Circulatory Failure - ShockCirculatory Failure - Shock

Case PresentationCase Presentation

56 year old man with a past history of type 56 year old man with a past history of type 2 diabetes and hypertension. Presented 2 diabetes and hypertension. Presented to the ER with a 12 hour history of to the ER with a 12 hour history of epigastric pain, nausea and vomiting. He epigastric pain, nausea and vomiting. He had recently eaten some fish at a had recently eaten some fish at a questionable restaurant downtown.questionable restaurant downtown.His vitals at the triage desk are 96/52, His vitals at the triage desk are 96/52, heart rate 119, respiratory rate 18, heart rate 119, respiratory rate 18, temperate 38.6 C and saturation 91%temperate 38.6 C and saturation 91%

What is the differential diagnosis for his What is the differential diagnosis for his presentation?presentation?

Is this man in shock?Is this man in shock?– What is the definition of shock?What is the definition of shock?– What further information do you need to What further information do you need to

determine that he is in shock?determine that he is in shock?

After being taken to an examination room, After being taken to an examination room, the patient complains of being light-the patient complains of being light-headed and that the fire truck in the room headed and that the fire truck in the room is taking up too much space. On is taking up too much space. On examination, he is in moderate respiratory examination, he is in moderate respiratory distress, clammy, with tenderness in the distress, clammy, with tenderness in the epigastric area to palpation, scattered epigastric area to palpation, scattered crackles in both bases and a faint S3.crackles in both bases and a faint S3.Lactate 5.9 on the first blood gas.Lactate 5.9 on the first blood gas.

What are the four main types of shock?What are the four main types of shock?– HypovolemicHypovolemic– CardiogenicCardiogenic– DistributiveDistributive– ObstructiveObstructive

What is the differential diagnosis for each type of What is the differential diagnosis for each type of shock?shock?Describe the characteristic findings in preload, Describe the characteristic findings in preload, afterload, cardiac output and tissue perfusion for afterload, cardiac output and tissue perfusion for each type of shock.each type of shock.

What would be your initial approach to this What would be your initial approach to this patient?patient?

Over the course of the next 30 minutes, the Over the course of the next 30 minutes, the patient’s level of consciousness continues to patient’s level of consciousness continues to decline and his shortness of breath worsens. decline and his shortness of breath worsens. On examination, the crackles are higher up the On examination, the crackles are higher up the chest and his oxygen saturations are 90% on chest and his oxygen saturations are 90% on flush oxygen.flush oxygen.ECG demonstrates inferior wall ST segment ECG demonstrates inferior wall ST segment elevation myocardial infarction.elevation myocardial infarction.

Describe the physiology and outline the Describe the physiology and outline the management of shock due to:management of shock due to:– Left ventricular failureLeft ventricular failure– AnaphylaxisAnaphylaxis– HemorrhageHemorrhage– SepsisSepsis– Massive pulmonary embolismMassive pulmonary embolism– Tension pneumothoraxTension pneumothorax

The patient is taken urgently to the The patient is taken urgently to the angiography suite and undergoes PTCA of angiography suite and undergoes PTCA of the right coronary artery. After the the right coronary artery. After the procedure, he remains hypotensive, procedure, he remains hypotensive, lactating, and obtunded. He is started on lactating, and obtunded. He is started on a norepinephrine and dobutamine infusion a norepinephrine and dobutamine infusion while awaiting a balloon pump.while awaiting a balloon pump.

What is the main mechanism of action and use What is the main mechanism of action and use for the following vasopressors/inotropes:for the following vasopressors/inotropes:– NorepinephrineNorepinephrine– VasopressinVasopressin– PhenylephrinePhenylephrine– EphedrineEphedrine– EpinephrineEpinephrine– DobutamineDobutamine

What is the difference between a vasopressor What is the difference between a vasopressor and an inotrope?and an inotrope?

Questions?Questions?