Core Lecture Series Shock

Daniel J. Riskin, MD September 9, 2007

Outline
 Definition  Epidemiology  Physiology  Classes of Shock  Clinical Presentation  Management  Controversies

Definition
 A physiologic state characterized by


Inadequate tissue perfusion

 Clinically manifested by
 

Hemodynamic disturbances Organ dysfunction

Epidemiology
 Mortality
  

Septic shock 35-40% (1 month mortality) Cardiogenic shock 60-90% Hypovolemic shock variable/mechanism

Pathophysiology
 Imbalance in oxygen supply and demand  Conversion from aerobic to anaerobic

metabolism  Appropriate and inappropriate metabolic and physiologic responses

Pathophysiology
 Cellular physiology  Cell membrane ion pump dysfunction  Leakage of intracellular contents into the extracellular space  Intracellular pH dysregulation  Resultant systemic physiology  Cell death and end organ dysfunction  MSOF and death

Physiology
 Characterized by three stages
  

Preshock (warm shock, compensated shock) Shock End organ dysfunction

Physiology
 Compensated shock


Low preload shock tachycardia, vasoconstriction, mildly decreased BP Low afterload (distributive) shock peripheral vasodilation, hyperdynamic state

Pathophysiology
 Shock


Initial signs of end organ dysfunction Tachycardia Tachypnea Metabolic acidosis Oliguria Cool and clammy skin

    

Physiology
 End Organ Dysfunction


Progressive irreversible dysfunction Oliguria or anuria Progressive acidosis and decreased CO Agitation, obtundation, and coma Patient death

   

Classification
 Schemes are designed to simplify complex

physiology  Major classes of shock

  

Hypovolemic Cardiogenic Distributive

Hypovolemic Shock
 Results from decreased preload  Etiologic classes  Hemorrhage - e.g. trauma, GI bleed, ruptured aneurysm  Fluid loss - e.g. diarrhea, vomiting, burns, third spacing, iatrogenic

Hypovolemic Shock
 Hemorrhagic Shock
Parameter Blood loss (ml) Blood loss (%) I <750 <15% II 7501500 1530% III 15002000 3040% IV >2000 >40%

Pulse rate (beats/min) Blood pressure

<100 Normal

>100 Decreased

>120 Decreased

>140 Decreased

Respiratory rate (bpm)

1420

2030

3040

>35

Urine output (ml/hour) CNS symptoms

>30 Normal

2030 Anxious

515 Confused

Negligible Lethargic

Crit Care. 2004; 8(5): 373381.

Cardiogenic Shock
 Results from pump failure
 

Decreased systolic function Resultant decreased cardiac output Myopathic Arrhythmic Mechanical Extracardiac (obstructive)

 Etiologic categories
   

Distributive Shock
 Results from a severe decrease in SVR
 

Vasodilation reduces afterload May be associated with increased CO Sepsis Neurogenic / spinal Other (next page)

 Etiologic categories
  

Distributive Shock
 Other causes
     

Systemic inflammation pancreatitis, burns Toxic shock syndrome Anaphylaxis and anaphylactoid reactions Toxin reactions drugs, transfusions Addisonian crisis Myxedema coma

Distributive Shock
 Septic Shock
SIRS 2 or more of the following: Temp >38 or <36 HR > 90 RR > 20 WBC > 20K >10% bands SIRS in the presence of suspected or documented infection Sepsis with hypotension, hypoperfusion, or organ dysfunction Sepsis with hyotension unresponsive to volume resuscitation, and evidence of hypoperfusion or organ dysfunction Dysfunction of more than one organ

Sepsis Severe Sepsis Septic Shock MODS

Clinical Presentation
 Clinical presentation varies with type and

cause, but there are features in common  Hypotension (SBP<90 or Delta>40)  Cool, clammy skin (exceptions early distributive, terminal shock)  Oliguria  Change in mental status  Metabolic acidosis

Evaluation
 Done in parallel with treatment!  H&P helpful to distinguish type of shock  Full laboratory evaluation (including H&H,

cardiac enzymes, ABG)  Basic studies CxR, EKG, UA  Basic monitoring VS, UOP, CVP, A-line  Imaging if appropriate FAST, CT  Echo vs. PA catheterization


CO, PAS/PAD/PAW, SVR, SvO2

Treatment
 Manage the emergency  Determine the underlying cause  Definitive management or support

Manage the Emergency

 Your patient is in extremis tachycardic,

hypotensive, obtunded  How long do you have to manage this?

 Suggests that many things must be done at

once  Draw in ancillary staff for support!  What must be done?

Manage the Emergency

 One person runs the code!  Control airway and breathing  Maximize oxygen delivery  Place lines, tubes, and monitors  Get and run IVF on a pressure bag  Get and run blood (if appropriate)  Get and hang pressors  Call your senior/fellow/attending

Determine the Cause

 Often obvious based on history  Trauma most often hypovolemic (hemorrhagic)  Postoperative most often hypovolemic

(hemorrhagic or third spacing)  Debilitated hospitalized pts most often septic

 Must evaluate all pts for risk factors for MI and

consider cardiogenic  Consider distributive (spinal) shock in trauma

Determine the Cause

 What if youre wrong?  85 y/o M 4 hours postop S/P sigmoid resection

for perforated diverticulitis is hypotensive on a monitored bed at 70/40

 Likely causes  Best actions for the first 5 minutes?

Definitive Management
 Hypovolemic Fluid resuscitate (blood or

crystalloid) and control ongoing loss  Cardiogenic - Restore blood pressure (chemical and mechanical) and prevent ongoing cardiac death  Distributive Fluid resuscitate, pressors for maintenance, immediate abx/surgical control for infection, steroids for adrenocortical insufficiency

Controversies
 IVF Resuscitation
  

Limited resuscitation in penetrating trauma Use of hypertonic saline resuscitation in trauma Endpoints for prolonged resuscitation Best pressors for distributive shock Most appropriate timing and use for PA catheterization or intermittent echocardiogram

 Pressors


 Monitoring


Cases