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Diagnosis and Management

of Shock

dr. Rudi, Sp.An

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Objectives

• Identify the major types of shock and principles of

management

•

Review fluid resuscitation and use of vasopressor andinotropic agents

• Understand concepts of O2 supply and demand

• Discuss the differential diagnosis of oliguria

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Shock

• Always a symptom of primary cause

• Inadequate blood flow to meet tissue oxygendemand

• May be associated with hypotension

• Associated with signs of hypoperfusion: mentalstatus change, oliguria, acidosis

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  Shock Categories

• Cardiogenic

• Hypovolemic• Distributive

• Obstructive

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Cardiogenic Shock

• Decreased contractility

• Increased filling pressures, decreased LV

stroke work, decreased cardiac output

• Increased systemic

vascular resistance – compensatory

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Hypovolemic Shock

• Decreased cardiac output

• Decreased filling pressures

• Compensatory increase in

systemic vascular resistance

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Distributive Shock

• Normal or increased cardiac output

• Low systemic vascular resistance

• Low to normal filling pressures

• Sepsis, anaphylaxis, neurogenic,

and acute adrenal insufficiency

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Obstructive Shock

• Decreased cardiac output

• Increased systemic vascular

resistance

•

Variable filling pressures dependenton etiology

• Cardiac tamponade, tension

pneumothorax, massive pulmonary

embolus

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Cardiogenic Shock Management

• Treat arrhythmias

• Diastolic dysfunction may require

increased filling pressures

• Vasodilators if not hypotensive

• Inotrope administration

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Cardiogenic Shock Management

• Vasopressor agent needed if

hypotension present to raise aortic

diastolic pressure

•

Consultation for mechanical assistdevice

• Preload and afterload reduction to

improve hypoxemia if blood pressure

adequate

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Hypovolemic Shock

Management

• Volume resuscitation – crystalloid, colloid

• Initial crystalloid choices

 – Lactated Ringer’s solution 

 – Normal saline (high chloride may produce

hyperchloremic acidosis)

• Match fluid given to fluid lost

 – Blood, crystalloid, colloid

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Distributive Shock Therapy

• Restore intravascular volume

• Hypotension despite volume therapy

 – Inotropes and/or vasopressors

• Vasopressors for MAP < 60 mm Hg

• Adjunctive interventions dependent onetiology

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Obstructive Shock Treatment

• Relieve obstruction

 – Pericardiocentesis

 – Tube thoracostomy

 – Treat pulmonary embolus

• Temporary benefit from fluid or

inotrope administration

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Fluid Therapy

• Crystalloids – Lactated Ringer’s solution 

 – Normal saline

• Colloids

 –Hetastarch

 – Albumin

 – Gelatins

• Packed red blood cells

•

Infuse to physiologic endpoints

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Fluid Therapy

• Correct hypotension first

• Decrease heart rate

•

Correct hypoperfusion abnormalities• Monitor for deterioration of oxygenation

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Inotropic / Vasopressor Agents

• Dopamine

 – Low dose (2-3 g/kg/min) – mild inotrope

plus renal effect

 – Intermediate dose (4-10 g/kg/min) – inotropic effect

 – High dose ( >10 g/kg/min) – vasoconstriction

 –

Chronotropic effect

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Inotropic Agents

• Dobutamine

 – 5-20 g/kg/min

 – Inotropic and variable chronotropic effects

 – Decrease in systemic vascular resistance

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Inotropic / Vasopressor Agents

• Norepinephrine

 – 0.05 g/kg/min and titrate to effect

 – Inotropic and vasopressor effects

 – Potent vasopressor at high doses

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Inotropic / Vasopressor Agents

• Epinephrine

 – Both  and  actions for inotropic and

vasopressor effects

 – 0.1 g/kg/min and titrate

 – Increases myocardial O2 consumption

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  Therapeutic Goals in Shock

• Increase O2 delivery

• Optimize O2 content of blood

• Improve cardiac output and

blood pressure

• Match systemic O2 needs with O2 delivery

• Reverse/prevent organ hypoperfusion

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Oliguria

• Marker of hypoperfusion• Urine output in adults

<0.5 mL/kg/hr for >2 hrs

•

Etiologies – Prerenal

 – Renal

 –

Postrenal

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Evaluation of Oliguria 

• History and physical examination

• Laboratory evaluation

 – Urine sodium

 – Urine osmolality or specific gravity

 – BUN, creatinine

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Therapy in Acute Renal Insufficiency

• Correct underlying cause

• Monitor urine output

• Assure euvolemia

• Diuretics not therapeutic

•Low-dose dopamine may  urine flow

• Adjust dosages of other drugs

• Monitor electrolytes, BUN, creatinine

• Consider dialysis or hemofiltration

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Pediatric Considerations

• BP not good indication of hypoperfusion

• Capillary refill, extremity temperature better

signs of poor systemic perfusion

• Epinephrine preferable to norepinephrine due to more

chronotropic benefit

• Fluid boluses of 20 mL/kg titrated to BP or total 60

mL/kg, before inotropes or vasopressors

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Pediatric Considerations

• Neonates – consider congenital

obstructive left heart syndrome as cause of

obstructive shock

• Oliguria – <2 yrs old, urine volume <2 mL/kg/hr

 – Older children, urine volume

<1 mL/kg/hr

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