Shock pathophysiology and management

Outline
Definition

Epidemiology
Physiology Classes of Shock Clinical Presentation Management Controversies

Definition
A physiologic state characterized by

Inadequate tissue perfusion

Clinically manifested by

Hemodynamic disturbances Organ dysfunction

Epidemiology
Mortality

Septic shock 35-40% (1 month mortality) Cardiogenic shock 60-90% Hypovolemic shock variable/mechanism

Pathophysiology
Imbalance in oxygen supply and demand Conversion from aerobic to anaerobic

metabolism Appropriate and inappropriate metabolic and physiologic responses

Pathophysiology
Cellular physiology Cell membrane ion pump dysfunction Leakage of intracellular contents into the extracellular space Intracellular pH dysregulation Resultant systemic physiology Cell death and end organ dysfunction MSOF and death

Physiology
Characterized by three stages

Preshock (warm shock, compensated shock) Shock End organ dysfunction

Physiology
Compensated shock

Low preload shock tachycardia, vasoconstriction, mildly decreased BP Low afterload (distributive) shock peripheral vasodilation, hyperdynamic state

Pathophysiology
Shock

Initial signs of end organ dysfunction

Tachycardia Tachypnea Metabolic acidosis Oliguria Cool and clammy skin

Physiology
End Organ Dysfunction

Progressive irreversible dysfunction

Oliguria or anuria Progressive acidosis and decreased CO Agitation, obtundation, and coma Patient death

Classification
Schemes are designed to simplify complex

physiology Major classes of shock

Hypovolemic Cardiogenic Distributive

Hypovolemic Shock
Results from decreased preload Etiologic classes

Hemorrhage - e.g. trauma, GI bleed, ruptured aneurysm Fluid loss - e.g. diarrhea, vomiting, burns, third spacing, iatrogenic

Hypovolemic Shock
Hemorrhagic Shock
Parameter Blood loss (ml) Blood loss (%) I <750 <15% II 7501500 1530% III 15002000 3040% IV >2000 >40%

Pulse rate (beats/min) Blood pressure

<100 Normal

>100 Decreased

>120 Decreased

>140 Decreased

Respiratory rate (bpm)

1420

2030

3040

>35

Urine output (ml/hour) CNS symptoms

>30 Normal

2030 Anxious

515 Confused

Negligible Lethargic

Cardiogenic Shock
Results from pump failure

Decreased systolic function Resultant decreased cardiac output Myopathic Arrhythmic Mechanical Extracardiac (obstructive)

Etiologic categories

Distributive Shock
Results from a severe decrease in SVR

Vasodilation reduces afterload May be associated with increased CO Sepsis Neurogenic / spinal Other (next page)

Etiologic categories

Distributive Shock
Other causes

Systemic inflammation pancreatitis, burns Toxic shock syndrome Anaphylaxis and anaphylactoid reactions Toxin reactions drugs, transfusions Addisonian crisis Myxedema coma

Distributive Shock
Septic Shock
SIRS 2 or more of the following: Temp >38 or <36 HR > 90 RR > 20 WBC > 20K >10% bands SIRS in the presence of suspected or documented infection Sepsis with hypotension, hypoperfusion, or organ dysfunction Sepsis with hyotension unresponsive to volume resuscitation, and evidence of hypoperfusion or organ dysfunction Dysfunction of more than one organ

Sepsis Severe Sepsis Septic Shock MODS

Clinical Presentation
Clinical presentation varies with type and

cause, but there are features in common Hypotension (SBP<90 or Delta>40) Cool, clammy skin (exceptions early distributive, terminal shock) Oliguria Change in mental status Metabolic acidosis

Evaluation
Done in parallel with treatment! H&P helpful to distinguish type of shock Full laboratory evaluation (including H&H,

cardiac enzymes, ABG) Basic studies CxR, EKG, UA Basic monitoring VS, UOP, CVP, A-line Imaging if appropriate FAST, CT Echo vs. PA catheterization

CO, PAS/PAD/PAW, SVR, SvO2

Treatment
Manage the emergency Determine the underlying cause Definitive management or support

Manage the Emergency

Your patient is in extremis tachycardic,

hypotensive, obtunded How long do you have to manage this?

Suggests that many things must be done at

once Draw in ancillary staff for support! What must be done?

Manage the Emergency

One person runs the code! Control airway and breathing Maximize oxygen delivery Place lines, tubes, and monitors Get and run IVF on a pressure bag Get and run blood (if appropriate) Get and hang pressors Call your senior/fellow/attending

Determine the Cause

Often obvious based on history Trauma most often hypovolemic (hemorrhagic) Postoperative most often hypovolemic

(hemorrhagic or third spacing) Debilitated hospitalized pts most often septic

Must evaluate all pts for risk factors for MI and

consider cardiogenic Consider distributive (spinal) shock in trauma

Determine the Cause

What if youre wrong? 85 y/o M 4 hours postop S/P sigmoid resection

for perforated diverticulitis is hypotensive on a monitored bed at 70/40

Likely causes Best actions for the first 5 minutes?

Definitive Management
Hypovolemic Fluid resuscitate (blood or

crystalloid) and control ongoing loss Cardiogenic - Restore blood pressure (chemical and mechanical) and prevent ongoing cardiac death Distributive Fluid resuscitate, pressors for maintenance, immediate abx/surgical control for infection, steroids for adrenocortical insufficiency

Controversies
IVF Resuscitation

Limited resuscitation in penetrating trauma Use of hypertonic saline resuscitation in trauma Endpoints for prolonged resuscitation Best pressors for distributive shock Most appropriate timing and use for PA catheterization or intermittent echocardiogram

Pressors

Monitoring

Cases