Clinical Evaluation Of Shock Flashcards
4 major types of shock
Hypovolemic: loss of total volume
- hemorrhagic
- fluid loss
Obstructive: blocking the pump/ systemic circulation
- PE
- pneumothorax
- cardiac tamponade
- valvular heart disease
Distributive: pathogenic vasodilation
- anaphylaxis
- sepsis
- neurogenic
Cardiogenic: loss of pump function
- ACS
- VHD
- arrhythmias
all shock presents w/ a base mortality of approx. 20%
Obvious symptoms of shock
Hemorrhage/fluid loss
Muffled heart sounds
Intense chest pains
Dyspnea even at rest
Leg edema
Hives/body selling
Fever/infection
Subtle symptoms of shock
No focal complaints w/ vague symptoms (usually systemic)
Widespread systemic fatigue
“I dont feel well or dont look the same”
Classic presentation of shocks
Typically pale/cool skin
- if cardiogenic or sepsis, can be hot/wet
Confused/fatigue/malaise
Poor pulses (even pulseless sometimes
Altered mental status
*NOTE: don’t look at just vital signs(especially BP), early shock will look normal especially in children
Shock index
HR/SBP
Normal is 0.5-0.7
- anything over 1.0 is very bad and is shock (usually cardiogenic)
Criteria for circulatory shock
- you need @ least 4 of these, but not all 6*
1) ill appearing or altered mental status
2) HR > 100/min
3) RR > 20/min
4) lactate > 4mm/L
5) urine output <0.5mL/hour
6) hypotensive for longer than 30 min
Labs for shock
CBC
CMP
PT/PTT
Urine/pregnancy tests
ABG (measures pH/acidity/O2 sat/CO2 levels in blood)
Lactate
Imagining for types of shock
Sepsis = CT or ultrasound fo the following
- pelvic
- abdominal and chest
Cardiogenic = echo and ECG
- also get cardiac enzymes
Obstructive = echo
- also get a CTPA (pulmonary angiogram)
Differences between the 4 types of shock
pay attention to SVR and CVP
Cardiogenic
- massive decreased heart contractility
- elevated Central venous pressure
- elevated SVR
Hypovolemic
- normal contractility
- massive decrease in central venous pressure
- increased SVR
Sepsis (distributive)
- normal contractility
- massive decrease in central venous pressure
- decrease in SVR
Obstructive
- normal contractility
- normal Central venous pressure
- either increased (tamponade or PE) or decreased (tension PTX) SVR
Systemic inflammatory response syndrome (SIRS) vs sepsis
SIRS:
- usually occurs w/ stress and is not always life threatening (ex: exercise)
- temperature will be greater than 38C or less than 36C
- elevated HR and RR w/ very widespread WBC levels
Sepsis:
- SIRS + a source of infection present
- there must be a source of infection!!
Severe sepsis:
- sepsis w/ organ dysfunction and/or hypotension
Septic shock:
- severe sepsis w/ persistent hypotension and organ dysfunction despite fluid resuscitation w/ vasopressin
Cardiogenic failure vs shock
Failure = loss of forward flow (can’t pump)
- dyspnea angina tachycardia and edema is present
- may also show cyanosis
Shock = failure w/ end-organ damage
- has 4 circulatory shock symptoms
- 40% of myocardium is involved
- seen in ACS, MIs and myocarditis
General steps for Treatment of shock
DONT WAIT FOR RESULTS
- however must recognize shock vs SIRS
1) get safety net immediately (o2 and IV)
2) control hemorrhage and fluid loss
3) consult w/ respective physician based on shock
Pharmacological treatment of shock
1) volume replacement
- 30mL/kg unless POCUS shows not fluid response (move to #2 early)
2) vasopressors
- norepinephrine is usually the best (especially for sepsis)
3) inotropic agents
- dobutamine is used for cardiogenic shock
- MUST use in conjunction w/ norepinephrine to prevent hypotension
4) Antibiotics
- broad spectrum agent immediately (dont wait for cultures)
- use specific spectrum once culture results get back
5) corticosteroids
- ONLY use in patients who are chronically on steroids for other conditions
Caveats for treatment of shock
1) needing to intubate a patient
- must be careful for hypotension (making epinephrine ineffective)
- in this case, use ketamine
2) determine if patient is fluid responsive or not responsive
- normal saline is used immediately if 100% certain will be fluid responsive
- lactate ringers is almost always better and has to be used for non responsive patients
- dont worry about hypokalemia (especially with lactate ringers)
3) determine if needing to get surgery
- cardiogenic shock especially usually requires PCI
- if so, CANT give vasopressors
4) determine if a special procedure must be done first for a specific reason
- example = PE must get TPA immediately before anything else
- tension PTX would need a middle and chest tube immediately before anything
When is treatment of shock done (disposition)?
Normal or stable hemodynamics
Lactate has decreased to normal levels (140-280 mL)
- need to see lactate decrease by 50% at least within 2-3 hrs
Normal volume status
Maximal tissue oxygenation (<96%)
Normal metabolic status (especially pH in blood is normal)
