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Shock

Shock . Shawn Dowling, PGY-5. Objectives. Briefly discuss general pathophysiology Classification of shock Review of vasopressors Lots of cases We will not talk about septic shock - this will be discussed in a future set of rounds. Intro. 35M. Pulled from an industrial fire.

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Shock

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  1. Shock Shawn Dowling, PGY-5

  2. Objectives • Briefly discuss general pathophysiology • Classification of shock • Review of vasopressors • Lots of cases • We will not talk about septic shock - this will be discussed in a future set of rounds

  3. Intro • 35M. Pulled from an industrial fire. • Brought in by EMS. • Pt is awake, but clearly altered. Only complaint is a HA. Prev well. • T37, HR 110, BP 160/70, RR 20/100% c/s 7 • The nurses have already drawn a venous gas • CO is 18%, lactate is 13 • Is this patient in shock?

  4. What do you think is going on? • Lactate > 10 is highly predictive of cyanide toxicity with inhalational exposure regardless of CO level • Baud FJ, et al: Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med 2001; 325:1761–1766. • How do you want to treat this patient other than with O2 +/- hyperbarics? Why? • Only give the sodium thiosulfate portion of the Cyanide Antidote Kit – if you give them the nitrite component you induce more of a functional anemia which they will not tolerate because of the other functional anemia – the CO

  5. Definition of shock • Rude unhinging of the machinery of life Or • The inability of the circulatory system to adequately supply tissues with 02 & nutrients and remove cellular waste

  6. Diagnosis of Shock – Rosen’s • Need 4 of 6 • Ill appearance or decreased LOC (as a general rule MAP< 50 before AMS) • HR > 100 • RR > 22 or PC02 < 32 • Base deficit <-5 or lactate >4 • Urine output < 0.5 ml/kg/hr • Hypotension > 20 minute duration NOTE - ↓BP not required for Dx

  7. Diagnosing Shock • The more advanced the shock state, the easier the Dx, but… • Significant tissue hypoxia appears to exist prior to development of significant signs & symptoms • THE BETTER WE CAN RECOGNIZE SHOCK, THE EARLIER WE CAN INSTITUTE Tx • TIME IS TISSUE (see RIVERS STUDY) • Can be is shock with “normal” vitals • Normal BP in face of hypovolemia means some organs are hypoperfused to maintain systemic BP

  8. Shock is the transition between life and death

  9. Shock unifying features: • Imbalance between cellular O2 demand and supply • Disrupted cellular homeostasis • Failed aerobic metabolism –> anaerobic metabolism –> lactic acidosis • Calcium shifts - impairs cardiac contractility • Failed ion gradients and cellular pumps • Cell edema and death

  10. How does our body compensate? • Counter-regulatory mediators • Catecholamines, glucocorticoids, angiotensin, vasopressin, insulin • Increased substrates • glucose, TG and FFA • Anaerobic metabolism • incr CO2:02 ratio

  11. Pertinent Critical Care formulas • CO = HR x SV • BP = CO x SVR • O2 content = 1.34 x hgb x O2 saturation + 0.003 x Po2 (02 bound to hgb) (02 in plasma) • Oxygen delivery is the CO x O2 content • Why is this equation so important to a shock talk? • In which shock scenario do we target the O2 in plasma for treatment? • CO poisoning

  12. What are some different shock classifications?

  13. Classification of Shock • Many different ways • Mnemonics • Physiologic • Clinical • It doesn’t matter which you use as long as • You know it cold • It’s exhaustive

  14. Shock BP = ↓CO x ↓SVR Hypovolemic Cardiogenic Obstructive Distributive

  15. Shock Shock Hypovolemic Cardiogenic Obstructive Distributive • Bleeding or • Fluid Loss • Overt • Occult • Excessive • Losses • Vessels • Rhythm • Valvular • Myocardium • Pericardium • Intravascular • Extravascular • NASTE • Neurogenic • Anaphylactic • Septic • Toxicologic • Endocrine

  16. Hypovolemic • Overt/Occult losses of blood • 5 sources of life threatening hemorrhage in trauma? • Chest, Abdo, Pelvis, Long bones, Street (from skin) • Excessive Fluid loss • 3rd spacing (burns, pancreatitis, dermatologic, ascites) • Excessive sweating/vomiting/diarrhea/urine output(diuretics, DI)

  17. Vessels AMI or acute or chronic– usually need to infarct 40% to cause shock AoD Rhythm Brady Tachydysthrythmias Valvular Stenosis Regurgitation Myocardium Rupture (FW or VSD) Myocarditis Cardiomyopathy RV involvement Pericardium Tamponade Cardiogenic

  18. Obstructive • Intravascular • PE • Amniotic Fluid Embolism • Air embolism • Fat embolism • Extravascular • Tension PTX • Cardiac tamponade • SVC syndrome

  19. Distributive • Neurogenic • Anaphylactic • Septic • Toxicologic • (CaCB, BB), CO, cyanide, iron, ASA, etc • Endocrine • Adrenal insufficiency, thyroid storm, electrolytes (hyperK)

  20. Top three causes of shock in infants • Sepsis • Hypovolemic • Cardiac • SHOCK in a neonate • Sepsis • Cardiac • non-Accidental Trauma • Metabolic • Surgical

  21. Physical Exam • Two purposes • Try to determine if the patients is in shock • Look for evidence of end organ damage • Determine the cause of the shock • JVP & perfusion status is VERY helpful

  22. Thanks to ICU Crash Course

  23. Sepsis Neurogenic Shock Anaphylactic Shock Epinephrine Ephedrine Phenylephrine Norepinephrine Dopamine Milrinone Match the shock with the appropriate vasopressor and why

  24. Direct agents stimulate the receptor directly Indirect agents have their effect by stimulating the adrenals to release catecholamines :. If stressor has been ongoing for a period of time -> body’s catecholamine reserve is likely deplete and the indirect agents will have less effect Direct Norepi Epi Phenylephrine Indirect Dopamine Dobutamine Ephedrine Direct vs indirect vasopressors

  25. Receptor Primary location Primary fx D=Dopaminergic

  26. Receptor Primary location Primary fx D=Dopaminergic

  27. Cochrane Review:(updated) Feb. 11, 2005. • For all kinds of shock • RCTs • Levo vs Dop (3 studies, N=62) • RR death 0.88 (0.57,1.36) • Levo + dob vs epi (2 studies, N=52) • RR death 0.98 (0.57,1.67) • Unfortunately, these studies are too small to definitively answer the question but better data to support that norepi achieves HD endpoints better and since it’s a direct agent likely better for septic patients

  28. Case 1 PP: 8yo F with known allergy to wasps PMHx: Healthy and no meds HPI: • At day camp and “forgot” her epi-pen • Stung by 2 hornets after accidentally running into a nest • Presents by personal vehicle to ED • Given PO Benadryl by family member

  29. Case 1 • Generally • Appears unwell and flushed • HR=128, RR=38, T=37.8, BP=85/40, Sat 89% RA • CVS • Tachy, warm extremities • Resp • Significant indrawing • Audible wheeze throughout • No stridor noted • Derm • Urticarial rash and diffuse flushing • ENT • Lip swelling noted and uvula swollen on exam

  30. Case 1 • Name the general category of shock • Describe the pathophysiology • Name the management goals • Define the best interventions to obtain the above goals • Name potential pitfalls

  31. Case 1 • The pediatric nurse is panicked….. • He wants to know how much Epinephrine you want to give this child and by what route…..

  32. Case 1 • The patient is not responding to your IM epinephrine • The pressure is 60 systolic and the patient has become obtunded…..

  33. Case 2 • PP: • 58yo Male with known shrimp allergy • PMHX • MI 2 years ago • NIDDM • HTN • HPI: • Ate the “egg roll special” at a Thai restaurant • Immediate throat swelling • EMS called and IM epinephrine given on route

  34. Case 2 • Generally • Appears flushed and unwell with marked work of breathing and distress • HR 62, RR 28, BP 80/46, Sat 89% on mask, T37.4 • CVS • Normal heart sounds, normal cap refill • Resp • Diffuse wheeze throughout • Abdomen • Soft but mildly tender • Neuro • Starting to appear somnolent

  35. Case 2 • You repeat another IM injection of 0.3cc of 1:1000 epi and give H1 and H2 blockers intravenously • There is no improvement and the patient remains hypotensive and relatively bradycardic…..

  36. Case 2 • Name the general category of shock • Describe the pathophysiology • Difference between anaphylaxis and anaphylactoid? • Name the management goals • Define the best interventions to obtain the above goals • Name potential pitfalls

  37. Management • Fluids • Meds • Epi is the first line Tx for anaphylaxis • IV (1:10,000) • 1 mL (100ug) aliquot – repeat q60sec until desired effect • Infusion - 1ug/min-4ug/min • If pt not in shock – IM (why not SC?) • Ventolin nebs • Benadryl 50mg IV • Zantac 50mg IV • Solu-medrol 125mg IV

  38. Glucagon (for pts on ßß, ?ACE-I) • 1-2mg IV • Then 5-15mcg/min infusion • Inotropic/chronotropic/vasoactive properties beyond the b-receptor

  39. Case 3 • 80M. Hx of COPD. • Presents with productive cough and feels unwell. • T-40, RR28, sats 85% on NRB, HR-120, BP 90/50 • Working Dx – Pneumonia + Sepsis • You decide you going to intubate this patient because of failure to oxygenate • Any concerns? How are you going to prepare? Induction agent? Other meds?

  40. Sepsis and airway management • Sepsis significantly increases you O2 requirements – therefore these patients can desaturate quite rapidly – :. Optimize the conditions (i.e. positioning, pre-oxygenate, best-intubator, etc) • Use of accessory muscles can ↑O2 consumption by 50-100%! • Another reason to manage their airway early or if you are not meeting your physiologic end points • Any other concerns

  41. Post-intubation hypotension • Septic patients are very catecholamine driven – intubating can remove that stimuli and they can drop their pressures precipitously • Also, the agents we give for intubation may play a role • ↑ intra-thoracic pressure (from mechanical ventilation) can drop the preload :. causing hypotension)

  42. Intubating a septic patient • Pre-oxygenate as much as possible • Pretreat with fluids +/- bicarb if you thing they are really acidotic (no evidence) • Careful choice of induction agent • Ketamine or ½ dose etomidate (0.15mg/kg) are likely best options, AVOID propofol • Have some pressors drawn up (phenyl/norepi) • Why not dopamine or ephedrine? • phenylephrine • How do you mix this? • 10mg in 100mL bag – draw up 10cc and give 1cc(100Ug)/dose • RSI if no CI (gives you the best look)

  43. http://ca.youtube.com/watch?v=pY8jaGs7xJ0

  44. Case 3 PP: 38yo Male transfer by STARS PmHx: Asthma but otherwise healthy Meds: Ventolin and Flovent PRN HPI: • Patient riding QUAD in kananaskis country and flipped • + Helmet and no LOC • Trapped under bike for 10 minutes extrication by friends • STARS scene call • No major blood loss noted on scene

  45. Case 3 • Generally • GCS 12/15 patient confused and aggitated • HR 120, BP 81/40, RR 15, Temp 37.2, Sats 92% • CVS • Tachycardic, normal HS, Cap refill 4 seconds, weak thready pulse • Resp • Clear bilaterally but poor inspiratory effort • Abdomen • Diffusely tender to palpation • Soft and not distended • MSK • Pelvis is grossly unstable to palpation • Perineal hematoma noted • Femurs and hips normal to exam • Neuro • PEARL, No signs of depressed skull or basal skull injury • No signs of head trauma

  46. Case 3 • Name the general category of shock • Describe the pathophysiology • Name the management goals • Define the best interventions to obtain the above goals • Name potential pitfalls

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