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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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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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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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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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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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Pediatric Considerations

Neonates consider congenitalobstructive left heart syndrome ascause of obstructive shock

Oliguria < 2 yrs old, urine volume

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Key Points