Shock evaluation protocol

Shock evaluation protocol

Shock definition Shock is the clinical syndrome that results from inadequate tissue perfusion.

Symptoms and signs : Oliguria, decreased mental status, decrease peripheral pulses and

diaphoresis. Clinical hypotension is usually found, i.e., mean arterial pressure 10 ug/kg/min increase BP by activation of peripheral alpha-1 receptors (2)Dobutamine (1-10 ug/kg/min)

Inotropic agent and indirect peripheral vasodilatation. (beta1>beta2>alpha1)(3)Epinephrine

Has alpha and beta-adernergic receptors, choice for anaphylactic shock. (beta1=beta2>>alpha1)(4)Norepinephrine (2-8 ug/kg/min)

Has alpha and beta receptors, is potent vaso-constricting agents

(beta1>alpha1>beta2)(5) Milrinone (0.375-0.75 ug/kg/min)

Non-catecholamine inhibitors of phophodiesterase III as inotropic and direct vasodilator.

(6)Vasopressin (0.01-0.04 U/min)Used in refractory septic shock.

(7) Phenylepherine (20-200 ug/kg/min)

Potential vasoconstrictor without inotropic effect.

Treatment guideline1.clinical sign evaluation

shock, (Cardiogenic or non-Cardiogenic)

hypotension, (Hypovolemia or non-Hypovolemia)

congestive heart failure, (Systolic/Diastolic; Acute/Chronic; Left-side/Right-side)

acute pulmonary edema,

which is most likely problem?

2.differential diagnosis A acute pulmonary edema

B volume problem

C pump problem

D rate problem (tachycardia or bradycardia) A. acute pulmonary edema-first line

Furosemide IV 0.5 to 1.0 mg/kg

Morphine IV 2 to 4 mg

Nitroglycerin SL

Oxygen/intubation as needed B. volume problem

Administer: fluids, blood transfusion, cause-specific interventions Consider vasopressors C. pump problem (cardiogenic failure)

Check blood pressure serial exam and further differential diagnosis Further pump problem differential diagnosis

According to systolic blood pressure level, divided to 5 conditions If acute pulmonary edema-second line Nitroglycerin/nitroprusside if BP>100 mmHg

Dopamine if BP=70-100 mmHg, signs/symptoms of shock

Dobutamine if BP>100 Hg, no signs/symptoms of shock If systolic BP100 mmHg Nitroglycerin 10 to 20 ug/min IV

Nitroprusside 0.1 to 5.0 ug/kg/min IV

D. If rate problem

Tachycardia evaluation treatment Anti-arrhythmia drugs or rate control, consider DC shock for hemodynamic unstable.

Bradycardia underlying diagnosis and treatment Atropine or TCP or temporary pacemaker.

further therapeutic considerations

Pulmonary artery catheter.

Intra-aortic balloon pump.

Angiography for AMI/ischemia.

Emergent CABG or other surgery.

Additional diagnosis studies.

Indication of intra-aortic balloon counterpulsation

1. Cardiogenic shock.

2. Refractory unstable angina.

3. Acute MI catheter-based reperfusion.

4. High-risk percutaneous revascularization.

5. End-stage cardiomyopathy/bridge to cardiac transplantation.

6. Support during noncardiac surgery.

7. Mechanical complications of acute MI.

8. Decompensated aortic stenosis.

9. Refractory ventricular arrhythmias.

10 weaning from cardiopulmonary bypass/postoperative pump failure.

Contraindication of intra-aortic balloon counterpulsation

1. Aortic dissection.

2. Abnormal of thoracic aneurysm.

3. Severe peripheral vascular disease.

4. Descending aortic and peripheral vascular grafts.

5. Coagulopathy of contraindication to heparin of LMWH.

6. Moderate to severe aortic insufficiency.

supplement Adrenal insufficiency if patient has septic shock with fulminant N.meningitis infection,

refractory hypotension, recent glucosteroid use, disseminated TB of AIDS.

Use hydrocortisone 50 mg IV q6h

Case sample 1

CHF with acute pulmonary edema, without cardiogenic shock (SBP>90 mmHg)

=> Tridil

=> Lasix, record I/O keep negative balance

=> diet salt control and water restriction

=> O2 therapy, keep SPO2>90%

=> Dobutamine use if systolic dysfunction or EF treat underlying organic heart disease or arrhythmia.

Case sample 2

CHF with acute pulmonary edema, and cardiogenic shock (SBP Dopamine

=> Dobutamine (C.I.90 mmHg

=> Nor-epinephrine even epinephrine use if refractory shock. => consider IABP and PA catheter. Surgical ECMO for severe cardiogenic shock

=> consider ACS possibility, further angioplasty or thrombolytic drugs if necessary.

=> treat nuderlying organic heart disease of arrhythmia.

=> O2 therapy keep SpO2>90%.

Case sample 3

AMI, inferior wall infarction with RV infarction

=> IV fluid challenge or hydration if hypotension of shock.

=> avoid overuse nitrate, lasix and morphine.

=> anticoagulant drugs and antiplatelet drugs.

=> consider angioplasty or thrombolytic drug use.

=> inotropic drugs use (Dopamine or Dobutamine)

=> watch out high-degree AV block and TCP or TPM if necessary .Case sample 4

Massive pulmonary embolism or cardiac tamponade compressive cardiogenic shock

=> emergent heart echo followed up

=> IV fluid hydration

=> inotropic agent use (dopamine or levophed) if necessary

=> pericardiocentesis for tamponade

=> thrombolysis for massive pulmonary embolism or consult CVS for thrombectomy.

=> O2 therapy keep Spo2 >90%

=> Anti-coagulant drugs use for pulmonary embolism.

Case sample 5

Severe inflammatory refractory sepsis with septic shock

=> on CVP or PA catheter

=> fluid supplement

=>Dopamine

=>Levophed

=> Broad-spectrum antibiotic drugs use.

=> Find out infection source and species