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Objectives
Understand the definition of the
three different types of shock
Be able to recognize the different
types of shock in patient scenarios
Understand and apply treatment
guidelines for the different types of
shock
What is Shock?
Shock is the physiologic state
characterized by significant reduction of
systemic tissue perfusion, resulting in
decreased tissue oxygen delivery.
Tissue perfusion is dependent on SVR and
CO
Imbalance between oxygen delivery and
oxygen consumption which leads to cell
death, end organ damage, multi-system
organ failure,
and
death
Gaieski et al. 2009
(Online
accessed 22 August 2013)
URL: http://lijhs.sandi.net/faculty/rtenenbaum/ap-biologyfolder/Links/Shock.utd.pdf
Combined
Case Study
Mrs. C is a 61yo F who presents to ED
complaining of fatigue and SOB. She has
significant PMHx: DM, obesity, HTN.
Husband also states she has become
slightly confused.
Vitals: HR 46, BP 68/32, RR 23, SpO2 95%
on RA, Afebrile.
Labs: WBC 8.1, Hgb 12.1, BUN 12, Creat
1.0, Troponin 3.1, BG 121.
EKG shows ST elevation in II, III, aVF
Cardiogenic Shock
Treatment of Cardiogenic
Shock
Correct hypotension:
Fluid resuscitation to correct hypovolemia
Inotropic or Vasopressor support:
Dobutamine
Milrinone
Norepinephrine
Dopamine
Epinephrine
Oxygenation
If MI ASA, Heparin, and Revascularization
If arrthymia correct arrthymia
If extracardiac abnormality reverse or treat
cause
Case Study
Mr. H is a 18yo M who presents to ED after
suffering a MCC into a tree. He was
unhelmeted and has an obvious left femur
fx. He was intubated for a GCS of 8 in the
field and given 1L NS en route for
hypotension.
Vitals: HR 145, BP 71/38, Intubated with
SpO2 100%, Afebrile.
Labs: WBC 12.3, Hgb 6.7, Plts 72, INR 2.1.
Traumagram shows Grade III liver lac.
Hypovolemic Shock
Shock caused by decreased preload
due to intravascular volume loss (1/5
of blood volume)
Results in decreased CO
SVR is typically increased in an effort to
compensate
Causes:
Hemorrhagic trauma, GI bleed, hemorrhagic
pancreatitis, fractures
Fluid loss induced Diarrhea, vomiting, burns
Medscape LLC. 2013 (Online access on 22 August 2013)
URL: http://emedicine.medscape.com/article/760145treatment#2
Treatment of Hypovolemic
Shock
Fluid resuscitation
NS fluid boluses
Blood product administration
Case Study
Mr. S is a 59yo M presents to ED with
worsening abdominal pain and N&V
He is POD#8 s/p ex-lap, SBR with primary
anastamosis for chronic SBO at OSH
Vitals: HR 128, BP 78/45, RR28, SpO2
94% on 4L NC, Fever 103.1
Labs: WBC 20.1, Hgb 9.5, BUN 34, Creat
2.1
CT scan of ABD shows anastamotic leak
Distributive Shock
Shock as a result of severely diminished
SVR
CO is typically increased in an effort to
maintain perfusion
Subtypes:
Septic secondary to an overwhelming infection
Anaphylactic secondary to a life-threatening
allergic reaction
Neurogenic secondary to a sudden loss of the
autonomic
nervous system function
Gaieski et al. 2009 (Online accessed 22 August 2013)
URL: http://lijhs.sandi.net/faculty/rtenenbaum/ap-biologyfolder/Links/Shock.utd.pdf
Identify Source
Pan cultures
CT scan
Line removal
Foley removal
Surgical exploration
Antibiotics
Treatment of Anaphylactic
Shock
Remove offending
agent
Bronchodilators
Soar, J et al. 2013 (Online Accessed on 22 August 2013)
URL: http://www.resus.org.uk/pages/reaction.pdf
Treatment of Neurogenic
Shock
Case Study
Mrs. D is a 71yo F who presented to
ED after a 3 day h/o N&V with inability
to tolerate PO intake. She is now
POD0 s/p exlap, pancretectomy for
necrotizing pancreatitis. She presents
to the Surgical ICU postop.
Vitals: HR 121, BP 82/41, Intubated on
100% FiO2, Fever 102.8
Labs: WBC 1.1, Hgb 8.4, BUN 61,
Creat 2.82, Lactate 3.7
E. Both B. and C.
Summary
Survival and outcomes
improve with early perfusion,
adequate oxygenation, and
identification with appropriate
treatment of the cause of
shock.
Questions?
References
Dellinger, R et al. Surviving Sepsis Campaign: International
Guidelines for Management of Severe Sepsis and Septic
Shock:2012, 41: 580-637, 2013.
Emergency Medicine. 2009 (Online Accessed on 22 August 2013)
URL: http://emergencymed.wordpress.com/2009/03/11/neurogenicshock/
Gaieski et al. 2009 (Online accessed 22 August 2013)
URL:http://lijhs.sandi.net/faculty/rtenenbaum/ap-biologyfolder/Links/Shock.utd.pdf
Medscape Reference. 1994 (Online accessed 22 August 2013) URL:
http://emedicine.medscape.com/article/152191-treatment#showall
Medscape LLC. 2013 (Online access on 22 August 2013) URL:
http://emedicine.medscape.com/article/760145-treatment#2
Soar, J et al. 2013 (Online Accessed on 22 August 2013) URL:
http://www.resus.org.uk/pages/reaction.pdf