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Diagnosis and Managementof Shock
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Objectives
Define the major types of shock and principlesof management
Review fluid resuscitation, vasopressors andinotropes Address the balance of O 2 supply and demand Discuss the differential diagnosis of oliguria
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SHK 3
Shock
Always a symptom of its cause Abnormally low organ perfusion
usually associated with decreasedblood pressure Signs of organ hypoperfusion: mental
status change, oliguria, acidosis
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Shock Categories
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Cardiogenic Hypovolemic Distributive Obstructive
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Cardiogenic Shock
Decreased contractility Increased filling pressures,
decreased LV stroke work,decreased cardiac output
Increased systemicvascular resistance
compensatory
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Hypovolemic Shock
Decreased cardiac output Decreased filling pressures Compensatory increase in
systemic vascular resistance
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SHK 7
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 etiology dependent Cardiac tamponade, tension
pneumothorax, massive
pulmonary embolus
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Cardiogenic Shock Management
Treat arrhythmias Diastolic dysfunction may
require increased fillingpressures
Vasodilators if not hypotensive Inotrope administration
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Cardiogenic Shock Management
Vasopressors if hypotensive toraise aortic diastolic pressure
Mechanical assistance Consultation
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Hypovolemic Shock
Volume resuscitation crystalloid,colloid
Initial crystalloid choices Lactated Ringers 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
Expand intravascular volume Hypotension despite volume therapy
Inotropes Vasopressors for MAP < 60 mm Hg Adjunctive antibiotics in sepsis
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Obstructive Shock Treatment
Relieve obstruction Pericardiocentesis Tube thoracostomy Treat pulmonary embolus
Temporary benefit from fluidor inotrope administration
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Therapeutic Goals in Shock Increase O 2 delivery Optimize O 2 content of blood Improve cardiac output and
blood pressure Match systemic O 2 needs with O 2 delivery Reverse/prevent organ hypoperfusion
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Fluid Therapy
Crystalloids Lactated Ringers solution Normal saline
Colloids Hetastarch Albumin
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 Agent
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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SHK 18
Inotropic Agent
Dobutamine 5-20 g/kg/min
Inotropic and variable chronotropiceffect
Decrease in systemic vascularresistance
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Inotropic / Vasopressor Agent
Norepinephrine 0.05 g/kg/min and titrate
Inotropic and vasopressor effects Potent vasopressor at high doses
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Epinephrine
Both and actions for inotropicand vasopressor effects
0.1 g/kg/min and titrate Increases myocardial O 2
consumption
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Oliguria
Marker of hypoperfusion Urine output in adults
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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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Evaluation of Oliguria
Laboratory Test Prerenal ATN
Blood Urea Nitrogen/ >20 10 20Creatinine Ratio
Urine Specific Gravity >1.020 500
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SHK 24
Therapy in Acute Renal Insufficiency
Correct underlying cause Monitor urine output Assure euvolemia Diuretics not therapeutic Low-dose dopamine? Adjust dosages of other drugs Monitor electrolytes, BUN, creatinine Consider dialysis
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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 tomore chronotropic benefit from epinephrine Fluid boluses of 20 mL/kg titrated to BP or total
60 mL/kg, before inotropes or vasopressors Pediatric dosages in text
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SHK 26
Pediatric Considerations
Neonates consider congenitalobstructive left heart syndrome ascause of obstructive shock
Oliguria < 2 yrs old, urine volume
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Key Points