure ensures complete exam
• History OPQRST, review PMHx, PSHx, ALL, SHx
• PE complete
• Labs include ABG (pH, base deficit, lactate)

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Case 1

• 55y M post-op day 0 s/p colectomy
• Called for tachycardia, hypotension, altered
  mental status, abdominal distension, decreased
  UOP
• PE pale, disoriented, abdomen tense, TTP,
  w/rebound tenderness, UOP 15mL/hr
• What is your diagnosis?
• What additional information should you obtain?
• What is the plan?

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Case 1 Continued

• Dx hemorrhagic shock
• Additional information CBC, coags, TC
• Management
• ABC (intubate, IV access)
• Resuscitate (isotonic IVF)
• Prepare for take-back

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Case 2

• 75y M h/o CAD, PVD, DM, POD 1 s/p AAA repair c/o
  nausea
• What do you need to think about?
• What is the plan?

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Case 2 Continued

• Dx MI
• Plan
• ABC
• MONA, beta-blockade
• Cardiology consult for catheterization
• Labs/x-rays cardiac enzymes Q8H x3 sets w/EKG,
  chemstick, BMP, CXR/KUB

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Case 2 Continued

• Cath w/critical stenosis of left main s/p balloon
  angioplasty
• PE intubated, 80/50, UOP 10mL/hr
• Echo severe LV dysfunction
• What is the diagnosis?
• What is the plan?

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Case 2 Continued

• Dx Post-myocardial infarction (cardiogenic)
  shock
• Plan
• ABC
• Pressor support as needed
• Placement of Swan-Ganz catheter
• /- Intra-aortic balloon pump, cardiac assist
  device
• Heparin (maintain coronary patency)

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Case 3

• 60y M h/o chronic ETOH use presents to ED w/ N/V
  and epigastric pain radiating to the back
• PE tachycardic, hypotensive, confused
• What is the working diagnosis?
• What is the plan?

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Case 3 Continued

• Dx Hypovolemic shock 2/2 acute pancreatitis
• Plan
• ABC (intubate, IV acess, NGT, Foley, DHT)
• Resuscitate
• Labs chemstick, ABG, BMP, LFT, amylase/lipase,
  CBC, coags
• Studies CXR, CT A/P

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Case 4

• 55y M POD 0 s/p colectomy, w/epidural placed for
  post-op pain control
• Called by nurse for hypotension and bradycardia
• PE AAOx3, abdomen ND, NT
• Recent post-op labs HCT 35
• What is your working diagnosis?

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Case 4 Continued

• DX Neurogenic shock 2/2 epidural
• Treatment is
• IVF
• Turn down or turn off epidural
• If BP does not respond to IVF, initiate pressor
  support w/alpha-agonist such as phenylephrine

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Case 5

• 25y M p/w diffuse abdominal pain. PMHx PUD.
• PE febrile, tachycardic, hypotensive, lethargic,
  rigid abdomen w/ involuntary guarding
• What is your working diagnosis?
• What is your plan?

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Case 5

• Dx septic shock 2/2 duodenal perforation
• Plan
• ABC
• Broad-spectrum IV antibiotics
• Emergent OR for ex-lap, washout repair

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Shock Take Home Points

• Shock inadequate tissue perfusion
• Types of shock hypovolemic, septic, cardiogenic,
  neurogenic, anaphylactic
• Signs of shock altered MS, tachycardia,
  hypotension, tachypnea, low UOP
• Always start with ABCs
• Resuscitation begins with fluid (exception -
  cardiogenic shock)