Shock Management

1
Shock Management

• Erin Burrell, ACNP-BC
• Surgical ICU Nurse Practitioner

2
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

3
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

4
Three Types of Shock

• Cardiogenic
• Hypovolemic
• Distributive
• Septic
• Anaphylactic
• Neurogenic
• Combined

5
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

6
What kind of shock does this patient have?

1. Cardiogenic
2. Hypovolemic
3. Distributive

7
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
  pneumothorax)

8
What information do you have to suggest that Mrs.
C has cardiogenic shock?

1. Hypotension
2. Evidence of MI
3. Altered Mental Status
4. All of the above
5. Both A. and B.

9
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

10
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.

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What kind of shock does this patient have?

1. Cardiogenic
2. Hypovolemic
3. Distributive

12
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

13
What information do you have to suggest that Mr.
H has hypovolemic shock?

1. Recent trauma
2. WBC 12.3
3. Hgb 6.7
4. All of the above
5. Both A. and C.

14
Treatment of Hypovolemic Shock

• Maximize oxygen delivery
• Control further blood loss
• Tourniquets
• Surgical intervention
• Fluid resuscitation
• NS fluid boluses
• Blood product administration

15
Case Study

• Mr. S is a 59yo M presents to ED with worsening
  abdominal pain and NV
• He is POD8 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

16
What kind of shock does this patient have?

1. Cardiogenic
2. Hypovolemic
3. Distributive

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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

18
What information do you have to suggest Mr. S has
distributive shock?

1. SpO2 94 on 4 L NC
2. Anastamotic leak on CT scan
3. WBC 20.1
4. All of the above
5. Both B. and C.

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Treatment of Septic Shock

• Resuscitate
• 30cc/kg of NS bolus
• Identify Source
• Pan cultures
• CT scan
• Line removal
• Foley removal
• Surgical exploration
• Antibiotics

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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

21
Treatment of Neurogenic Shock

• Establish an airway to maintain adequate
  oxygenation and ventilation
• Fluid resuscitation for MAPgt65mmHg
• Inotropic support
• Dobutamine
• Dopamine
• Atropine for severe bradycardia
• High dose methylprednisolone therapy

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• All three types of shock can occur at the same
  time to have a combined shock picture.

23
Case Study

• Mrs. D is a 71yo F who presented to ED after a 3
  day h/o NV 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

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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

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What type of shock does this patient have?

1. Cardiogenic
2. Hypovolemic
3. Distributive
4. All of the Above

26
What information leads you to believe Mrs. D has
a component of cardiogenic shock?

1. BP 82/41
2. Temp 102.8
3. CI 1.7 L/min
4. Cr 2.82

27
What information demonstrates a component of
hypovolemic shock?

1. CVP 1 mmHg
2. PCWP 2 mmHg
3. SVR 615 dynes/sec/cm-5
4. PAP 18/6 mmHg
5. Both A. B. and D.

28
What information indicates a degree of
distributive shock?

1. PCWP 2 mmHg
2. SVR 615 dynes/sec/cm-5
3. PAP 18.16 mmHg
4. WBC 1.1

29
Mrs. S is suffering from distributive septic
shock along with cardiogenic and hypovolemic
shock.

1. True
2. False

30
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

31
Mrs. S. continues to have a combined shock of
hypovolemic, distributive, and cardiogenic shock.

1. True
2. False

32
Mrs. S continues to suffer from cardiogenic and
distributive septic shock as evidence by the
following

1. CI 1.5 L/min
2. SVR 682 dynes/sec/cm-5
3. Both A. and B.

33
As an intensivist, what treatment should be
implemented next?

1. More fluid resuscitation
2. Initiate vasopressor support
3. Initiate inotropic support
4. No change in current therapy
5. Both B. and C.

34
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

35
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

36
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.

37
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.

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What kind of shock is Mrs. S exhibiting?

1. Cardiogenic
2. Hypovolemic
3. Distributive

39
What would you include in your treatment plan?

1. Benadryl 25 mg IV
2. Reintubation
3. Hydrocortisone 100 mg IV
4. Epinephrine 50 mcg IV
5. All of the above

40
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!

41
Summary

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

42

• Questions?

43
References

• Dellinger, R et al. Surviving Sepsis Campaign
  International Guidelines for Management of Severe
  Sepsis and Septic Shock2012, 41 580-637, 2013.
• Emergency Medicine. 2009 (Online Accessed on 22
  August 2013) URL http//emergencymed.wordpress.co
  m/2009/03/11/neurogenic-shock/
• Gaieski et al. 2009 (Online accessed 22 August
  2013) URLhttp//lijhs.sandi.net/faculty/rtenenbau
  m/ap-biology-folder/Links/Shock.utd.pdf
• Medscape Reference. 1994 (Online accessed 22
  August 2013) URL http//emedicine.medscape.com/ar
  ticle/152191-treatmentshowall
• Medscape LLC. 2013 (Online access on 22 August
  2013) URL http//emedicine.medscape.com/article/7
  60145-treatment2
• Soar, J et al. 2013 (Online Accessed on 22 August
  2013) URL http//www.resus.org.uk/pages/reaction.
  pdf