SHOCK

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SHOCK

• Kelsey Gray, M.D., M.S.
• Pulmonary CCM Fellow

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Objectives

• Define SHOCK
• Differentiate and Understand Different Types of
  SHOCK
• Hypovolemic
• Obstructive
• Cardiogenic
• Distributive
• Understand the Physiology Basic Principles of
  Hemodynamic Monitoring
• Treatment

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SHOCK

• A Medical Emergency!
• A multifactorial syndrome resulting in inadequate
  tissue perfusion and cellular oxygenation
  affecting multiple organs
• Perfusion is inadequate to meet metabolic demands
  at the cellular level ? tissue hypoxia, anaerobic
  metabolism, activation of inflammatory cascade ?
  vital organ dysfunction ? DEATH

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SHOCK

• Early diagnosis of cellular ischemia with prompt
  restoration of tissue perfusion and oxygenation
  is key!
• Four Categories of SHOCK
• 1) Hypovolemic Inadequate circulating volume
• 2) Obstructive extra-cardiac obstruction of
  blood flow
• 3) Cardiogenic pump failure
• 4) Distributive Maldistribution of blood flow
  and volume

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Physiology Review

• Check out this website www.PACEP.org
• Rarely are Swan-Ganz catheters indicated
• The physiology is key to understanding shock

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Keep It Simple
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Key Equations

• BP CO X SVR
• Oxygen Delivery (DO2) CO X Arterial O2 content
• CO SV X HR
• SV is a function of preload, afterload,
  contractility

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Preload
Rhythm
Stroke Volume
Contractility
Cardiac output
Afterload
Heart Rate
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The Key is Tissue Oxygenation

• Oxygen Delivery
• CO
• Arterial O2 content
• Hemoglobin
• Oxygen saturation
• Oxygen Demand
• Metabolic activity of the tissue

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CVP2-8 VOLUME
Sv02 65-75
PCW LV Function 2-12 book, THINK 8-12
SVR 800-1200 RESISTANCE
Sa02 95-100
CO 4-6 EJECTION
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Case 1

• Mr. Simpson is a 32 y.o. man who was involved in
  a MVA on a county road outside of Denver. At the
  scene, he was A O X 3, he was normotensive, and
  his HR was 105.
• He was helicoptered to SAC.
• In the ED, he became acutely hypotensive,
  tachycardic, and unresponsive.

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Hypovolemic Shock

• 2 types
• Hemorrhagic GI Bleed, Trauma, operative
  bleeding, vaginal bleed, ruptured AAA,
• Non-hemorrhagic Burns, Pancreatitis, Fistulae,
  high UOP,
• An Empty Heart
• Decreased CO
• Decreased filling pressures
• Compensatory increase in SVR

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Hypovolemia Physical Findings

• Cold, Clammy Skin
• CNS stimulation ? sweat gland activation
• Peripheral Hypoperfusion
• Blood is shunted centrally
• Significant volume may be lost in the absence of
  any clinical signs!!!

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Hypovolemic Shock Classification
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Case 2

• Mr. Jones is a 23 y.o. man with no significant
  PMH who presents with a one week h/o pleuritic
  chest pain. He came to the ED because he was
  acutely SOB and dizzy.
• In the ED, his EKG shows electrical alternans
  with diffuse ST elevations. His troponin is
  elevated.
• His blood pressure is 80/55 mm Hg, HR is 145, and
  his mentation is worsening by the minute. You
  check for pulsus paradoxus and he has it.

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Obstructive Shock

• Mechanical Obstruction to normal cardiac output
  and subsequent decrease in systemic perfusion
• Low CO, Increased SVR
• Causes Tamponade, Massive PE, Venous air
  embolism, Tension PTX

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Case 3

• Ms. Vasculopath is an 82 y.o. female with a h/o
  CAD, HTN, DM II, Hyperlipidemia, FHX for CAD
  who was BIBA after being found down by her
  daughter. She was intubated in the field.
• On your exam, her BP is 60/40 mm Hg, HR is 110,
  her skin is cold and you are unable to palpate a
  pulse.
• An emergent TTE shows a ruptured papillary muscle
  and wide open MR.

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Cardiogenic Shock Pump Failure

• Causes MI, cadiomyopathy, ventricular outflow
  obstruction (AS, aortic dissection), ventricular
  filling abnormalities (cardiac mass, mitral
  stenosis), acute valvular failure (MR, AR), VSD.
• Decreased Contractility
• Decreased LV Stroke work
• Decreased CO
• Compensatory Increase in SVR

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Cardiogenic Shock Physical Exam

• Cool or cold periphery
• Systemic hypotension
• Elevated Wedge Pressure
• Signs of RHF
• JVD
• Peripheral Edema
• HJR

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Case 4

• 65 y.o. female with h/o atrial fibrillation with
  a 3 day h/o abdominal pain (worse after eating),
  fever, nausea, and vomiting.
• She is brought into the ED with AMS, a rigid
  abdomen, rigors, hypotension, and atrial
  fibrillation with RVR.
• Her skin is warm and clammy and a saturation
  taken off of blood from her CVC is 55. She is
  still hypotensive despite a 1 Liter fluid bolus.

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Distributive Shock

• Causes Sepsis, Anaphylaxis, Neurogenic
  (autonomic dysfunction from spinal cord injury
  above the upper thoracic level), Acute Adrenal
  Insufficiency
• Physiology
• Low SVR as they are vasodilated
• Increased or normal CO/CI at least initially
• Low to normal filling pressures at least
  initially

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Treatment

• Shock is a medical emergency!
• Key is to restore tissue perfusion oxygen
  delivery
• Close monitoring is key, so what endpoints do you
  use?
• How do you choose the right Vasopressor?

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Initial Assessment

• Sick or Not Sick? ? If they are sick, do
  something about it.
• ABCs
• Access (IV, CVC, Cordis)
• Exam
• BP, HR, RR, SaO2, Temp.

• Exam
• Listen and feel are they cold or warm
• Mental Status
• JVD? Edema? Rub? Murmur?
• No Breath Sounds? Crackles? Tracheal deviation?
• UOP, CVO2 or SVO2, MAP

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What Kind of Line?

• Central or Peripheral
• What Kind of Time Do You Have?
• Big or Small
• Single or Multi-lumen
• Location
• Femoral
• Subclavian
• IJ

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Vasopressors/Inotropes
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Hypovolemic Shock TX

• Give them volume, including blood!
• Crystalloid (LR, NS) should be given immediately
• Blood ASAP
• Match fluid given to fluid lost
• Crystalloid Colloid
• Fix the Problem
• Surgery if indicated

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Cardiogenic Shock TX

• Treat the Underlying Cause
• Inotropes
• Dobutamine
• Balloon Pump
• VADs
• RV Failure (Inferior MI) needs volume
• No BB or ACE-I acutely

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Obstructive Shock TX

• Treat the Cause of the Obstruction!
• Fluids wide open Vasopressors if needed
• Pericardial Effusion with Tamponade
• Emergent Pericardiocentesis
• Massive PE
• Lytics
• Tension PTX
• Angiocaths to the 2nd intercostal space in the
  mid-clavicular line ? Chest Tube
• Venous Air Embolism
• Lay patient with head down in the left lateral
  decubitus position
• Aspirate air from RV

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Distributive Shock TX

• Fluids and vasopressors if not responsive (goal
  MAP gt 65 mm Hg)
• Neurogenic Shock usually are euvolemic so give
  fluids cautiously, alpha-adrenergic agent
  (phenylephrine), atropine for symptomatic
  bradycardia (these guys have excess
  parasympathetic tone)
• Antibiotics
• Anaphylaxis H2B, antihistamine, epinephrine,
  fluids, Vasopressors (dopamine)

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Early Goal Directed Therapy
Severe Sepsis or Septic Shock
lt 8 mm Hg
CVP
IV Fluids
8-12 mm Hg
lt 65 mm Hg
MAP
Vasopressors
gt 65 mm Hg
gt 70
Transfuse blood until Hct gt 30
lt 70
SvO2
lt 70
gt 70
Dobutamine
No
Goals Met ?
Yes
ICU Admission
Rivers. NEJM 3451368-1377,2001
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CCM 2008 36 296-327
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Pressors
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Objectives

• Define SHOCK
• Differentiate and Understand Different Types of
  SHOCK
• Hypovolemic
• Obstructive
• Cardiogenic
• Distributive
• Understand the Physiology Basic Principles of
  Hemodynamic Monitoring
• Treatment

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QUESTIONS