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SHOCKComplications &Approach to Patient Dr.Mohammed Sharique Ahmed QuadriAssistant Prof.PhysiologyAlmaarefa College Complications of Shock Acute respiratory distress syndromeAcute renal failureGastrointestinal complicationsDisseminated intravascular coagulationMultiple organ dysfunction syndrome 22Acute Respiratory Distress Syndrome (ARDS)Potentially life threatening form of lung injury Characterized by Severe dyspnea of rapid onsetRespiratory rate increasesProfound hypoxemia (cyanosis)Pulmonary infiltration ( x-ray chest)

33Pathophysiology of (ARDS)

4cytokinesAccumulates in pulmonary vasculatureActivation of neutrophils Injury to endothelial cells Leakage of fluid and plasma proteins in alveolar spacesAtelectasis Impaired gas exchangeDecrease compliance (stiffness)Decrease surfactant 4Acute Renal Failure (ARF)Renal vasoconstriction cuts off urine productionAcute renal failureContinued vasoconstriction cuts off renal oxygen supplyRenal tubular cells die Acute tubular necrosis55G.I Complication Constriction of vessels supplying GIT for redistribution of blood flow

Decrease mucosal perfusionGIT ulceration Bleeding 6Disseminated IntravascularCoagulation (DIC)coagulation pathways activatedclots in many small blood vesselsmicroinfarcts, ischemiaplatelets and clotting proteins used upbleeding problems7ORAGAN FAILURE7Multiple Organ Dysfunction Syndrome (MODS)The most frequent cause of death in the noncoronary intensive care unit Mortality rates vary from 30% to 100% Pathogenesis not clearly understood

88Approach to the Patient in Shock9Avoid over reliance on invasive haemodynamic monitoringPulse rateCapillary fill timeCore-toe temperatureBlood pressureLevel of consciousnessBlood-gas estimationAssessInterveneRE-assessSeek helpPractically Speaking.Keep eye on these patientsFrequent vitals signs:Monitor success of therapiesWatch for decompensated shockLet your nurses know that these patients are sick!Is this the appropriate environment?

ABCsCardiorespiratory monitorPulse oximetrySupplemental oxygen IV accessABG, labsFoley catheterVital signs Approach to the Patient in ShockDiagnosisPhysical exam (VS, mental status, skin color, temperature, pulses, etc.)Infectious sourceLabs:CBCChemistriesLactateCoagulation studiesCulturesABG

Further EvaluationCVP and PCWPCT of head/sinusesLumbar punctureWound culturesAbdominal/pelvic CT or USCortisol levelFibrinogen, FDPs(fibrin degradation product), D-dimerApproach to the Patient in ShockHistoryRecent illnessFeverChest pain, SOBAbdominal painComorbiditiesMedicationsToxins/IngestionsRecent hospitalization or surgeryBaseline mental status

Physical examinationVital SignsCNS mental statusSkin color, temp, rashes, soresCV JVP, heart soundsResp lung sounds, RR, oxygen sat, ABGGI abd pain, rigidity, guarding, reboundRenal urine output

Is This Patient in Shock?Patient looks illAltered mental statusSkin cool and mottled or hot and flushedWeak or absent peripheral pulses SBP 10 g/dLSerial lactate levels or central venous oxygen saturations to assess tissue oxygen extraction23SmvOEnd Points of ResuscitationGoal of resuscitation is to maximize survival and minimize morbidityUse objective hemodynamic and physiologic values to guide therapyGoal directed approachUrine output > 0.5 mL/kg/hrCVP 8-12 mmHgMAP 65 to 90 mmHgCentral venous oxygen concentration > 70%

Treatment objectivesSpecific treatment will depend on the underlying causeABC approachVolume replacement: Hypovolemic or septicInotropes: CardiogenicVasopressors: SepticAdrenaline: Anaphylactic

What Type of Shock is This?68 yo M with hx of HTN and DM presents to the ER with abrupt onset of diffuse abdominal pain with radiation to his low back. The pt is hypotensive, tachycardic, afebrile, with cool but dry skin

Types of ShockHypovolemicSepticCardiogenic AnaphylacticNeurogenic Obstructive

Hypovolemic ShockHypovolemic ShockABCsEstablish 2 large bore IVs or a central lineCrystalloidsNormal Saline or Lactate RingersUp to 3 litersPRBCsO negative or cross matchedControl any bleedingArrange definitive treatmentWhat Type of Shock is This?An 81 yo F resident of a nursing home presents to the ED with altered mental status. She is febrile to 39.4, hypotensive with a widened pulse pressure, tachycardic, with warm extremitiesTypes of ShockHypovolemicSepticCardiogenic AnaphylacticNeurogenic Obstructive

SepticSepsisTwo or more of SIRS criteriaTemp > 38 or < 36 CHR > 90RR > 20WBC > 12,000 or < 4,000Plus the presumed existence of infectionBlood pressure can be normal!Treatment of Septic Shock2 large bore IVsNS IVF bolus- 1-2 L wide open (if no contraindications) Supplemental oxygenEmpiric antibiotics, based on suspected source, as soon as possible

Persistent Hypotension If no response after 2-3 L IVF, start a vasopressor (norepinephrine, dopamine, etc) and titrate to effectGoal: MAP > 60Consider adrenal insufficiency: hydrocortisone 100 mg IVWhat Type of Shock is This?A 55 yo M with hx of HTN, DM presents with crushing substernal CP, diaphoresis, hypotension, tachycardia and cool, clammy extremitiesTypes of ShockHypovolemicSepticCardiogenic AnaphylacticNeurogenic Obstructive

CardiogenicCardiogenic ShockSigns:Cool, mottled skinTachypnea HypotensionAltered mental statusNarrowed pulse pressureRales, murmurDefined as:SBP < 90 mmHgCI < 2.2 L/m/m2PCWP > 18 mmHgAncillary TestsEKGCXRCBC, Chemistry , cardiac enzymes, coagulation studiesEchocardiogram

Treatment of Cardiogenic ShockGoals- Airway stability and improving myocardial pump functionCardiac monitor, pulse oximetrySupplemental oxygen, IV accessIntubation will decrease preload and result in hypotension Be prepared to give fluid bolusWhat Type of Shock is This?A 34 yo F presents to the ER after dining at a restaurant where shortly after eating the first few bites of her meal, became anxious, diaphoretic, began wheezing, noted diffuse pruritic rash, nausea, and a sensation of her throat closing off. She is currently hypotensive, tachycardic and ill appearing. Types of ShockHypovolemicSepticCardiogenic AnaphylacticNeurogenic Obstructive

AnaphylacticAnaphylactic Shock- DiagnosisClinical diagnosisDefined by airway compromise, hypotension, or involvement of cutaneous, respiratory, or GI systemsLook for exposure to drug, food, or insectLabs have no roleABCsAngioedema and respiratory compromise require immediate intubationIV, cardiac monitor, pulse oximetryIVFs, oxygenEpinephrineSecond lineCorticosteriodsH1 and H2 blockers

Anaphylactic Shock- Treatment38Epi the single most important step in treatmentWhat Type of Shock is This?A 41 yo M presents to the ER after an RTA complaining of decreased sensation below his waist and is now hypotensive, bradycardic, with warm extremitiesTypes of ShockHypovolemicSepticCardiogenic AnaphylacticNeurogenic Obstructive

NeurogenicA,B,CsRemember c-spine precautionsFluid resuscitationKeep MAP at 85-90 mm Hg for first 7 daysThought to minimize secondary cord injuryIf crystalloid is insufficient use vasopressorsSearch for other causes of hypotensionFor bradycardiaAtropinePacemaker Neurogenic Shock- TreatmentWhat Type of Shock is This?A 24 yo M presents to the ED after an RTA c/o chest pain and difficulty breathing. On PE, you note the pt to be tachycardic, hypotensive, hypoxic, and with decreased breath sounds on leftTypes of ShockHypovolemicSepticCardiogenic AnaphylacticNeurogenic Obstructive

Obstructive Any Questions?