Shock

Differential Diagnosis and Hemodynamic

Monitoring

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 Shock
Shock is a Cardiovascular Derangement.
1. Deliver Oxygen and Metabolic Substrates
2. Remove Products of Cellular Metabolism
3. Thermoregulation
Definition:
A physiological state characterized by a significant,
systemic reduction in tissue perfusion, resulting in
decreased tissue oxygen delivery and insufficient
removal of cellular metabolic products, resulting in
tissue injury.
 Classification of Shock
•Hypovolemic
•Septic/Inflammatory
•Cardiogenic (Intrinsic, compressive &
Obstructive)
•Neurogenic
•Anaphylactic
 Clinical Markers of Shock
•Brachial systolic blood pressure: <110mmHg
•Sinus tachycardia: >90 beats/min
•Respiratory rate: <7 or >29 breaths/min
•Urine Output: <0.5cc/kg/hr
•Metabolic acidemia: [HCO3]<31mEq/L or base deficit>3mEq/L
•Hypoxemia: 0-50yr: <90mmHg; 51-70yr:
K <80mmHg;
>71yo<70mmHg; l
k
•Cutaneous vasoconstriction vs. vasodilation.
j

•Mental Changes: anxiousness, agitation, indifference, lethargy,

obtundation
Etiology & Hemodynamic Changes
in Shock

Etiology of example CVP CO SVR VO2 sat

shock
preload hypovolemic low low high low

contractility cardiogenic high low high low

afterload distributive
Etiology & Hemodynamic Changes
in Shock (Afterload)
ETIOLOGY EXAMPLE CVP CO SVR VO2 SAT
OF SHOCK
AFTERLOAD DISTRIBUTIVE

Hyperdynamic Septic Low/High High Low High

Hypodynamic Low/High Low High Low/High

Septic

Neurogenic Low Low Low Low

Anaphylactic Low Low Low Low

 Hypovolemic Shock
•Decreased preload->small ventricular end-diastolic
volumes -> inadequate cardiac generation of pressure
and flow
•Causes:
-- bleeding: trauma, GI bleeding, ruptured aneurysms,
hemorrhagic pancreatitis
-- protracted vomiting or diarrhea
-- adrenal insufficiency; diabetes insipidus
-- dehydration
-- third spacing: intestinal obstruction, pancreatitis,
cirrhosis
 Hypovolemic Shock
• Signs & Symptoms: Hypotension, Tachycardia,
MS change, Oliguria, Deminished Pulses.

• Markers: monitor UOP,CVP, BP, HR, Hct, MS,

CO, lactic acid and PCWP

• Treatment: ABCs, IVF (crystalloid), Trasfusion

Stem ongoing Blood Loss

• Patients on β-blockers, w/ spinal shock &

athletes may not be tachycardic
 Septic/Inflammatory Shock
Mechanism: release of inflammatory mediators leading to
1. Disruption of the microvascular endothelium
2. Cutaneous arteriolar dilation and sequestration of blood in
cutaneous venules and small veins
Causes:
1. Anaphylaxis, drug, toxin reactions
2. Trauma: crush injuries, major fractures, major burns.
3. infection/sepsis: G(-/+ ) speticemia, pneumonia,
peritonitis, meningitis, cholangitis, pyelonephritis,
necrotic tissue, pancreatitis, wet gangrene, toxic shock
syndrome, etc.
 Septic/Inflammatory Shock
Signs: Early– warm w/ vasodilation, often adequate urine
output, febrile, tachypneic.
Late-- vasoconstriction, hypotension, oliguria,
altered mental status.

Monitor/findings: Early—hyperglycemia, respiratory

alkylosis, hemoconcentration,
WBC typically normal or low.
Late – Leukocytosis, lactic acidosis
Very Late– Disseminated Intravascular
Coagulation & Multi-Organ
System Failure.

Tx : ABCs, IVF, Blood cx, ABX, Drainage (ie abscess)

pressors.
 Cardiogenic Shock
Mechanism: Intrinsic abnormality of heart -> inability to
deliver blood into the vasculature with adequate power
Causes:
1. Cardiomyopathies: myocardial ischemia, myocardial infarction,
cardiomyopathy, myocardiditis, myocardial contusion
2. Mechanical: cardiac valvular insufficiency, papillary muscle
rupture, septal defects, aortic stenosis
3. Arrythmias: bradyarrythmias (heart block), tachyarrythmias
(atrial fibrillation, atrial flutter, ventricular fibrillation)
4. Obstructive disorders: PE, tension peneumothorax, pericardial
tamponade, constrictive pericaditis, severe pulmonary
hypertension
 Cardiogenic Shock
• Characterized by high preload (CVP) with low CO
• Signs/SXS: Dyspnea, rales, loud P2 gallop, low BP,
oliguria
• Monitor/findings: CXR pulm venous congestion, elevated
CVP, Low CO.
• Tx: CHF– diuretics & vasodilators +/- pressors.
LV failure – pressors, decrease afterload,
intraaortic ballon pump &
ventricular assist device.
 Neurogenic Shock
Mechanism: Loss of autonomic innervation of the
cardiovascular system (arterioles, venules, small
veins, including the heart)

Causes:
1. Spinal cord injury
2. Regional anesthesia
3. Drugs
4. Neurological disorders
 Neurogenic Shock
• Characterized by loss of vascular tone & reflexes.

• Signs: Hypotension, Bradycardia, Accompanying

Neurological deficits.

• Monitor/findings: hemodynamic instability, test bulbo-

carvernous reflex

• Tx: IVF, vasoactive medications if refractory

 Monitoring Adjuncts in Shock

• Sphyngomanometry

• Pulse Oximeter

• Arterial Line

• Central Venous Line (Cordice, Triple Lumen,

Pulmonary Artery Catheter)
 Pulmonary Artery
Catheterization
Allows for accurate and continuous hemodynamic monitoring
in shock patients
1. Evaluate Fluid Resuscitation
2. Titration of Vasoactive Medications
3. Allows for Assessment of Cardiovascular
K
l
Performance. k
j
4. Monitor the Effects of Changes in Mechanical
Ventilation.
Pulmonary Artery
Catheterization

K
l
k
j
 Pulmonary Artery
Catheterization: cardiovascular
performance
Central Venous Pressure (CVP):
CVP = right atrial pressure (RAP) = right-ventricular
end-diastolic pressure (RVEDP) (Right Ventricular
Preload)

K
Pulmonary Capillary Wedge Pressure (PCWP)
l
PCWP = left atrial pressure (LAP) k=
left-ventricular
j
end-diastolic pressure (LVEDP) (Left Ventricular
Preload)
 Cardiovascular Performance
Cardiac Output (CO) = HR x SV (L/min)
Normal CO = 4 to 8 L/min

Cardiac Index (CI) = CO/BSA (L/min/m2)

Normal CI = 2.5-4.2 L/min/m2

Stroke Volume Index (SVI): CI/HR (ml/beat/m2)

Normal SVI = 40-85 ml/beat/m2

Systemic Vascular Resistance = MAPK– CVP / CO x 80

l
Normal SVR = 900-1600 dynes/sec/cm-5 k
j
Systemic Vascular Resistance Index = MAP – CVP / CI x 80
Normal SVRI = 1970-2390 dynes/sec/cm-5
 Pulmonary Artery
Catheterization: systemic oxygen
transport
Oxygen Delivery (DO2) [520-570 mL/min x m2]: rate
of oxygen transport in arterial blood
DO2= CI x 13.4 x Hb x SaO2

Oxygen Uptake (VO2) [110-160 Kml/min x m2]: rate of

l
oxygen taken up from the systemic
k microcirculation
j
VO2 = CI x 13.4 x Hb x (SaO2 – SvO2)
 Hemodynamic Profiles
Shock

PCWP CVP CO/CI SVR/I

Hypovolemic Low Low Low High
Cardiogenic High High K Low High
l
Inflammatory k
Low / N Low/N j High Low
Neurogenic Low Low Low Low