1. SHOCK

2. DEFINITION Profound hemodyamic and metabolicdisturbance characterized by failure of thecirculatory system to maintain adequateperfusion of vital organs 3. Types of Shock Cardiogenic (intracardiac vs extracardiac) Hypovolemic Distributive sepsis**** neurogenic (spinal shock) adrenal insufficiency anaphylaxis 4. Cardiogenic Shock, intracardiac Myocardial Injury or Obstruction to Flow Arrythymias valvular lesions AMI Severe CHF VSD Hypertrophic Cardiomyopathy 5. Presentation of CardiogenicShock Pulmonary Edema JVD hypotensive weak pulses oliguria 6. Cardiogenic Shock, extracardiac(Obstructive) Pulmonary Embolism Cardiac Tamponade Tension Pneumothorax Presentation will be according to underlyingdisease process. 7. Hypovolemic Shock Reduced circulating blood volume withsecondary decreased cardiac output Acute hemorrhage Vomiting/Diarrhea Dehydration Burns Peritonitis/Pancreatitis 8. Presentation of HypovolemicShock Hypotensive flat neck veins clear lungs cool, cyanotic extremities evidence of bleeding? Anticoagulant use trauma, bruising oliguria 9. Distributive Shock Peripheral Vasodilation secondary to disruptionof cellular metabolism by the effects ofinflammatory mediators. Gram negative or other overwhelming infection. Results in decreased Peripheral VascularResistance. 10. Distributive Shock: Presentation Febrile Tachycardic clear lungs, evidence of pneumonia warm extremities flat neck veins oliguria 11. Diagnosing Shock Response to fluids Echo/EKG CXR Evidence of infection Swan-Ganz Catheter? 12. Swan-Ganz Catheter Utilized to differentiate types of shock andassist in treatment response. Probably overused by physicians. Studiesdocumenting increased mortality in patientswith catheters versus no catheters, althoughsomewhat swayed by selection bias. 13. Swan-Ganz Catheter 14. Swan-Ganz InterpretationEtiology COPCWP SVRcardiogenicdecreased increased increasedhypovolemicdecreased decreased increaseddistributive increased decreased decreasedobstructivedecreased Increased increased 15. Management Correct underlying disorder if possible andthen direct efforts at increasing the bloodpressure to increase oxygen delivery to thetissues. Maintain a mean arterial pressure of 60(1/3 systolic + 2/3 diastolic) Keep O2 sats >92%, intubate if neccesary 16. Correction of hypotension Normal Saline should be administeredanytime a patient is hypotensive. Ifhypotension exists give more NS. *** If possible give blood as it replaces colloid. Vasopressors Inotropic agents for cardiogenic shock Intra-aortic Balloon Pump for cardiogenic 17. Autonomic Drugs in ShockDrug IndicationDoseMOAPrincipal actionsDopamine Renal perfusion 2-5 mcg/kg/minDopaminergic Renal a. dilation hypotension 5-10 mcg/kg/min 1&+ inotrope dopaminergic Hypotension >10 mcg/kg/min1 vasoconstrictionDobutamine Cardiogenic shock 2.5-25 mcg/kg/min Selective 1+ inotropeNorepinephrine Hypotension 2-4 mcg/min 1& 1VasoconstrictionPhenylephrineHypotension 40-180 mcg/minSelective 1Vasoconstriction 18. Management of Cardiogenic Shock Attempt to correct problem and increasecardiac output by diuresing and providinginotropic support. IABP is utilized ifmedical therapy is ineffective.Catheterization if ongoing ischemia Cardiogenic shock is the exception to therule that NS is always given forhypotension NS will exacerbate cardiacshock. 19. Intra-Aortic Balloon Pump 20. Management of Septic Shock Early goal directed therapy Identification of source of infection Broad Spectrum Antibiotics IV fluids Vasopressors Steroids ?? Recombinant human activated protein C ( Xygris) Bicarbonate if pH < 7.1 21. Management of Hypovolemic Shock Correct bleeding abnormality If PT or PTT elevated then FFP Aggressive Fluid replacement with 2 largebore IVs or central line. Pressors are last line, but commonlyrequired. 22. Addisons Disease Deficiency of cortisol and aldosteroneproduction in the adrenal glands This is suspected when patient is non-responsive to fluids and antibiotics. Electrolytes may reveal hyponatremia andhyperkalemia Hydrocortisone 100 mg IV immediatelythen taper appropriately