©ACS

SHOCK
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Objectives
 Define shock
 Recognize the shock state
 Determine the cause
 Apply treatment principles
 Apply principles of fluid management
 Monitor patient’s response
 Employ options for vascular access
 Recognize complications of vascular access
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Key Issues: Shock

Management
 Recognize inadequate organ perfusion
 Identify the cause

Hemorrhagic vs nonhemorrhagic
 Treatment

Stop the bleeding!

Restore volume
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Cardiac
Physiology
CO = SV x HR

Preload Contractility Afterload

Venous dp / dt Vascular
Capacitance Tone
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Pathophysiolog
y Venous Capacitance
Circuit
Component 2

Volume in
component 2
Component 1
determines
filling pressure
Tissue
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Cellular Alterations in
Shock
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Recognition of Shock
State
1. Tachycardia
2. Vasoconstriction
2.  Cardiac output
2. Narrow pulse pressure
3.  MAP
3.  Blood flow
Caution: Compensatory mechanisms
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Pitfalls in Shock
Recognition
 Extremes of age
 Athletes
 Pregnancy
 Medications
 Hematocrit / hemoglobin concentration
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Etiology of
Shock
Hemorrhagic Nonhemorrhagic
 Most common  Tension
pneumothorax
 Clinical clues

H&P  Cardiogenic

Selected
diagnostic tests
 Neurogenic
 Septic
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Hemorrhagic
Shock
 Loss of circulating blood volume
 Normal blood volume

Adult: 7% of ideal
weight

Child: 9% of ideal
weight
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Classification of
Hemorrhage
 Class I – IV
 Not absolute
 Only a clinical guide
 Subsequent treatment determined
by patient response
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Class I
Hemorrhage
750 mL BVL
Respirations
Slightly 14-20/min
anxious

Heart rate
<100/min  BP
Urine
30 mL/hr
Crystalloids
Class II ©ACS

Hemorrhage
750-1500 mL BVL
Respirations
Mildly 20-30/min
anxious

Heart rate
<100/min  BP
Urine
20-30 mL/hr
 Pulse
Crystalloids, ? Blood
Pressure
Class III ©ACS

Hemorrhage
1500-2000 mL BVL
Respirations
Confused, 30-40/min
anxious

Heart rate
>120/min  BP
Urine
5-15 mL/hr
 Pulse
Crystalloids, Blood
Pressure
Class IV ©ACS

Hemorrhage
≥2000 mL BVL
Respirations
Confused, >35/min
lethargic

Heart rate
>140/min  BP
Urine
negligible
 Pulse
Rapid fluids, Blood,
Operation Pressure
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Fluid Shifts: Soft-tissue

Injury
Blood loss into Tissue
injury site edema

Compounds
intravascular loss
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Assessment and
Management
 Recognize shock
 Stop the bleeding!
 Replendish intravascular volume
 Restore organ perfusion
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Assessment and
Management
 Airway and Breathing

Oxygenate and ventilate

PaO2 >80 mmHg (10.6 kPa)

 Circulation

Assess

Control

Treat
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Assessment and
Management
 Disability – Cerebral perfusion
 Exposure / Environment

Associated injuries

Prevent hypothermia
 Gastric and bladder decompression
 Urinary output
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Management: Vascular
Access
 2 large-caliber, peripheral IVs
 Central access

Femoral

Subclavian
 Intraosseous
 Obtain blood for crossmatch
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Management: Fluid
Therapy
 Warmed crystalloid solution
 Rapid fluid bolus

Adult: 2 liters Ringer’s
lactate

Child: 20 mL/kg Ringer’s
lactate
 Monitor response to initial therapy
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Reevaluate Organ
Perfusion
Monitor
 Vital signs
 CNS status
 Skin perfusion
 Urinary output
 Pulse oximetry
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Resuscitation
Evaluation
Hourly Urinary Output
Inadequate output suggests
inadequate resuscitation
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Acid-Base
Abnormalities
 Monitor with ABGs
 Usual etiology
Adult: Acidosis due to inadequate
perfusion
Child: Acidosis due to inadequate
ventilation
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Acid-Base
Abnormalities
 Treatment

Oxygenate and ventilate

Stop the bleeding !

Consider inadequate volume restoration

 Bicarbonate rarely indicated!

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Therapeutic
Decisions
 Patient response determines
subsequent therapy
 Hemodynamically “normal” vs
hemodynamically “stable”
 Recognize need to resuscitate in
operating room
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Therapeutic
Decisions
Rapid Response
 < 20% blood loss
 Responds to fluid replacement
 Surgical consultation, evaluation
 Continue to monitor
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Therapeutic
Decisions
Transient Response
 20% - 40% blood loss
 Deteriorates after initial fluids
 Surgical consultation, evaluation
 Continued fluid plus blood
 Continued hemorrhage: Operation
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Therapeutic
Decisions
Minimal to No Response
 > 40% blood loss
 No response to fluid resuscitation
 Immediate surgical consultation
 Exclude nonhemorrhagic shock
 Immediate operation
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Volume
Replacement
Warmed Fluids
 Crossmatched PRCBs
 Type-specific
 Type O, Rh-negative
 Autotransfusion
 Coagulapathy
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Pitfalls
 Equating BP with  Athletes
cardiac output
 Pregnancy
 Extremes of age
 Medications
 Hypothermia
 Pacemaker
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Avoiding
Complications
 Continued hemorrhage
 Fluid overload
 Invasive monitoring (ICU)

CVP

Pulmonary artery catheter
 Other problems
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Keys to Successful
Treatment
 Early control of hemorrhage
 Euvolemia
 Continuous reevaluation
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Questions
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Summary
 Restore organ perfusion
 Early recognition of the shock state
 Oxygenate and ventilate
 Stop the bleeding
 Restore volume
 Continuous monitoring of response
 Anticipate pitfalls