SHOCK SHOCK

By Dr Sneha KhobragadeBy Dr Sneha Khobragade

Guided by Dr Deepak Guided by Dr Deepak RuparelRuparel

GMC NagpurGMC Nagpur

Definition of ShockDefinition of Shock Inadequate tissue perfusion to meet Inadequate tissue perfusion to meet

tissue demandstissue demands

Usually result of inadequate blood Usually result of inadequate blood flow and/or oxygen deliveryflow and/or oxygen delivery

What is Shock?What is Shock?

pathophysiologypathophysiology

CLASSIFICATIONCLASSIFICATION

CAUSE?CAUSE?

Cause?Cause?Cardiogenic shock

Hypovolemic shock

Septic shock

Pulse pressure Decreases Decreases IncreasesDiastolic pressure Decreases Decreases DecreasesExtremities Cool Cool WarmNailbed blood return Slow Slow Rapid

Jugular venous pressure

Increases Decreases Decreases

Respiratory creptitions +++ - -

S3,S4 gallop rhythm +++ - -Chest radiograph Large heart,

Pulmonary edema

Diminished cardiac size

Normal,unless pneumonia presesnt

Identified site of infection

- - +++

Cause?Cause?

Hypovolemic shockHypovolemic shock

Decrease circulating blood volumeDecrease circulating blood volume

ClassificationClassification

Compensation – increase endogenous Compensation – increase endogenous

catecholaminescatecholamines Increase HR – increase C.O., O2 deliveryIncrease HR – increase C.O., O2 delivery Increase SVR – increase BP (esp Increase SVR – increase BP (esp

diastolic)diastolic) Lactic acidosisLactic acidosis Increase in serum lactate- early indicator Increase in serum lactate- early indicator

of tissue hypoperfusionof tissue hypoperfusion

Aim- reverse organ hypoperfusionAim- reverse organ hypoperfusion ( Optimizing the tissue o2 delivery)( Optimizing the tissue o2 delivery) - requires sufficient hemoglobin - requires sufficient hemoglobin

concentrationconcentration - adequate intravascular volume- adequate intravascular volume - dobutamine (despite adequate preload, - dobutamine (despite adequate preload,

cardiac output is not sufficient) cardiac output is not sufficient)

Determinants of Oxygen DeliveryDeterminants of Oxygen Delivery

Oxygen content = 1.34 (Hb x SaO2) + (PaO2 Oxygen content = 1.34 (Hb x SaO2) + (PaO2 x 0.0031)x 0.0031)

SaO2: arterial hemoglobin Oxygen saturationSaO2: arterial hemoglobin Oxygen saturation Hb: Hemoglobin concentrationHb: Hemoglobin concentration PaO2: arterial oxygen tensionPaO2: arterial oxygen tension

To improve Oxygen contentTo improve Oxygen content Increase Hemoglobin concentrationIncrease Hemoglobin concentration Increase saturationIncrease saturation

Cardiac outputCardiac output

C.O. = Heart rate x stroke volumeC.O. = Heart rate x stroke volume To improve Cardiac outputTo improve Cardiac output

Increase Heart rateIncrease Heart rate Increase Stroke VolumeIncrease Stroke Volume

Preload – volume of blood in the ventriclePreload – volume of blood in the ventricle Afterload – resistance to contractionAfterload – resistance to contraction Contractility – force appliedContractility – force applied

ManagementManagement Goal : Goal : 1. control the source of hemorrhage1. control the source of hemorrhage 2. administer adequate intravascular volume 2. administer adequate intravascular volume replacementreplacement Clinical picture:Clinical picture: - SBP <90 mm hg- SBP <90 mm hg - MAP <60 mm hg- MAP <60 mm hg - lactate > 4 mmol/L- lactate > 4 mmol/L

simultaneouslysimultaneously

- control source of bleeding- control source of bleeding

- establish vascular access- establish vascular access (8.5 fr central venous catheter/(8.5 fr central venous catheter/ two 14 G peripheral vein catheter)two 14 G peripheral vein catheter)

Measure hemoglobinMeasure hemoglobin - > 9 g/dl - > 9 g/dl administer 0.9 NaCl / RL administer 0.9 NaCl / RL - < 9 g/dl - < 9 g/dl RBC transfusion until Hg > RBC transfusion until Hg > 9g/dl and correct any 9g/dl and correct any identified coagulation or identified coagulation or platelet abnormalitiesplatelet abnormalities

In on going hemorrhage: - administer 2 – 4 l of crystalloid - group ‘0’ blood should be given Rh - positive - men and women who are in non childbearing age Rh - negative – women in childbearing age - Type specific blood administered after first four units of non-typed blood are given - Goal – maintain hemoglobin > 9 g/dl

Adjunctive TherapiesAdjunctive TherapiesTherapy Rationale

Airway control -To provide appropriate gas exchange- to prevent aspiration

Cardiac/hemodynamic monitoring

-To identify dysrhythmias and inadequate fluid resuscitaion

Platelet/fresh frozen plasmaadminsitration

- required because of dilutional effect of crystalloid and blood- Consumption due to ongoing bleeding- Platelet count > 50,000 /mm3

Calcium chloride Magnesium chloride

-To reverse ionized hypocalcemia and hypomagnesemia resulting from administration of citrate with transfused blood

Antibiotics -When open and contaminated wounds are present

Corticosteroids -For patients presumed to have adrenal injury and unable to mount stress response

Cardiogenic ShockCardiogenic Shock

Cardiac dysfunctionCardiac dysfunctionInadequate circulationInadequate circulation

Compromised organ perfusionCompromised organ perfusion

when to say?when to say?

Prolonged hypotension (SBP< 90 mmhg) Prolonged hypotension (SBP< 90 mmhg) in settings of decreased cardiac output (< in settings of decreased cardiac output (< 1.8 L/min/m2 without support and <2.2 1.8 L/min/m2 without support and <2.2 L/min/m2 with support) despite adequate L/min/m2 with support) despite adequate intravascular volume (left ventricular end-intravascular volume (left ventricular end-diastolic pressure > 18 mm Hg and/or diastolic pressure > 18 mm Hg and/or pulmonary artery occlusion pressure >15 pulmonary artery occlusion pressure >15 mm Hg)mm Hg)

EtiologyEtiology Acute myocardial infarctionAcute myocardial infarction Mechanical causesMechanical causes Severe cardiomyopathy /congestive heart failureSevere cardiomyopathy /congestive heart failure Acute myocarditisAcute myocarditis Calcium channel or beta blocker overdoseCalcium channel or beta blocker overdose Acute /severe valvular insufficiency Acute /severe valvular insufficiency Obstruction to left ventricular outflowObstruction to left ventricular outflow Obstruction to ventricular fillingObstruction to ventricular filling

PathophysiologyPathophysiology

SymptomsSymptoms TachycardiaTachycardia TachypneaTachypnea Respiratory distressRespiratory distress Mental status changeMental status change Cool extremitiesCool extremities oliguriaoliguria

ManagementManagement

Suspected cardiogenic shockSuspected cardiogenic shockSBP< 90 mm HgSBP< 90 mm HgSigns of low cardiac output stateSigns of low cardiac output state

Initial evaluation & rapid stabilizationInitial evaluation & rapid stabilizationImmediate ECGImmediate ECGLook for evidence of AMILook for evidence of AMI

EvaluationEvaluation

Supplement oxygen/mech ventilation (for Supplement oxygen/mech ventilation (for hypoxia)hypoxia)

BP supportBP supportSBP< 90 mm Hg - dopamine (5 – 15 mcg/kg/min)SBP< 90 mm Hg - dopamine (5 – 15 mcg/kg/min)SBP< 80 mm Hg – add norepinephrineSBP< 80 mm Hg – add norepinephrine (1 – 20 mcg/kg/min) (1 – 20 mcg/kg/min) Goal MAP> 65 mm HgGoal MAP> 65 mm Hg(all pt should have intra-arterial monitoring)(all pt should have intra-arterial monitoring)

Suitable for revascularization-PCI (Infarct artery only)-emergent CABG (3V dz, L main dz, PCI not possible)

No revascularization possible-ct medical supportIf BP stableConsider inotropic support-dobutamine (2.5- 10 mcg/min)-milrinone (0.375-0.75 mcg/kg/min)Avoid in hypotension, renal failure (milrinone)

REFRACTORY SHOCK consider left ventricular assist device, transplantation evaluation

Distributive ShockDistributive Shock

Abnormal vessel toneAbnormal vessel tone(decreased afterload)(decreased afterload)

Vasodilatation Vasodilatation

Venous PoolingVenous Pooling

Decreased AfterloadDecreased Afterload

Maldistribution of regional blood flowMaldistribution of regional blood flow

Diminished or absent sympathetic toneDiminished or absent sympathetic tone

Reduce peripheral vascular toneReduce peripheral vascular tone

Peripheral pooling of blood volumePeripheral pooling of blood volume

Inadequate venous returnInadequate venous return

Decreased perfusion, acidosis, hypotensionDecreased perfusion, acidosis, hypotension

Septic ShockSeptic Shock

Terminology in SepsisTerminology in Sepsis Infection = response to micro organismInfection = response to micro organism Bacteremia = bug in bloodBacteremia = bug in blood Systemic Inflammatory Response Syndrome Systemic Inflammatory Response Syndrome

(SIRS)(SIRS) Sepsis = SIRS as response to a known Sepsis = SIRS as response to a known

infectioninfection

Terminology in SepsisTerminology in Sepsis

severe sepsis - acute organ dysfunction severe sepsis - acute organ dysfunction secondary to documented or suspected infectionsecondary to documented or suspected infection

septic shock - severe sepsis + hypotension not septic shock - severe sepsis + hypotension not reversed with fluid resuscitationreversed with fluid resuscitation Multiple Organ Dysfunction Syndrome (MODS) – Multiple Organ Dysfunction Syndrome (MODS) –

two or more organ dysfunction that requires two or more organ dysfunction that requires interventionintervention

Sepsis-induced tissue hypoperfusionSepsis-induced tissue hypoperfusion

- infection-induced hypotension,- infection-induced hypotension, - elevated lactate, - elevated lactate, - oliguria- oliguria

Recognition of Septic ShockRecognition of Septic Shock

Early – Early – warm shockwarm shock

Late – Late – Cold shockCold shock

Early vs Late Septic ShockEarly vs Late Septic Shock

EarlyEarly LateLateHeart rateHeart rate TachycardiaTachycardia Tachycardia/Tachycardia/

bradycardiabradycardiaBlood Blood pressurepressure

NormalNormal decreaseddecreased

PeripheralPeripheralPerfusionPerfusion

Warm/coolWarm/coolDec./inc. Dec./inc. pulsespulses

CoolCoolDec. pulsesDec. pulses

Early vs Late Septic ShockEarly vs Late Septic Shock

EarlyEarly LateLate

End-organ: End-organ: skinskin

Dec. cap refillDec. cap refill Very dec. capVery dec. capRefillRefill

BrainBrain Irritable, Irritable, restlessrestless

Lethargic, Lethargic, unresponsiveunresponsive

KidneysKidneys OliguriaOliguria Oliguria, Oliguria, AnuriaAnuria

Diagnosis Diagnosis General variables:General variables: 1. Fever (> 38.3°C) 1. Fever (> 38.3°C) Hypothermia (core temperature < 36°C) Hypothermia (core temperature < 36°C) 2.Heart rate > 90/min2.Heart rate > 90/min 3.Tachypnea3.Tachypnea 4. Altered mental status4. Altered mental status

5. Significant edema or positive fluid 5. Significant edema or positive fluid

balance (> 20mL/kg over 24hr) balance (> 20mL/kg over 24hr)

6. Hyperglycemia (plasma glucose > 6. Hyperglycemia (plasma glucose > 140mg/dL or 7.7 mmol/L) in the absence 140mg/dL or 7.7 mmol/L) in the absence of diabetesof diabetes

Inflammatory variables:Inflammatory variables: 1. Leukocytosis (WBC count > 12,000 µL–1) 1. Leukocytosis (WBC count > 12,000 µL–1) 2. Leukopenia (WBC count < 4000 µL–1) 2. Leukopenia (WBC count < 4000 µL–1) 3. Normal WBC count with greater than 3. Normal WBC count with greater than 10% immature forms 10% immature forms 4. Increased Plasma C-reactive protein4. Increased Plasma C-reactive protein 5. Increased Plasma procalcitonin5. Increased Plasma procalcitonin

Hemodynamic variables:Hemodynamic variables: - Arterial hypotension: - Arterial hypotension: SBP < 90mm Hg SBP < 90mm Hg MAP < 65mm HgMAP < 65mm Hg - SVO2 > 70%- SVO2 > 70% - CI > 3.5 L/min/m2- CI > 3.5 L/min/m2

Organ dysfunction variables:Organ dysfunction variables: 1. 1. Arterial hypoxemia (Pao2/Fio2 < 300) Arterial hypoxemia (Pao2/Fio2 < 300)

2. Acute oliguria (urine output < 0.5mL/kg/hr 2. Acute oliguria (urine output < 0.5mL/kg/hr for at least 2 hrs despite adequate fluid for at least 2 hrs despite adequate fluid resuscitation)resuscitation)

3. Creatinine increase > 0.5mg/dL or 44.2 µmol/L3. Creatinine increase > 0.5mg/dL or 44.2 µmol/L

4. Coagulation abnormalities4. Coagulation abnormalities (INR > 1.5 )(INR > 1.5 )

5. Ileus (absent bowel sounds)5. Ileus (absent bowel sounds) 6. Thrombocytopenia (platelet count < 100,000 6. Thrombocytopenia (platelet count < 100,000

/µL)/µL)

7. Hyperbilirubinemia (plasma total bilirubin > 7. Hyperbilirubinemia (plasma total bilirubin > 4mg/dL or 70 µmol/L)4mg/dL or 70 µmol/L)

Tissue perfusion variables:Tissue perfusion variables: Hyperlactatemia (> 1 mmol/L)Hyperlactatemia (> 1 mmol/L)

Decreased capillary refill or mottlingDecreased capillary refill or mottling

Severe sepsis Severe sepsis

Lactate above upper limits laboratoryLactate above upper limits laboratory

Urine output < 0.5mL/kg/hr for more than 2 Urine output < 0.5mL/kg/hr for more than 2 hrs despite adequate fluid resuscitationhrs despite adequate fluid resuscitation

Acute lung injury with Pao2/Fio2 < 250 in the Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source absence of pneumonia as infection source

Acute lung injury with Pao2/Fio2 < 200 in the Acute lung injury with Pao2/Fio2 < 200 in the

presence of pneumonia as infection sourcepresence of pneumonia as infection source Creatinine > 2.0mg/dL (176.8 µmol/L)Creatinine > 2.0mg/dL (176.8 µmol/L) Bilirubin > 2mg/dL (34.2 µmol/L) Bilirubin > 2mg/dL (34.2 µmol/L) Platelet count < 100,000 µL Platelet count < 100,000 µL Coagulopathy (international normalized ratio > Coagulopathy (international normalized ratio >

1.5)1.5)

Treatment Strategies in Treatment Strategies in ShockShock

MonitoringMonitoring Blood pressure Blood pressure Heart rate Heart rate Respiratory rate Respiratory rate Urine output Urine output Blood CBC Blood CBC Pulse - oximetry Pulse - oximetry ECG ECG U/S , CT , X-rayU/S , CT , X-ray

Special MonitoringSpecial Monitoring CARDIO – VASCULAR:CARDIO – VASCULAR:

1. Central venous pressure 1. Central venous pressure 2. Cardiac output :2. Cardiac output : - Pulmonary catheter - Pulmonary catheter - Doppler ultrasound - Doppler ultrasound - Pulse waveform analysis- Pulse waveform analysis

SYSTEMIC & ORGAN PERFUSION SYSTEMIC & ORGAN PERFUSION 1. - Clinically - urine output & LOC 1. - Clinically - urine output & LOC - Sr. Lactate estimation- Sr. Lactate estimation - Blood gas analysis - Blood gas analysis - Mixed venous O2 saturation - Mixed venous O2 saturation 2. Newer methods 2. Newer methods - Muscle tissue O2 probes - Muscle tissue O2 probes - Near –infrared spectroscopy - Near –infrared spectroscopy - Sublingual capnometry- Sublingual capnometry

Severe sepsis bundle Severe sepsis bundle

Design to optimize the timing ,sequence, and Design to optimize the timing ,sequence, and goals of the individual element care.goals of the individual element care.

Includes:Includes: - goal directed hemodynamic stabilization- goal directed hemodynamic stabilization - early appropriate antimicrobial therapy- early appropriate antimicrobial therapy - associated adjunctive therapy- associated adjunctive therapy

SURVIVING SEPSIS CAMPAIGN BUNDLESSURVIVING SEPSIS CAMPAIGN BUNDLES TO BE COMPLETED WITHIN 3 HOURS:TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level1) Measure lactate level 2) Obtain blood cultures prior to administration of 2) Obtain blood cultures prior to administration of antibiotics antibiotics 3) Administer broad spectrum antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 mL/kg crystalloid for hypotension or 4) Administer 30 mL/kg crystalloid for hypotension or lactate > 4mmol/L lactate > 4mmol/L

TO BE COMPLETED WITHIN 6 HOURS:TO BE COMPLETED WITHIN 6 HOURS: 5) Apply vasopressors (for hypotension not 5) Apply vasopressors (for hypotension not

responding to initial fluid resuscitation)responding to initial fluid resuscitation) 6) persistent arterial hypotension despite volume 6) persistent arterial hypotension despite volume

resuscitation or initial lactate 4 mmol/L resuscitation or initial lactate 4 mmol/L measure: measure:

- central venous pressure - central venous pressure - central venous oxygen saturation - central venous oxygen saturation 7) Remeasure lactate 7) Remeasure lactate

Fluid management Fluid management

ADJUNCTIVE THERAPIESADJUNCTIVE THERAPIES

Antibiotic ManagementAntibiotic Management

Is patient immunocompromised? HIV Neutropenia Chronic corticosteroids Malnutrition Receiving chemotherapy

Give antibiotic therapy to opportunistic pathogens

+ Bacterial pathogens

Consider likely bacterial infection based on

clinical presenatation

Human immunodeficiency antibodies

Extended spectrum beta-lactamase

Methicillin resistant staphylococcus aureus

Risk factors for healthcare-associated infection present:• Recent hospitalization• residence in nursing home/rehabilitation• Regular visits to hospital• Home infusion or wound therapy

Consider nosocomial bacterial pathogens that are potentially antibiotic resistant:• MRSA• pseudomonas aeruginosa• acinetobacter species•Klebsiella pneumonia• E - coli

Consider community-based bacterial pathogens that are antibiotic sensitive :•Streptococcus pneumoniae• e coli• legionaella pneumophila• haemophillia influenza• klebsiella pneumonia

* Broad spectrum cephalosporin /* Carbapenam /* Beta-lactam /* Fluroquinolone /* Aminoglycoside /* MRSA- Directed agent(vancomycin, linezolid, tigecycline)

Select single agent therapy:• ceftriaxone• fluroquinolone• ampicillin/sulbactum• macrolides (azithromycin, clarithromycin, telithromycin)

Modify and/or narrow antibiotic regimen based on

organism identified and susceptibilty testing

Activated Protein CActivated Protein C (drotrecogin - alpha) (drotrecogin - alpha)

Recombinant Human Activated Protein CRecombinant Human Activated Protein C Prevent DIC cascade with antithrombotic Prevent DIC cascade with antithrombotic

activity by inhibiting factors Va & VIIIaactivity by inhibiting factors Va & VIIIa May exerts anti-inflammatory effects by May exerts anti-inflammatory effects by

inhibiting TNF and by blocking leukocytes inhibiting TNF and by blocking leukocytes adhesionsadhesions

Side effectsSide effects BleedingBleeding Pediatric trial terminated early (03/04) Pediatric trial terminated early (03/04)

due to no benefit to known risk of due to no benefit to known risk of bleedingbleeding

Anaphylactic shockAnaphylactic shock

Immunoglobulin E mediated immediate Immunoglobulin E mediated immediate hypersensitivity reactionhypersensitivity reaction

It involve mast cell and basophil degranulationsIt involve mast cell and basophil degranulations Clinically it is indistinguishable from Clinically it is indistinguishable from

anaphylactoid reactions (direct mast cell anaphylactoid reactions (direct mast cell degranulation)degranulation)

Reaction develop in < 1hour after Reaction develop in < 1hour after exposure to triggering substancesexposure to triggering substances

Initial symptoms:Initial symptoms: - flushing- flushing - pruritis - pruritis - sense of doom- sense of doom

Causes?Causes?Anaphylaxis (IgE mediated)

Anaphylactoid reaction

-Foods (nuts, egg, fish, shellfish, cows milk)- vaccines- anesthetic agents- insulin and other harmones- antitoxins- blood and blood products- insect stings and bites (bee, wasp and ant)- snake bites- latex- allergy immunotherapy

-NSAIDs- opiates- sulfites- radioconstrast media- neuromuscular blocking agents- gamma globulin- antisera- exercise

Clinical ManifestationsClinical Manifestations

1. Cardiovascular collapse (shock) – seen in 20%1. Cardiovascular collapse (shock) – seen in 20% Results from:Results from: - hypovolemia induced by increased vascular - hypovolemia induced by increased vascular permeability and loss of intravascular volume.permeability and loss of intravascular volume. - hypotension from peripheral vasodilation- hypotension from peripheral vasodilation - myocardial depression- myocardial depression - bradycardia- bradycardia

2. Respiratory symptoms - seen in 50% of 2. Respiratory symptoms - seen in 50% of patientspatients

Can results in : Can results in : - severe upper airway edema- severe upper airway edema - bronchospasm- bronchospasm - cardiogenic and non- cardiogenic pulmonary - cardiogenic and non- cardiogenic pulmonary edemaedema Biphasic reactions occurs in 20 % within, 1 to 8 Biphasic reactions occurs in 20 % within, 1 to 8

hours after initial reactionshours after initial reactions

3. Eyes :3. Eyes : - pruritus- pruritus - lacrimation- lacrimation - conjunctival erythema- conjunctival erythema - periorbital edema- periorbital edema4. Gastrointestinal :4. Gastrointestinal : - nausea / vomiting- nausea / vomiting - diarrhoea- diarrhoea - abdominal pain- abdominal pain

5. skin:5. skin: - pruritus- pruritus - flushing- flushing - urticaria- urticaria - angioedema- angioedema6. Neurologic :6. Neurologic : - anxiety and sense of doom- anxiety and sense of doom - syncope - syncope - seizures- seizures

Acute TreatmentAcute Treatment

Remember….Remember…. - intravenous steroids have no role in the acute - intravenous steroids have no role in the acute treatment of anaphylaxis but may prevent treatment of anaphylaxis but may prevent phase 2 reactionphase 2 reaction - given IV methyl prednisolone 1-2 mg/kg and - given IV methyl prednisolone 1-2 mg/kg and continue up to 4 days (IV / Orally)continue up to 4 days (IV / Orally) - on discharge, refer the patient to allergist for - on discharge, refer the patient to allergist for testing and monitoring and provide with home testing and monitoring and provide with home epinephrine self – injectors (EpiPen)epinephrine self – injectors (EpiPen)

Practically Speaking….Practically Speaking…. Know how to distinguish different types of shock and Know how to distinguish different types of shock and

treat accordingly. treat accordingly. Look for early signs of shock. Look for early signs of shock. Monitor the patient using the HR, MAP, mental status, Monitor the patient using the HR, MAP, mental status,

urine output. urine output. SHOCK is not equal to hypotension. SHOCK is not equal to hypotension. Start antibiotics within an hour ! Start antibiotics within an hour ! Do not wait for cultures or blood work.Do not wait for cultures or blood work.

THANK YOUTHANK YOU