Shock

Definition

SHOCK: inadequate organ perfusion

to meet the tissues oxygenation
demand.
 Three major types of shock
Hypovolemic shock
Decreased intravascular volume resulting form loss of
blood, plasma, or fluids and electrolytes
Cardiogenic shock
Pump failure due to myocardial damage or massive
obstruction of outflow tracts
Distributive shock
Reduction of vascular resistance form
Sepsis
Anaphylaxis
Systemic inflammatory response syndrome (SIRS)
Cardiogenic Shock
 Cardiogenic Shock
Diminished cardiac output leading to
impaired tissue perfusion

Most extreme form of pump failure

 Cardiogenic Shock

Occurs in about 15% of acute MI patients

Usually occurs when 40% or more of the left
ventricular muscle mass infarcts
Mortality is 85% or more with treatment
 Etiologies
Other conditions complicating large
Acute myocardial MIs
infarction/ischemia Hemorrhage
LV failure Infection
Papillary Excess negative inotropic or
vasodilator medications
muscle/chordal Prior valvular heart disease
rupture- severe MR Hyperglycemia/ketoacidosis
Ventricular free wall Post-cardiac arrest
rupture with subacute Post-cardiotomy
tamponade Refractory sustained
tachyarrhythmias
Acute fulminant myocarditis
End-stage
cardiomyopathyHypertrophic
cardiomyopathy with severe
outflow obstruction
Aortic dissection with aortic
insufficiency or tamponade
Pulmonary embolu
Severe valvular heart disease -
Critical aortic or mitral stenosis,
Acute severe aortic or MR
Pathophysiology
 Characteristics of Cardiogenic Shock
Low cardiac output

Peripheral vasoconstriction

Left sided heart failure leads to pulmonary venous

congestion and pulmonary edema

Right sided heart failure leads to systemic venous

congestion and peripheral edema
It is essential to distinguish a cardiogenic from a hypovolemic
shock!
Both forms are associated with reduced cardiac out put, and increased peripheral
vascular resistance, however:

Cardiogenic shock:
jugular venous distention (high
CVP)

Hypovolemic shock: collapsed

capacitance veins (low CVP)
 Signs/Symptoms

Confusion, restlessness, anxiety, stupor,

coma
Cool, clammy skin
Pallor
Weak or absent extremity pulses
Tachycardia
Slow or absent capillary refill
 Signs/Symptoms

BP < 90 systolic or > 30mmHg below

normal
BP is NOT the same as perfusion
Shock can be present with a normal BP
Evaluate signs of peripheral perfusion in
addition to BP
 Cardiogenic Shock
Treatment Priorities:
Rate
Rhythm
BP (Volume, Pump/Vascular tone)
Correct major disorders of rate, rhythm before
directly treating BP
 Goals of Management
Improve oxygenation and peripheral perfusion
Avoid increasing cardiac workload
myocardial oxygen demand
 Management
Primary assessment & Focused Hx
Identify source of problem
Acute pulmonary edema
Volume problem
Pump problem
Rate problem
 Acute Pulmonary Edema
First line interventions
IV/O2/ECG Monitor
If BP > 90-100 mm Hg:
furosemide 0.5 1.0 mg/kg slow IV (or twice
patients single daily dose up to 120 mg)
Morphine 2 10 mg slow IV
Nitroglycerin 0.4 mg SL
If BP < 90 mm Hg:
Vasopressors based on SBP
 Volume Problem
IV/O2/ECG Monitor
Fluid challenge until rales or if evidence
of anterior wall AMI
Vasopressors based on SBP
 Pump Problem
IV/O2/ECG Monitor
SBP <70 mmHg:
norepinephrine 0.5 30 mcg/min IV inf
SBP 70 100 mm Hg & shock
dopamine 5 15 mcg/kg/min IV inf
SBP > 100 mm Hg w/o shock
dobutamine 2 20 mcg/kg/min IV inf
 Management
If rate/rhythm adequate, treat BP
Consider fluid challenge of 250cc LR over
10-15 minutes if relative or absolute
hypovolemia possible, including RVF and
NO pulmonary edema
Avoid use of vasopressors until volume
deficits corrected or pulmonary edema
presents
 BP Treatment Review
If rate, rhythm, volume adequate, treat BP
with vasopressors:
Norepinephrine, or
Dopamine
 Norepinephrine
0.5 - 30 mcg/min
Inotropic and vasoconstrictive properties
Can be used if systolic BP < 70
If systolic BP > 70, use dopamine instead
DO NOT use until hypovolemia corrected
DO NOT allow infiltration
 Dopamine
2 - 20 mcg/kg/min
Place 200 mg/250cc of D5W
Begin at 5 mcg/kg/min
In 2 - 10 mcg/kg/min range, effects dominate
> 20 mcg/kg/min effects dominate
Use lowest dose that produces good perfusion
Use as initial vasopressor if BP 70-100 systolic
If dopamine infusion rate is > 20 mcg/kg/min use
norepinephrine
 Dopamine

May cause tachycardia, ectopy, nausea

DO NOT use until hypovolemia is
corrected
Distributive Shock
 Distributive Shock
Reduced peripheral vascular tone leads to pooling of
blood in extremities poor venous return
Physical exam depends on stage
Early: Warm extremities, wide pulse pressure, low
diastolic pressure
Late: perfusion pressure falls and acidosis develops
 Distributive Shock

Sepsis
Due to gram negative or gram positive bacteria
Anaphylaxis
Due to previous sensitization to an allergen
Neurogenic
Due to traumatic spinal cord injury
Effects of epidural or spinal anesthetics
Reflex parasymapthetic stimulation
 Bacteremia, SIRS, Sepsis
Bacteremia: an identifiable organism cultured from the
blood
Systemic Inflammatory Response Syndrome (SIRS): sepsis
without organism identified. Meet at least 2 of criteria:
Hypo or hyperthermia
Tachycardia or bradycardia
Tachypnea
Leukocytosis or leukopenia
Sepsis: SIRS from a systemic illness (bacterial, viral,
protozoal)
 Pathogenesis of Septic Shock
(vasodilatory shock)

Sepsis is defined as a systemic inflammatory response to a

bacterial infection with bacteriemia (though blood cultures can
be negative)

Severe sepsis is defined by additional end-organ dysfunction

(mortality rate: 25-30%)

Septic shock is defined as sepsis with hypotension despite fluid

resuscitation and evidence of inadequate tissue perfusion (40-
70%)
NEJM 2004, Vol. 351;2 pp 159-169
 The syndrome of septic shock is characterized
by
Systemic vasodilation (hypotension)

Diminished myocardial contractility

Widespread endothelial injury and activation leading to fluid

leakage (capillary leak) resulting in acute respiratory distress
syndrome (ARDS)

Activation of the coagulation cascade (DIC)

 Septic Shock
Early Warm Shock Late Cold Shock
CO and SVR and wide Uncompensated shock
pulse pressure with drop in CO
Signs: warm extremities, Signs: cyanosis, cold,
flushing, bounding pulses, clammy skin, thready
HR, confusion pulse, shallow respiration
Hypocarbia, elevated Metabolic acidosis,
lactate, hyperglycemia hypoxia, coagulopathy,
hypoglycemia
 S/S of Septic Shock
Increased to low blood pressure
High fever, no fever, hypothermic
Skin flushed, Pale, Cyanotic
Difficulty breathing and altered lung sounds
 TX of Septic Shock
Airway control
Administer oxygen
IV of crystalloid solution
Dopamine for blood pressure support
Monitor other vitals
 Anaphylatic Shock
Severe immune response to foreign
substance
S/S most often occur within minutes
but can take up to hours to occur
The faster the reaction develops the
more severe it is likely to be
Death will occur if not treated promptly
 S/S of Anaphylactic Shock
Skin
- Flushing
- Itching
- Hives
-Swelling
-Cyanosis
 S/S of Anaphylactic Shock
Respiratory System
- Breathing difficulty
- Sneezing, Coughing
- Wheezing, Stridor
- Laryngeal edema
- Laryngospasm
 S/S of Anaphylactic Shock
Cardiovascular System
- Vasodilation
- Increased heart rate
- Decreased blood pressure
 S/S of Anaphylactic Shock
Gastrointestinal System
- Nausea, vomiting
- Abdominal cramping
- Diarrhea
 TX for Anaphylactic Shock

Airway protection which may include Endotracheal

Intubation
Establish IV with crystalloid solution
Pharmacological interventions: Epinephrine,
Antihistamines(Benadryl),
Corticosteroids(dexamethasone),
Vasopressors(dopamine, Epinephrine), and inhaled
beta agonist(albuterol)