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Shock

Shock

Tad Kim

UF Surgery

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Shock

Overview

• Definitions• Initial Assessment – ABC

• Stages of Shock

• Physiologic Determinants of Shock

• Types of Shock

• Common Features of Shock

• H & P / Work-up

• Case scenarios and Management

• Take Home Points

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Shock

Definitions

• Shock is a physiologic state characterized

by systemic reduction in tissue perfusion,

resulting in decreased tissue oxygen

delivery

• Hypotension is not a requirement

•  Poor tissue perfusion

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Shock

Initial Assesment - ABC

•  Airway: – Does pt have mental status to protect airway?

 – GCS less than “eight” means “intubate” 

 – Airway is compromised in anaphylaxis

• Breathing:

 – If pt is conversing with you, A & B are fine

 – Place patient on oxygen

• Circulation: – Vitals (HR, BP)

 – 2 large bore (#16g) IV, start fluids (careful if

cardiogenic shock), put on continuous monitor

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Shock

 ABC “DE” 

• In a trauma, perform ABCDE, not just ABC

•  Deficit or Disability

 – Assess for obvious neurologic deficit – Moving all four extremities? Pupils?

 – Glascow Coma Scale (V6, M5, E4)

•  Exposure – Remove all clothing on trauma patients

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Shock

Stages / Spectrum of Shock

• “Preshock” aka compensated/warm shock  – Body is able to compensate for ↓perfusion 

 – Up to ~10% reduction in blood volume

 – Tachycardia to ↑cardiac output & perfusion

• “Shock” 

 – Compensatory mechanisms overwhelmed

 – See signs/symptoms of organ dysfunction

 – ~20-25% reduction in blood volume

• “End-organ dysfunction” 

 – Leading to irreversible organ damage/death

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Shock

Physiologic Determinants

• Global tissue perfusion is determined by:

• Cardiac output (CO)

 – CO = Heart rate (HR) times Stroke Volume (SV)

 – SV = function of Preload, Afterload, Contractility

• Systemic vascular resistance (SVR) – Variables: Length, Inverse of Diameter , Viscosity

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Shock

Types of Shock

•  Hypovolemic shock – from ↓preload – Hemorrhage

 – Fluid Loss (Vomiting, Diarrhea, Burns)

•  Cardiogenic shock – pump failure or ↓SV 

 – MI, arrhythmia, aortic stenosis, mitral regurg

 – Extracardiac obstructive causes such as PE,tension pneumothorax, tamponade

•  Distributive (vasodilatory) shock - ↓SVR  – Septic, anaphylactic, and neurogenic shock

 – Pancreatitis, burns, multi-trauma via activationof the inflammatory response

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Shock

Common Features of Shock

• Hypotension (not an absolute requirement) – SBP < 90mm Hg, not seen in “preshock” 

• Cool, clammy skin

 – Vasoconstrictive mechanisms to redirectblood from periphery to vital organs

 – Exception is warm skin in early distrib. shock

• Oliguria (↓kidney perfusion) •  Altered mental status (↓brain perfusion)\

• Metabolic acidosis

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Shock

H&P / Work-up

• History to determine etiology – Bleeding (recent surgery, trauma, GI bleed)

 – Allergies or prior anaphylaxis

 – Sx consistent with pancreatitis, EtOH history – Hx of CAD, MI, current chest pain/diaphoresis

• Physical examination

 – Mucous membranes, JVD, lung sounds,cardiac exam, abdomen, rectal (blood), neuro

exam, skin (cold & clammy or warm)

• Labs/Tests directed toward suspected dx’s 

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Shock

Case 1

• 55yo male otherwise healthy who is freshpost-op from a colon resection for CA

• Called for tachycardia, hypotension,

altered mental status, and abd distension• On exam: pale, dry mucous membranes,

disoriented, abdomen is tender and tense

• UOP is 15mL over past hour• What else do you want to know?

• What is the most likely diagnosis?

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Shock

Case 1

• The one thing you want to know: Hct (Hgb)

• Dx: Hemorrhagic (hypovolemic) shock

• Management – ABC (need intubation? IV access?)

 – Wide open fluids and T&C 6 units PRBC

 – Should send coags when sending for CBC

 – Make sure it’s not an MI (chest pain, EKG) 

 – Give blood & prepare for re-exploration in OR

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Shock

Case 2

• 75yo male PMH CAD, PVD, DM who is

post-op from AAA repair complains of

crushing substernal chest pain

• Vitals: SBP 80/50

• Pale, diaphoretic, cool & clammy on exam

• What do you do?

• What is the diagnosis?

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Shock

Case 2

•  ABC, get good access, continuous monitor

• Stat 12-lead EKG shows ST elevation in 2

contiguous leads

• Dx: Cardiogenic shock 2ndary to STEMI

• Treatment: “MONA” 

 – Oxygen, Aspirin, Nitroglycerin, Morphine

 – Beta-blockade (no heparin or tPA due to surg)

 – Stat cardiology consult for cardiac cath 

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Shock

Case 3

• 60yo male heavy drinker brought in byEMS with nausea, vomiting, severe

epigastric pain radiating to the back

• Tachycardic, hypotensive•  Altered mentation, dry mucous

membranes, minimal UOP after Foley

• What is the most likely diagnosis? – Differential diagnosis?

• How do you manage this patient?

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Shock

Case 3

•  Acute pancreatitis – DDx of acute abdomen: Perforated viscus,

acute mesenteric ischemia, cholecystitis,SBO, Ruptured AAA, MI

•  Hypovolemic shock from vomiting andDistributive shock from the inflammation:vasodilation, vasopermeability (3rd-space)

• These pts require heavy, heavy fluid resus• Treatment: Push heavy fluids, NPO, NGT

• Can feed post-pyloric, consider CT scan

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Shock

Case 4

• 55yo male also post-op from colon

resection for CA, epidural placed for post-

operative pain control

• Called by nurse for hypotension and

bradycardia

•  Abdomen soft, no pallor, altered mentation

• Hct is 38

• Most likely diagnosis?

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Shock

Case 4

• Neurogenic shock 2ndary to epidural

• Differentiated from hypovolemic due to

bradycardia

• Treatment is:

 – IVF

 – Turn down or turn off epidural

 – If BP does not respond, then alpha-agonistsuch as phenylephrine until above measures

stabilize patient, then wean the vasopressor

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Shock

Case 5

• 25yo male presents with diffuse abdominal

pain of 1day duration, started initially as

epigastric pain after a meal. Takes

ibuprofen 3x a day.

• Vitals: hypotensive, tachycardic

• Tense abdomen, involuntary guarding,

altered mental status, oliguric

• What is the diagnosis & management?

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Shock

Case 5

• Septic shock 2ndary to perf duodenal ulcer – This patient has diffuse peritonitis

• Management:

 – ABC, IV & resuscitation (requires heavy fluids) – Broad-spectrum IV antibiotics

 – Emergent OR for ex-lap, washout & repair

 – If pt does not respond to fluids, may needvasopressors (norepinephrine, dopamine)

• Have beta-agonist effects to help pump function as

well as alpha-agonist for periph vasoconstriction

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Shock

Take Home Points

• Shock = poor tissue perfusion/oxygenation – Know difference btw compensated/uncomp shock

• 3 types are based on physiology of shock – Hypovolemic due to decreased preload

 – Cardiogenic due to decreased SV or CO – Distributive due to decreased SVR

• Know the common signs a/w shock – Oliguria, AMS, cool/clammy skin, acidosis

• Work-up & management starts with ABC

•  Aggressive resuscitation except if cardiogenic

• Vasopressors if hypotensive despite fluids