SHOCK Flashcards
Types of Shock
-Hypovolemic
-Obstructive
-Cardiogenic
-Distributive
Hypovolemic Shock
-Hemorrhage, GI losses, Third spacing of fluids
-Decreased preload, diastolic filling, CO, increased SVR, decreased MAP, Shock/MODS
-Cool extremities, dry mucous membranes, flat neck veins, decreased CO, PAWP, SvO2 <65%, Increased SVR. Elevated lactate
Obstructive Shock
-Cardiac tamponade, tension ptx, PE
-Cool
-Decreased diastolic filling > decreased diastolic function > decreased CO > decreased MAP > Shock +/- MODS
-Increased ventricular afterload > decreased systolic function > decreased CO > Decreased MAP > Shock +/- MODS
-Impede venous return: Tension PTX, tamponade, restrictive pericarditis, auto-peep
–Obstruct cardiac outflow: PE, venous air embolism, aortic dissection
-TTE is the standard for dx
-Beck’s triad: Hotn, muffled heart tones, JVD
-Cool extremities, diminished breath sounds
-Decreased CO, PAWP, increased SVR, <65% Svo2, elevated lactate
Cardiogenic Shock
-MI, Stress cardiomyopathy, myocardial depression
-Parameters: persistent hotn SBP <80-90 or MAP 30 lower than baseline. CI <1.8 w/out support, or <2-2.2 with support. adequate and elevated filling pressures. End organ hypoperfusion (Urine output < 30 mL/h or cool extremities)
-ACS is still the most common etiology and accounts for ~80% of cardiogenic shock
Distributive Shock
-Sepsis, neurogenic, anaphylactic
-Decreased SVR, preload, diastolic filling, CO, decreased MAP, Shock/MODS
-Distributive shock is secondary to another process
-Warm extremities, dry mucous membranes, flat neck veins, febrile, decreased CO, PAWP, SVR. Svo2 >65%. Elevated lactate, leukocytosis, cultures positive
Neurogenic Shock (vasogenic shock)
-Combo of primary and secondary injuries that lead to loss of sympathetic tone and thus unopposed parasympathetic response driven by the vagus nerve.
-Consequently, patients suffer from instability in blood pressure, heart rate, and temperature regulation.
-symptoms: hotn, bradyarrhythmia’s, temp dysregulation
Prognosis of Neurogenic Shock
Prognosis: depends on the extent of spinal cord injury (ASIA) and response to treatment. Those associated with neurological deficits tend to have poor outcomes.
Neurogenic Shock Management
-Management of hemodynamics w/ fluids and pressors
-Recommend MAP 85-90 for first 7 days to improve spinal cord perfusion
-Phenylephrine is commonly used as its pure alpha 1 agonist that causes peripheral vasoconstriction to counteract the loss of sympathetic tone. —-lack of beta activity leads to reflex bradycardia
-Norepinephrine (both alpha and beta)
-Tx of bradycardia is atropine and glycopyrrolate to oppose vagal tone.
-Isoproterenol is considered for pure chronotropic effect
-Methylxanthines (theophylline and aminophylline) have been cited for refractory bradycardia
-Methylprednisolone and corticosteroids showed promised in animal modes
-Symptoms of neurogenic shock can persist for 4-5 weeks
Definition of severe sepsis
-Severe sepsis: Sepsis definition plus any evidence of organ dysfunction including altered mental status (brain hypoperfusion), renal failure, liver dysfunction, tissue hypoperfusion (diminished capillary refill), and/or lactic acid level >4.0
Definition of septic shock
-persistent hypotension despite adequate fluid resuscitation + sepsis + end-organ hypoperfusion/dysfunction
Management of Obstructive Shock
-Pericardial effusion: IV fluids, vasopressor, pericardiocentesis, pericardiostomy
-PE: IV fluids, AC, massive versus submassive (systemic lysis, surgical embolectomy, catheter directed thrombolysis), risk stratification
Which Fluid?
-Crystalloid: LR, NS -30 mls/kg
-Colloid: Albumin, RBC
-Semisynthetic colloids: Hetastarch, Succinylated gelatin
Toxic Shock Syndrome
“Toxic shock syndrome is a rare, life-threatening complication of certain types of bacterial infections.”
-Staphylococcus aureus–Treated w/ combo of antistaphylococcal penicillin plus clindamycin
-Streptococcus pyogenes (group A)-treated with a combination of penicillin plus clindamycin
-Rapid recognition and medical/surgical therapy is required
-Rapid progression, especially streptococcal disease
-80% of streptococcal-caused infections have soft tissue involvement
-IV immunoglobulin may improve outcomes
Surviving Sepsis Campaign
- EARLY IDENTIFICATION IS KEY!
qSOFA is out. SIRS/NEWS/MEWS are in!
Measure a lactate on those suspected of having sepsis. - EARLY TREATMENT IS KEY!
For those with hypoperfusion or shock, at least 30 ml/kg of crystalloid should be given within the first three hours of resuscitation. Resuscitation to be guided by decrease in serum lactate versus. not using a serum lactate - Main pts of treatment
“Balanced” crystalloid over normal saline.
Norepinephrine, vasopressin, and epinephrine
Broad spectrum antibiotics based on risk factors
Source control
Cardiogenic Shock: Cold and Wet
-Classic cardiogenic shock
-decreased CI
-Increased PCWP, SVRI
-Levophed, Dopamine
-Iontropes only after revascularization
Cardiogenic Shock: Dry and cold
-Euvolemic cardiogenic shock
-decreased CI
-Increased SVRI, PCWP
-Fluid boluses 250-500 mL
-Norepinephrine or Dopamine
-Inotropes – Dobutamine, Milrinone, Epinephrine
Cardiogenic Shock Wet and Warm
-Vasodilatory cardiogenic shock or mixed shock
-decreased CI, SVRI
-Increased PCWP
-Norepinephrine or Dopamine
-PA catheter guided therapy
Cardiogenic Shock Warm and Dry
-Vasodilatory shock (non-cardiogenic shock)
-increased CI
-Decreased SVRI, PCWP
Neurogenic Shock Etiology
-Neurogenic shock is a devastating consequence of spinal cord injury (SCI), also known as vasogenic shock
-Sudden loss of sympathetic tone: hotn, temperature dysregulation, bradyarrhythmias
Colloid Albumin
Suggested in Liver Disease, but still suggest 30 mls/kg of crystalloid first.
Consider 7 mls/kg of 5% after 30 mls/kg of crystaloid
Fluid Resuscitation: Vasopressors
-Norepinephrine 0.05 mcg/kg/min Recommended
-Vasopressin 0.03 units/min
-Phenylephrine 0.5 mcg/kg/min
-Epinephrine 0.05 mcg/kg/min
For pressor resistant hypotension start Hydrocortisone 50 mg IV q6h STAT
Monitoring During Shock with Fluid Resuscitation
-Monitor urine output every hour
-Trend 3 Lactates the first 6 hours
Initial
-After 30 mls/kg
-2nd bolus and or pressors
-Consider monitoring CVP
-Eary abx is essential
Abx Pneumonia
CAP
-Rocephin, Levaquin
-Ceftriaxone, Azithromycin
-MRSA Concern? Add vancomycin
Healthcare Associated
-Vancomycin, Zosyn, Atypical coverage
-Cefepime/Flagyl are replacing Zosyn in many Kidney Injury/CKD patients
Intra-abdominal Abx
Community Acquired
-Rocephin and Flagyl
Healthcare Associated
-Zosyn or Ceftriaxone
-Hx MRSA? Add Vancomycin
Urinary Abx
-Urosepsis is no longer used.
Community Acquired
-Zosyn
Healthcare Associated
-Zosyn
Hx MRSA? Vancomycin
Soft Tissue Abx
Necrotizing
-Zosyn, Clindamycin, and Vancomycin
-Cefepime/Flagyl are replacing Zosyn in many Kidney Injury/CKD patients
Non-surgical wounds
-Zosyn and Vancomycin
-Cefepime/Flagyl are replacing Zosyn in many Kidney Injury/CKD patients
Cellulitis
-Vancomycin
Goals of Cardiogenic Shock Management
-Address the etiology
-Preload reduction
-Afterload reduction
-Ionotropic support
-Mechanical support
Management of cardiogenic shock
-Preload: Gentle 250-500 mL fluid bolus with careful hemodynamic monitoring
-Oxygenation: Goal saturation >92%, consider early intubation to decrease work of breathing
-Arrhythmias
-DC cardioversion of tachyarrhythmias
-Transvenous pacing of bradyarrhythmias
-Discontinue anti-hypertensives
-Usually avoid vasopressin and phenylephrine unless vasodilatory shock, outflow obstruction or pure RV failure
-Caution with rate-control in regurgitant lesions
-Consider pacing/cardioversion as a hemodynamic stabilization adjunct
