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D. P. Laporta MDD. P. Laporta MD
SMBD-JGH SMBD-JGH
Dept of Adult Critical CareDept of Adult Critical Care
SHOCK - SHOCK - OUTLINEOUTLINE
DEFINITIONDEFINITION CAUSESCAUSES EFFECTS OF INEFFECTIVE TREATMENTEFFECTS OF INEFFECTIVE TREATMENT ASSESSMENTASSESSMENT CLINICAL APPROACHCLINICAL APPROACH
CASECASE
CASECASE
CASECASE
CASECASE
CASECASE
CASECASE
SHOCK CASESSHOCK CASES1. post Cardiac Surgery1. post Cardiac Surgery- same day- same day- 1 week postop- 1 week postop
2. in MVA victim2. in MVA victim
3. In young male with Crohn ’s 3. In young male with Crohn ’s disease found febrile in shockdisease found febrile in shock
4. In drug addict, hospital 4. In drug addict, hospital workerworker
SHOCK -SHOCK -
DEFINITIONDEFINITION
CAUSESCAUSES EFFECTS OF INEFFECTIVE TREATMENTEFFECTS OF INEFFECTIVE TREATMENT ASSESSMENTASSESSMENT CLINICAL APPROACHCLINICAL APPROACH
A profound disturbance of the circulationA profound disturbance of the circulation
and metabolism, leading to and metabolism, leading to
inadequate perfusion of vital organs,inadequate perfusion of vital organs,
necessary to maintain homeostasisnecessary to maintain homeostasis
DEFINITION
SHOCK -SHOCK -
DEFINITIONDEFINITION
CAUSESCAUSES
EFFECTS OF INEFFECTIVE TREATMENTEFFECTS OF INEFFECTIVE TREATMENT ASSESSMENTASSESSMENT CLINICAL APPROACHCLINICAL APPROACH
HYPOPERFUSED STATESHYPOPERFUSED STATES
RVRV LVLVArterial Arterial (resistance)(resistance)
Venous Venous (capacitance)(capacitance)
PVRPVR
EF End-Diastolic Volume
SVRSVR
HypovolemicHypovolemicBP 60/30BP 60/30
HR 140/minHR 140/min
CVP 0CVP 0
Lactate 10Lactate 10
CardiogenicCardiogenicBP 70/50BP 70/50
HR 130/minHR 130/min
CVP 18CVP 18
Lactate 12Lactate 12
ObstructiveObstructiveBP 70/50BP 70/50
HR 140/minHR 140/min
CVP 15CVP 15
Lactate 12Lactate 12
VTED
OAD
DLD
DistributiveDistributiveBP 70/40BP 70/40
HR 140/minHR 140/min
CVP 5CVP 5
Lactate 12Lactate 12
SHOCK -SHOCK - DEFINITIONDEFINITION CAUSESCAUSES
EFFECTS OF INEFFECTIVE TREATMENTEFFECTS OF INEFFECTIVE TREATMENT
ASSESSMENTASSESSMENT MEASUREMENTMEASUREMENT CLINICAL APPROACHCLINICAL APPROACH
EFFECTS OF INEFFECTIVE TREATMENT
MISERY !!!MISERY !!!MODSMODS
• PO2/ FiO2 ratio
• Serum creatinine
• Platelet count
• Glasgow coma score
• Serum bilirubin
• Pressure-adjusted heart rate
(hr x CVP/MAP)
INFECTIONINFECTION
SHOCK -SHOCK - DEFINITIONDEFINITION CAUSESCAUSES EFFECTS OF INEFFECTIVE TREATMENTEFFECTS OF INEFFECTIVE TREATMENT
ASSESSMENTASSESSMENT
MEASUREMENTMEASUREMENT CLINICAL APPROACHCLINICAL APPROACH
SHOCK: asssessmentSHOCK: asssessment
Class 1&2 vs 3&4Class 1&2 vs 3&4 needs blood or crystalloid ?needs blood or crystalloid ?
hypercarbia is a universal indicator of critically reduced tissue perfusion.
Sublingual capnometrySublingual capnometry: : A new noninvasive measurement for diagnosis and A new noninvasive measurement for diagnosis and
quantitation of severity of circulatory shockquantitation of severity of circulatory shock
Max Harry Weil MD, PhD, FCCM - CCM 1999Max Harry Weil MD, PhD, FCCM - CCM 1999
Sublingual capnometrySublingual capnometry: : A new noninvasive measurement for diagnosis and A new noninvasive measurement for diagnosis and
quantitation of severity of circulatory shockquantitation of severity of circulatory shock
Sublingual capnometrySublingual capnometry: : A new noninvasive measurement for diagnosis and A new noninvasive measurement for diagnosis and
quantitation of severity of circulatory shockquantitation of severity of circulatory shock
Sublingual capnometrySublingual capnometry: : A new noninvasive measurement for diagnosis and A new noninvasive measurement for diagnosis and
quantitation of severity of circulatory shockquantitation of severity of circulatory shock
P P SLSL CO CO22
provides a prompt provides a prompt indication of the indication of the reversal of tissue reversal of tissue hypercarbia hypercarbia when circulatory when circulatory shock is reversedshock is reversed
SHOCK -SHOCK -
DEFINITIONDEFINITION CAUSESCAUSES EFFECTS OF IEFFECTIVE TREATMENTEFFECTS OF IEFFECTIVE TREATMENT MEASUREMENTMEASUREMENT
CLINICAL APPROACHCLINICAL APPROACH
SHOCK: an EMERGENCY !!!SHOCK: an EMERGENCY !!!
GOAL:GOAL:
RAPIDLY RESTORE TISSUE PERFUSIONRAPIDLY RESTORE TISSUE PERFUSION
• Recognize it !!!Recognize it !!!
•Immediate stabilization: ABCImmediate stabilization: ABC
…… ……. SHOTGUN approach. SHOTGUN approach
• ICU & Surgical consultationICU & Surgical consultation
•Treat the causeTreat the cause
Management Management prioritiespriorities
in hypoperfused statesin hypoperfused states
Priority # Physiology to improve
Intervention Parameter to target PAC targets
Avoid
1 Volume Fluids CVP 10-15 DO2 Low Sao2 See CXR
2 Pressure Vasopressor SBP? 100 or within 20-25 torr MBP ? 80 of patient's Nl
Low SV, DO2 High HR, Resistances
3 Flow Inotrope Signs of perfusion DO2 Low BP, SV, Resistances
BP potency: Dopamine...NE…Vasopressin/Phenylephrine