Shock Management

Erin Burrell, ACNP-BCSurgical ICU Nurse Practitioner

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-biology-folder/Links/Shock.utd.pdf

Three Types of Shock

• Cardiogenic• Hypovolemic• Distributive– Septic– Anaphylactic– Neurogenic

• 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

What kind of shock does this patient have?

A. CardiogenicB. HypovolemicC. Distributive

Cardiogenic Shock• Shock caused as a result of cardiac pump

failure– Results in a decrease in CO– SVR is increased in an effort to compensate to

maintain organ perfusion– Causes:

• Myocardial Infarction• Arrythmias (Atrial fibrillation, ventricular tachycardias,

bradycardias, etc)• Mechanical abnormalities (valvular defects)• Extracardiac abnormalities (PE, pulm HTN, tension pneumothorax)

Medscape Reference. 1994 (Online accessed 22 August 2013) URL: http://emedicine.medscape.com/article/152191-treatment#showall

What information do you have to suggest that Mrs. C has cardiogenic shock?

A. HypotensionB. Evidence of MIC. Altered Mental

StatusD. All of the aboveE. Both A. and B.

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.

What kind of shock does this patient have?

A. CardiogenicB. HypovolemicC. Distributive

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/760145-treatment#2

What information do you have to suggest that Mr. H has hypovolemic shock?

A. Recent traumaB. WBC 12.3C. Hgb 6.7D. All of the aboveE. Both A. and C.

Treatment of Hypovolemic Shock• Maximize oxygen delivery• Control further blood loss–Tourniquets–Surgical intervention

• 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

What kind of shock does this patient have?

A. CardiogenicB. HypovolemicC. Distributive

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-biology-folder/Links/Shock.utd.pdf

What information do you have to suggest Mr. S has distributive shock?

A. SpO2 94% on 4 L NCB. Anastamotic leak on

CT scanC. WBC 20.1D. All of the aboveE. Both B. and C.

Treatment of Septic Shock• Resuscitate– 30cc/kg of NS bolus

• Identify Source– Pan cultures– CT scan– Line removal– Foley removal– Surgical exploration

• AntibioticsDellinger, R et al. Surviving Sepsis Campaign: International Guidelines for Management

of Severe Sepsis and Septic Shock:2012, 41: 580-637, 2013.

Treatment of Anaphylactic Shock• Remove offending agent• Establish an airway and return circulation• Pharmacologic support:– Epinephrine – reverses peripheral vasodilation, dilates

bronchial airways, increases myocardial contractility, and suppresses histamine/ leukotriene release

– Antihistamine (benadryl) – may help counter histamine-mediated vasodilation and bronchoconstriction

– Corticosteroids (hydrocortisone) – may help shorten reaction

– BronchodilatorsSoar, J et al. 2013 (Online Accessed on 22 August 2013) URL:

http://www.resus.org.uk/pages/reaction.pdf

Treatment of Neurogenic Shock• Establish an airway to maintain adequate

oxygenation and ventilation• Fluid resuscitation for MAP>65mmHg• Inotropic support– Dobutamine– Dopamine

• Atropine for severe bradycardia• High dose methylprednisolone therapy

Emergency Medicine. 2009 (Online Accessed on 22 August 2013) URL: http://emergencymed.wordpress.com/2009/03/11/neurogenic-shock/

All three types of shock can occur at the same time to have a combined shock picture.

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

Case Study cont..• The Surgical ICU team places a MAC with PAC

to obtain further data about the patient’s hemodynamic status.

• PAC numbers: PAP 18/6, CVP 1, PCWP 2, CI 1.7, SVR 615

What type of shock does this patient have?

A. CardiogenicB. HypovolemicC. DistributiveD. All of the Above

What information leads you to believe Mrs. D has a component of cardiogenic shock?

A. BP 82/41B. Temp 102.8C. CI 1.7 L/minD. Cr 2.82

What information demonstrates a component of hypovolemic shock?

A. CVP 1 mmHgB. PCWP 2 mmHgC. SVR 615

dynes/sec/cm-5D. PAP 18/6 mmHgE. Both A. B. and D.

What information indicates a degree of distributive shock?

A. PCWP 2 mmHgB. SVR 615

dynes/sec/cm-5 C. PAP 18.16 mmHgD. WBC 1.1

Mrs. S is suffering from distributive septic shock along with cardiogenic and hypovolemic shock.

A. TrueB. False

Case Study cont..• The Surgical ICU team starts by giving Mrs. S a

2L NS bolus and 1L 5% Albumin bolus• Vitals: HR 114, BP 89/45, Remains intubated

on SIMV/PRVC 60% FiO2, Febrile 101.7• Labs: WBC 3.4, Hgb 7.4, BUN 72, Creat 3.21,

Lactate 2.1• Broad spectrum ABX are started immediately

upon arrival• PAC numbers after the initial resuscitation:– PAP 22/10, CVP 9, PCWP 11, CI 1.5, SVR 682

Mrs. S. continues to have a combined shock of hypovolemic, distributive, and cardiogenic shock.

A. TrueB. False

Mrs. S continues to suffer from cardiogenic and distributive septic shock as evidence by the following:

A. CI 1.5 L/minB. SVR 682

dynes/sec/cm-5C. Both A. and B.

As an intensivist, what treatment should be implemented next?

A. More fluid resuscitationB. Initiate vasopressor

supportC. Initiate inotropic

supportD. No change in current

therapy

E. Both B. and C.

Case study cont..• After initiating milrinone and levophed

therapy, Mrs. S improves. • Vitals: HR 93, BP 122/61, Intubated on

PS/CPAP 40%, Afebrile. Levophed at 4mcg/min and Milrinone at 0.375mcg/kg/min

• PA numbers: PAP 24/10, CVP 12, PCWP 14, CI 3.6, SVR 1120

Case study cont..• The Surgical ICU team decides to attempt to

wean vasopressor support first. • Mrs. S is successfully weaned off levophed

support after approximately 12 hours. • Vitals: HR 87, BP 117/58, Intubated on

PS/CPAP 40%, Afebrile. Levophed is off and Milrinone at 0.375mcg/kg/min

• PA numbers: PAP 22/14, CVP 12, PCWP 14, CI 3.4, SVR 1068

Case Study cont..• After an additional 12 hours, Mrs. S is

successfully weaned off milrinone support as well.

• She is extubated the next day and progressing well.

• On HOD 6, Mrs. S is complaining of a HA and would prefer not to take narcotics.

• Ibuprofen 200mg q6h PRN is added to HA pain.

Case Study cont..• After approximately 15 min of her first dose of

Ibuprofen, Mrs S starts to complain of difficult breathing, flushing, and airway edema.

• The bedside RN notices a new onset of hives around Mrs. S’s neck and mouth.

• Vitals: HR 147, BP 54/31, SpO2 91% on 100% NRB, Febrile 102.6.

What kind of shock is Mrs. S exhibiting?

A. CardiogenicB. HypovolemicC. Distributive

What would you include in your treatment plan?

A. Benadryl 25 mg IVB. ReintubationC. Hydrocortisone 100

mg IVD. Epinephrine 50 mcg

IVE. All of the above

Case Study cont..• Mrs. S is successfully intubated and

administered treatment for her anaphylaxis. After approximately 12hours, her symptoms have resolved. She is again extubated and progressing well.

• Mrs. S goes on to rehab and eventually home!

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/neurogenic-shock/• Gaieski et al. 2009 (Online accessed 22 August 2013)

URL:http://lijhs.sandi.net/faculty/rtenenbaum/ap-biology-folder/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