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Diagnosis and Management of

Shock

Dr. Anas Khan


Consultant, EM
MBBS, MHA, ArBEM
428 C2 notes

Objectives

Identify

the 4 main categories of shock.


Discuss the goals of resuscitation in shock.
Summarize the general principles of shock
management.
Describe the physiologic effects of
vasopressors and inotropic agents.

CASE STUDY

A 25

Years old lady, with no prior history of


any chronic disease, presented to the
emergency department C/O productive
cough of greenish yellow sputum.

V/S
Temp:

38.8 ( each 1o C higher in temperature


must have an increase in HR by 10-15 beats,
here after calculations HR is still higher then it
should be (115).
HR:
129 /Min (60-100/min)
R.R:
27 /Min ( 16-20/min)
BP:
112/68

Questions

Where do you triage this Pt.?


Triage : to prioritize the patients
Information we still have to collect to be able to classify the
patient : condition of patient , if in distress, check vitals
BP,HR,RR,temperature,oxygen saturation,glucocheck if the
patient is dizzy

What information do you need to determine if this Pt. is in shock?

What initial interventions are needed to stabilize that Pt.?

Shock

Shock is a syndrome of impaired tissue oxygenation and


perfusion due to a variety of etiologies that will result in different
manifestations according to organ affected.
Liver --- nausea/vomiting
Heart --- tachycardia
Lung --- SOB
Brain --- confusion
kidney --- oliguria and late stage anuria
If left untreated
- Irreversible injury
- Organ dysfunction
- Death

Clinical Alterations in Shock


The

presentation of patients with shock may


be subtle (mild confusion, tachycardia).

Or

easily identifiable (profound hypotension,


anuria)

:Pathophysiology
1- Inadequate tissue perfusion and oxygenation
2- Compensatory responses
3- The specific etiology --- you should manage
the patient but must aim to treat the underlying
cause.

Classification
1- Hypovolemic: (hemorrhagic (internal as bleeding ulcers or external as acute blood
loss), non-hemorrhagic ( dehydration as vomiting and diarrhea,3rd fluid spacing as in
burns and pancreatitis).
2- Cardiogenic: pump related, any type of cardiomyopathies (ischemic, myopathy,
mechanical,
arrhythmogenic either braycardic or tachycardia).
3- Distributive: mainly due to vasodilation (septic, adrenal crises due to steroids
withdrawal mostly iatrogenic, neurogenic loss of sympathetic tone when there is trauma
to the thoracic or lumbar sympathetic chain or spinal cord injury, anaphylactic as in
hypersensitivity reactions if severe form).
4- Obstructive: (massive PE, tension pneumothorax(space is obstructed by fluid),
cardiac tamponade( space is obstructed with blood, constrictive pericarditis(space
is obstructed due to the inflammation.)
*spinal shock is different from neurogenic , its just motor loss which is transient and due to
concussion, no vascular changes so not considered as an ER shock

X-ray of tension pneumothorax


.which is an immediate ER

CT of pulmonary embolism

Hypovolemic Shock
When

the IV volume is depleted relative to


the vascular capacity as a result of:

1- Hemorrhage.
2- GI loss
3- Urinary loss
4- Dehydration

Hypovolemic Shock
Management

- The goal is to restore the fluid lost


- Vasopressors are used only as a temporary
method to restore B.P until fluid resuscitation
take place
* Mainly we give good volume of fluids to
prevent heart failure . Vasopressors has no
role .

Distributive shock

It

is characterized by loss of vascular tone.

The

most common form of distributive shock


is septic shock.

Hemodynamic Profile
Cardiac

output
normal or increased
Ventricular filing pressure normal or low
SVR
low
Diastolic pressure low
Pulse pressure
wide

Management of Septic Shock


The initial approach to the patient with septic shock is the
restoration and maintenance of adequate intravascular volume.
* If not maintained by fluids we give vasopressors unlike
hypovolemic shock .

Prompt institution of appropriate antibiotic.


* In each 1 hour delay in antibiotics initiation will increase 6.7%
mortality .

Cardiogenic Shock
Forward

flow of blood is inadequate because


of pump failure due to loss of functional
myocardium.
It is the most severe form of heart failure and
it is distinguished from chronic heart failure
by the presence of:
- hypotension, hypo perfusion and the need
for different therapeutic interventions.

:Hemodynamic Profile
Cardiac

output

Low

Ventricular filing pressure * Venous return

SVR

High

*systemic vascular resistance


Mixed venous O2 sat
Low

High

Management of Cardiogenic Shock


The main goal is to improve myocardial function.
Arrhythmia should be treated.
Reperfusion PCI is the treatment of choice in
ACS.
* Percutaneous Coronary Intervention standard of
care , should be started within 90 minutes
window if not then go for thrombolytic agents .
Inotropes and vasopressors.

Obstructive Shock
Obstruction to the outflow due to impaired cardiac
filling and excessive after-load
Cardiac tamponade & constrictive pericarditis impair
diastolic filling of the Rt. ventricle
Tension pneumothorax obstructs venous return
limiting Rt. ventricular filing.
* In tension pneumothorax there is positive gradient
pressure limiting venous return
Massive pulmonary embolism increase the Rt.
ventricular after-load.

Hemodynamic Profile
Cardiac

output
low
Afterload * same as SVR (systemic venous return )
high
Lt.Vent.filling pressure
variable
Pulsus paradoxicus
(in Tamponade)
* Pulsus paradoxicus normally with inspiration it
increase by 10 beats if more then positive for
temponade .
Distended Jugular veins

Management Of Obstructive Shock

Directed Mainly to Management of the cause.

General Principles
The overall goal of shock management is to improve oxygen
delivery or utilization in order to prevent cellular and organ
injury.
* Defect in utilization as in CO poising because hemoglobin has
higher affinity to CO and even if one oxygen went there the CO
will prevent the off-load and if it did at the mitochondrial level it
wil block the respiratory chain .

Effective therapy requires treatment of the underlying etiology.

Restoration of adequate perfusion, monitoring and comprehensive


supportive care.
Interventions to restore perfusion center on achieving an adequate BP,
increasing cardiac output and optimizing oxygen content of the blood (goal
directed therapy).

Oxygen demand should also be reduced .

* Most important is 1- Brain , 2- Heart and


3- Diaphragm which take 30% of oxygen found in blood , mechanical
ventilation in all this you should decrease demand .
* Hyperdynamic state : Thryrotoxicosis , Anemia , Fever and late term
pregnancy .

:In Summery, Shock Management

1- Monitoring.
2- Fluid Therapy.
3- Vasoactive agents.
4- Treat the underlying cause.

THANK YOU