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Shock Resident Lecture
Shock Resident Lecture
SHOCK
2012
SHOCK
OXYGEN
DEMAND
OYGEN
DELIVERY
Cardiac
Output
Heart rate
Stroke Volume
Preload
After load
Contractility
Hemoglobin
Oxygen Saturation
Partial pressure of oxygen dissolve
plasma
Oxygen Delivery
Types of Shock
Case 1
9 year old girl RJ with a history of variceal bleed
presents with new onset bleed. O/E-responsive,
HR-135, RR-38, BP-88/60, Sats-92%. I stat7.08/24/80/12/-4. Hb-4.2
What type of shock is this?
Hypovolemic Shock
What is the very first thing you would like to do
for this patient?
Oxygen
Is this compensated or uncompensated shockhow does the body compensate?
Compensated
Stages of Shock
Compensatory
Mechanisms
Compensatory
Mechanisms
Hypovolemic shock
Oxygen-What a
difference!
RJs Management
Labs
ABG
Blood sugar
Electrolytes
CBC
PT/PTT/Fibrinogen
Type and Cross
Cultures
Imaging
Volume expansion
RJ At Endoscopy
Case 2
TN is a 5 year old girl with a history of URI
symptoms 2 weeks ago presents with
decreased effort tolerance, tachypnea . O/EHR-192, RR-70, BP-45 systolic.
Hepatomegaly, b/l rales, no heart murmur
on exam but a gallop is heard.
What type of shock is this?
Uncompensated cardiogenic shock
What is the diagnosis? How do you manage
this patient?
Myocarditis
Differentiating Cardiogenic
Shock
History
PE-enlarged liver, gallop, murmur,
rales
Chest X ray-Enlarged heart,
pulmonary venous congestion
Myocarditis
OYGEN
DELIVERY
Cardiac
Output
Heart rate
Stroke Volume
Preload
After load
Contractility
Hemoglobin
Oxygen Saturation
Partial pressure of oxygen dissolve
plasma
Managing TN
Increasing Oxygen supplySupplemental Oxygen
Improving myocardial output-altering
preload, after load and contractility
Correct Anemia-Blood
Decreasing oxygen demandControl temperature
Sedation
Reduce myocardial work and thus oxygen
consumption
Fluids in Cardiogenic
Shock
Ionotropes/Cardiotonics
Ionotropes/ Cardiotonics
Norepinephrine-0.05-1.0mcg/kg/min. Increases
SVR.
Other causes of
Cardiogenic Shock
Dysrhythmia
Infection
Metabolic
Obstructive
Drugs
Congenital heart disease
Trauma
Case 3
4 year old boy RS presents with 3 day h/o fever,
malaise. He has a past history of nephrotic
syndrome.O/E-Minimally responsive,skin appears
flushed and warm, and he has bounding pulses. HR170 RR-30 BP-40 systolic, sats-88%.
What type of shock does the patient have
Uncompensated distributive shock- Warm septic shock
What medications could be used in the management
of this patient?
Fluid, antibiotics, pressors, steroids
Septic Shock
Warm Shock
Cold Shock
PALS ALGORITHM
1ST hour-20ml/kg/boluses.
Correct hypoglycemia and
hypocalcemia.
Administer 1st dose of antibiotics
Consider vasopressor drip and stress
dose hydrocortisone
DETERMINE WHETHER FLUID
RESPONSIVE
PALS ALGORITHM
IF NOT FLUID RESPONSIVE
Normotensive-Start Dopamine
Hypotensive vasodilated(warm shock)Norepinephrine
Hypotensive vasoconstricted(cold
shock)-Epinephrine
EVALUATE MIXED VENOUS SAT,
GOAL>70%
PALS ALGORITHM
Conclusions