Shock

Shock
Tad Kim
UF Surgery
Shock
Overview
Definitions
Initial Assessment ABC
Stages of Shock
Physiologic Determinants of Shock
Types of Shock
Common Features of Shock
H & P / Work-up
Case scenarios and Management
Take Home Points
Shock
Definitions
Shock is a physiologic state characterized
by systemic reduction in tissue perfusion,
resulting in decreased tissue oxygen
delivery
Hypotension is not a requirement

Poor tissue perfusion
Shock
Initial Assesment - ABC
Airway:
Does pt have mental status to protect airway?
GCS less than eight means intubate
Airway is compromised in anaphylaxis
Breathing:
If pt is conversing with you, A & B are fine
Place patient on oxygen
Circulation:
Vitals (HR, BP)
2 large bore (#16g) IV, start fluids (careful if
cardiogenic shock), put on continuous monitor
Shock
ABC DE
In a trauma, perform ABCDE, not just ABC
Deficit or Disability
Assess for obvious neurologic deficit
Moving all four extremities? Pupils?
Glascow Coma Scale (V6, M5, E4)
Exposure
Remove all clothing on trauma patients
Shock
Stages / Spectrum of Shock
Preshock aka compensated/warm shock
Body is able to compensate for perfusion
Up to ~10% reduction in blood volume
Tachycardia to cardiac output & perfusion
Shock
Compensatory mechanisms overwhelmed
See signs/symptoms of organ dysfunction
~20-25% reduction in blood volume
End-organ dysfunction
Leading to irreversible organ damage/death
Shock
Physiologic Determinants
Global tissue perfusion is determined by:

Cardiac output (CO)
CO = Heart rate (HR) times Stroke Volume (SV)
SV = function of Preload, Afterload, Contractility

Systemic vascular resistance (SVR)
Variables: Length, Inverse of Diameter, Viscosity
Shock
Types of Shock
Hypovolemic shock from preload
Hemorrhage
Fluid Loss (Vomiting, Diarrhea, Burns)
Cardiogenic shock pump failure or SV
MI, arrhythmia, aortic stenosis, mitral regurg
Extracardiac obstructive causes such as PE,
tension pneumothorax, tamponade
Distributive (vasodilatory) shock - SVR
Septic, anaphylactic, and neurogenic shock
Pancreatitis, burns, multi-trauma via activation
of the inflammatory response
Shock
Common Features of Shock
Hypotension (not an absolute requirement)
SBP < 90mm Hg, not seen in preshock
Cool, clammy skin
Vasoconstrictive mechanisms to redirect
blood from periphery to vital organs
Exception is warm skin in early distrib. shock
Oliguria (kidney perfusion)
Altered mental status (brain perfusion)\
Metabolic acidosis
Shock
H&P / Work-up
History to determine etiology
Bleeding (recent surgery, trauma, GI bleed)
Allergies or prior anaphylaxis
Sx consistent with pancreatitis, EtOH history
Hx of CAD, MI, current chest pain/diaphoresis
Physical examination
Mucous membranes, JVD, lung sounds,
cardiac exam, abdomen, rectal (blood), neuro
exam, skin (cold & clammy or warm)
Labs/Tests directed toward suspected dxs
Shock
Case 1
55yo male otherwise healthy who is fresh
post-op from a colon resection for CA
Called for tachycardia, hypotension,
altered mental status, and abd distension
On exam: pale, dry mucous membranes,
disoriented, abdomen is tender and tense
UOP is 15mL over past hour
What else do you want to know?
What is the most likely diagnosis?
Shock
Case 1
The one thing you want to know: Hct (Hgb)
Dx: Hemorrhagic (hypovolemic) shock
Management
ABC (need intubation? IV access?)
Wide open fluids and T&C 6 units PRBC
Should send coags when sending for CBC
Make sure its not an MI (chest pain, EKG)
Give blood & prepare for re-exploration in OR
Shock
Case 2
75yo male PMH CAD, PVD, DM who is
post-op from AAA repair complains of
crushing substernal chest pain
Vitals: SBP 80/50
Pale, diaphoretic, cool & clammy on exam

What do you do?
What is the diagnosis?
Shock
Case 2
ABC, get good access, continuous monitor
Stat 12-lead EKG shows ST elevation in 2
contiguous leads
Dx: Cardiogenic shock 2ndary to STEMI
Treatment: MONA
Oxygen, Aspirin, Nitroglycerin, Morphine
Beta-blockade (no heparin or tPA due to surg)
Stat cardiology consult for cardiac cath
Shock
Case 3
60yo male heavy drinker brought in by
EMS with nausea, vomiting, severe
epigastric pain radiating to the back
Tachycardic, hypotensive
Altered mentation, dry mucous
membranes, minimal UOP after Foley
What is the most likely diagnosis?
Differential diagnosis?
How do you manage this patient?
Shock
Case 3
Acute pancreatitis
DDx of acute abdomen: Perforated viscus,
acute mesenteric ischemia, cholecystitis,
SBO, Ruptured AAA, MI
Hypovolemic shock from vomiting and
Distributive shock from the inflammation:
vasodilation, vasopermeability (3
rd
-space)
These pts require heavy, heavy fluid resus
Treatment: Push heavy fluids, NPO, NGT
Can feed post-pyloric, consider CT scan
Shock
Case 4
55yo male also post-op from colon
resection for CA, epidural placed for post-
operative pain control
Called by nurse for hypotension and
bradycardia
Abdomen soft, no pallor, altered mentation
Hct is 38
Most likely diagnosis?
Shock
Case 4
Neurogenic shock 2ndary to epidural
Differentiated from hypovolemic due to
bradycardia
Treatment is:
IVF
Turn down or turn off epidural
If BP does not respond, then alpha-agonist
such as phenylephrine until above measures
stabilize patient, then wean the vasopressor
Shock
Case 5
25yo male presents with diffuse abdominal
pain of 1day duration, started initially as
epigastric pain after a meal. Takes
ibuprofen 3x a day.
Vitals: hypotensive, tachycardic
Tense abdomen, involuntary guarding,
altered mental status, oliguric
What is the diagnosis & management?
Shock
Case 5
Septic shock 2ndary to perf duodenal ulcer
This patient has diffuse peritonitis
Management:
ABC, IV & resuscitation (requires heavy fluids)
Broad-spectrum IV antibiotics
Emergent OR for ex-lap, washout & repair
If pt does not respond to fluids, may need
vasopressors (norepinephrine, dopamine)
Have beta-agonist effects to help pump function as
well as alpha-agonist for periph vasoconstriction
Shock
Take Home Points
Shock = poor tissue perfusion/oxygenation
Know difference btw compensated/uncomp shock
3 types are based on physiology of shock
Hypovolemic due to decreased preload
Cardiogenic due to decreased SV or CO
Distributive due to decreased SVR
Know the common signs a/w shock
Oliguria, AMS, cool/clammy skin, acidosis
Work-up & management starts with ABC
Aggressive resuscitation except if cardiogenic
Vasopressors if hypotensive despite fluids