Shock DEFINITION Syndrome Decreased tissue perfusion Impaired cellular metabolism STAGES Compensatory   Response to imbalance between O2 supply

pply & demand Correction can prevent permanent damage

Progressive  Decreased cellular perfusion>altered cap permeability > interstitial edema

Refractory   Peripheral vasoconstriction + decreased CO > decreased perfusion anaerobic metabolism Recovery unlikely kidney, liver & lungs fail DIAGNOSTIC STUDIES

12 lead CXR Pulse oximetry Hemodynamic monitoring CBC Chemistry Cardiac enzymes Coagulation studies Lactic acid UA Cultures GOALS OF CARE

Restore

Tissue perfusion Oxygenation Cellular metabolism CARDIOGENIC

CLINICAL MANIFESTATIONS Decreased cap refill Tachypnea, cyanosis, crackles, rhonchi Sodium & water retention, decreased urine ouput Pale, cool, clammy Decreased cerebral perfusion Decreased bowel sounds, N/V Elevated cardiac enzymes, glucose, BUN Dysrythmnias Left ventricular dysfunction Pulmonary infiltrates

USUAL MEDICAL TREATMENT Goal  Rx     IABP VAD Transplant HYPOVOLEMIC CLINICAL MANIFESTATIONS Nitrates Diuretics (preload) Vasodilators (afterload) Beta blockers decrease heart rate and contractility Restore blood flow to myocardium

Decreased cap refill Tachypnea brady late Decreased urine output Pale, cool, clammy Decreased cerebral perfusion Absent bowel sounds Decreased hgb, hct Elevated lactate, urine specific gravity

USUAL MEDICAL TREATMENT Fluid resuscitation 3mL crystalloids:1mL blood loss NEUROGENIC Hypotension <loss of sympathetic tone vasodilation and decreased venous return CLINICAL MANIFESTATIONS Increased or decreased temperature Pulmonary related level of injury Bladder dysfunction Cool or warm, dry Flaccid paralysis, loss of reflex activity Bowel dysfunction

USUAL MEDICAL TREATMENT Treat cause Vasoressors Atropine Fluids ANAPHYLACTIC Dramatic presentation

CLINICAL MANIFESTATIONS

Chest pain Third spacing of fluid Lips & tongue swell SOB, larynx & epiglottis swell Wheezing, rhinitis, stridor Flushing, pruitis, uricaria, angioedema Anxiety, confusion, feeling of impending doom, level of consciousness decreased Metallic taste, cramping, abdominal pain, N/V/D, Sudden onset, exposure to allergen, contrast media

USUAL MEDICAL TREATMENT Prevention Epinephrine drug of choice  Peripheral vasoconstriction & bronchodilation

Diphenhydramine  Block release of histamnie

Airway patency Fluids  Colloids keep fluids in vascular space

Corticosteroids  If no improvement w/1-2h of aggressive tx SEPTIC

CLINICAL MANIFESTATIONS Increased or decreased temp Hyperventilation >resp alkalosis >resp acidosis Hypoxemia, resp failure, ARDS, pulmonary htn, crackles Decreased urine output Warm & flushed > cool & mottled Decreased cerebral perfusion

GI bleed, paralytic ileus Decreased WBC, platelets, urine Na+ Increased glucose, lactate, urine specific gravity + blood cultures

USUAL MEDICAL TREATMENT Fluids   6-10L crystalloids, 2-4L colloids Goal to restore perfusion

Vasopressors Vasopressin Dobutamine Steroids Cultures antibiotics broad>specific Drotrecogin alpha (Xigris) Glucose control 100-150 H2 agonists