The Many Faces of ShockThe Many Faces of Shock
Søren Boysen, DVM, DACVECCSøren Boysen, DVM, DACVECCUniversity of Montreal University of Montreal
Saint Hyacinthe, Quebec, CanadaSaint Hyacinthe, Quebec, Canada
Université de Montréal
mmU
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ShockShock
What is the definition of shock?What is the definition of shock?
ShockShock
What is the definition of shock?What is the definition of shock? Inadequate oxygen delivery to the tissues to meet Inadequate oxygen delivery to the tissues to meet
tissue demandtissue demand
ShockShock
What is the definition of shock?What is the definition of shock? Inadequate oxygen deliveryInadequate oxygen delivery to the tissues to meet to the tissues to meet
tissue demandtissue demand What causes inadequate oxygen delivery to the What causes inadequate oxygen delivery to the
tissues?tissues?
ShockShock
What factors influence oxygen delivery (DOWhat factors influence oxygen delivery (DO22))
Oxygen Delivery (DOOxygen Delivery (DO22))
Influenced by two important factorsInfluenced by two important factors Cardiac outputCardiac output
Oxygen Delivery (DOOxygen Delivery (DO22))
Influenced by two important factorsInfluenced by two important factors Cardiac outputCardiac output Arterial oxygen contentArterial oxygen content
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O2
O2
O2
O2
O2
O2
DODO22 = CO x CaO = CO x CaO22
DODO22 = = COCO x CaO x CaO22
What factors influence cardiac output?What factors influence cardiac output?
DODO22 = = COCO x CaO x CaO22
Stroke volumeHeart rate x
DODO22 = = COCO x CaO x CaO22
Stroke volume - Preload - Aferload - Contractility
Heart rate x
DODO22 = CO x = CO x CaOCaO22What factors influence arterial oxygen What factors influence arterial oxygen content?content?
DODO22 = CO x = CO x CaOCaO22
CaO2 = (Hgb × 1.34 × SaO2) + (PaO2 × .003)Hematocrit Hemoblobin saturation Arterial oxygen pressure
General Therapy for ShockGeneral Therapy for Shock
Increase cardiac output Increase cardiac output (CO)(CO) Heart rate: Correct arrhythmias Heart rate: Correct arrhythmias Preload: Fluid therapy (except heart disease)Preload: Fluid therapy (except heart disease) Afterload: Nitropursside, ACE inhibitors Afterload: Nitropursside, ACE inhibitors Contractility: Positive ionotropesContractility: Positive ionotropes
Increase the arterial oxygen content Increase the arterial oxygen content (CaO(CaO22)) Blood transfusion: when indicatedBlood transfusion: when indicated Increased inspired oxygen contentIncreased inspired oxygen content
Correct refractory (vasodilatory) hypotensionCorrect refractory (vasodilatory) hypotension
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Delivery of blood to the tissuesDelivery of blood to the tissues
Vascular diseases (volume, tone) Vascular diseases (volume, tone)
Oxygenation of bloodOxygenation of blood
Severe pulmonary diseaseSevere pulmonary disease
Problems with hemoglobin (anemia, MetHgb)Problems with hemoglobin (anemia, MetHgb)
Cardiac disease (arythmia, contractility)Cardiac disease (arythmia, contractility)
Oxygen uptake/use by cellsOxygen uptake/use by cellsMitochondrial dysfunctionMitochondrial dysfunction (sepsis, cyanosis)(sepsis, cyanosis)
Inadequate Oxygen DeliveryInadequate Oxygen Delivery
Classifications of ShockClassifications of Shock
The causeThe cause HypovolemiaHypovolemia HemorrhagicHemorrhagic TraumaticTraumatic CardiogenicCardiogenic SepticSeptic AnaphylacticAnaphylactic ObstructiveObstructive AnemicAnemic HypoxemicHypoxemic
Classifications of ShockClassifications of Shock
The physiologic stateThe physiologic state Compensated (normal BP)Compensated (normal BP) Uncompensated (low BP)Uncompensated (low BP) Terminal (about to die)Terminal (about to die)
Classifications of ShockClassifications of Shock
Cardiac outputCardiac output HyperdynamicHyperdynamic HypodynamicHypodynamic
ZolaZola
5 year old m/n Husky5 year old m/n Husky 40 kg40 kg Hit by carHit by car
ZolaZola
Physical examinationPhysical examination T 98.6 P 168 bpm R 38 BPMT 98.6 P 168 bpm R 38 BPM MM: Pale CRT: > 2 secondsMM: Pale CRT: > 2 seconds Weak peripheral pulses Weak peripheral pulses
ZolaZola
Physical examinationPhysical examination T 98.6 P 168 bpm R 38 BPMT 98.6 P 168 bpm R 38 BPM MM: Pale CRT: > 2 secondsMM: Pale CRT: > 2 seconds Weak peripheral pulses Weak peripheral pulses Lung sounds increased (no crackles or wheezes)Lung sounds increased (no crackles or wheezes) Mentally depressedMentally depressed
Is shock present?
ZolaZola
Physical examinationPhysical examination T 98.6 P 168 bpm R 38 BPMT 98.6 P 168 bpm R 38 BPM MM: Pale CRT: > 2 secondsMM: Pale CRT: > 2 seconds Weak peripheral pulses Weak peripheral pulses Lung sounds increased (no crackles or wheezes)Lung sounds increased (no crackles or wheezes) Mentally depressedMentally depressed
Is shock present?
ZolaZola
Physical examinationPhysical examination T 98.6 T 98.6 P 168 bpmP 168 bpm R 38 BPM R 38 BPM MM: Pale CRT: > 2 secondsMM: Pale CRT: > 2 seconds Weak peripheral pulsesWeak peripheral pulses Lung sounds increased (no crackles or wheezes)Lung sounds increased (no crackles or wheezes) Mentally depressedMentally depressed
ShockShock
Immediate therapy Immediate therapy Place 2 large bore 18 g cathetersPlace 2 large bore 18 g catheters
Difficult IV Access?Difficult IV Access?
Intraosseous catheter:Intraosseous catheter:
Difficult IV Access?Difficult IV Access?
Intraosseous catheter:Intraosseous catheter:
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Emergency Venous CutdownEmergency Venous Cutdown
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Emergency Venous CutdownEmergency Venous Cutdown
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Venous Jugular CutdownVenous Jugular Cutdown
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Difficult IV Access?Difficult IV Access?
Bone intraosseous gun?Bone intraosseous gun?
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ShockShock
Immediate therapy Immediate therapy Place 2 large bore 18 g cathetersPlace 2 large bore 18 g catheters Collect pre-treatment blood samplesCollect pre-treatment blood samples
Zola: Minimum Data BaseZola: Minimum Data Base
Big 5 resultsBig 5 results Hct 38% Hct 38% (37-55)(37-55) TS 5.5 mg/dL TS 5.5 mg/dL (6.0-7.8)(6.0-7.8) BUN 15-26 BUN 15-26 (<26)(<26) Glu 185 mmol/LGlu 185 mmol/L (70-120)(70-120) Lac 11.3 mmol/L Lac 11.3 mmol/L (<2.5)(<2.5)
Zola: Minimum Data BaseZola: Minimum Data Base
Blood pressure 76 mmHg systolicBlood pressure 76 mmHg systolic
ECGECG
Shock Therapy for ZolaShock Therapy for Zola
DO2 = C.O x CaODO2 = C.O x CaO22
Increase C.O: Increase C.O: Fluid therapyFluid therapy Correct arrhythmia?Correct arrhythmia?
Increase CaOIncrease CaO22 Administer oxygenAdminister oxygen Blood transfusion?Blood transfusion?
Shock Therapy for ZolaShock Therapy for Zola
DO2 = C.O x CaODO2 = C.O x CaO22
Increase C.O: Increase C.O: Fluid therapyFluid therapy Correct arrhythmia?Correct arrhythmia?
Increase CaOIncrease CaO22 Administer oxygenAdminister oxygen Blood transfusion?Blood transfusion?
Shock TherapyShock Therapy
If cardiogenic shock can be ruled out, fluid If cardiogenic shock can be ruled out, fluid resuscitation is the cornerstone of therapy resuscitation is the cornerstone of therapy for all other forms of shockfor all other forms of shock
What is a Shock Dose of Fluids?What is a Shock Dose of Fluids?
What is a Shock Dose of Fluids?What is a Shock Dose of Fluids?
90 ml/kg/hr in dogs90 ml/kg/hr in dogs40-60 ml/kg/hr in cats40-60 ml/kg/hr in cats
What is a Shock Dose of Fluids?What is a Shock Dose of Fluids?
90 ml/kg/hr in dogs90 ml/kg/hr in dogs40-60 ml/kg/hr in cats40-60 ml/kg/hr in cats
Is every animal that receives the same Is every animal that receives the same “shock dose” going to respond in the “shock dose” going to respond in the same manner?same manner?
What is a Shock Dose of Fluids?What is a Shock Dose of Fluids?
Goal of shock fluid therapy?Goal of shock fluid therapy?
What is a Shock Dose of Fluids?What is a Shock Dose of Fluids?
Goal of shock fluid therapy?Goal of shock fluid therapy? 1) reverse the symptoms of shock1) reverse the symptoms of shock
What is a Shock Dose of Fluids?What is a Shock Dose of Fluids?
Goal of shock fluid therapy?Goal of shock fluid therapy? 1) reverse the symptoms of shock 1) reverse the symptoms of shock 2) as quickly as possible2) as quickly as possible
What is a Shock Dose of Fluids?What is a Shock Dose of Fluids?
Goal of shock fluid therapy?Goal of shock fluid therapy? 1) reverse the symptoms of shock 1) reverse the symptoms of shock 2) as quickly as possible2) as quickly as possible 3) while minimizing side effects3) while minimizing side effects
Fluid ResuscitationFluid Resuscitation
This may require less than 90 ml/kgThis may require less than 90 ml/kg
Fluid ResuscitationFluid Resuscitation
This may require less than 90 ml/kgThis may require less than 90 ml/kg
May require more than 90 ml/kgMay require more than 90 ml/kg
This may require less than 90 ml/kgThis may require less than 90 ml/kg
May require more than 90 ml/kgMay require more than 90 ml/kg
May need to be given faster than 1 hourMay need to be given faster than 1 hour
90 ml/kg/hr90 ml/kg/hrX
Fluid ResuscitationFluid Resuscitation
Fluid ResuscitationFluid Resuscitation
Calculate shock doseCalculate shock dose Administer 1/4 to 1/3 the shock dose over 10 Administer 1/4 to 1/3 the shock dose over 10
minutes minutes (20-30 ml/kg for isotonic crystalloids)(20-30 ml/kg for isotonic crystalloids)
Fluid ResuscitationFluid Resuscitation
Calculate shock doseCalculate shock dose Administer 1/4 to 1/3 the shock dose Administer 1/4 to 1/3 the shock dose over 10 over 10
minutesminutes (20-30 ml/kg for isotonic crystalloids)(20-30 ml/kg for isotonic crystalloids)
Fluid ResuscitationFluid Resuscitation
Calculate shock doseCalculate shock dose Administer 1/4 to 1/3 the shock dose Administer 1/4 to 1/3 the shock dose over 10 over 10
minutesminutes (20-30 ml/kg for isotonic crystalloids) (20-30 ml/kg for isotonic crystalloids) Continue with 1/4 to 1/3 shock doses every Continue with 1/4 to 1/3 shock doses every
10 minutes……..10 minutes……..
Fluid ResuscitationFluid Resuscitation
When do we stop fluid resuscitation for When do we stop fluid resuscitation for shock?shock?A)A) Animal is cardiovascularly stable Animal is cardiovascularly stableB)B) Intravascular volume is maximized Intravascular volume is maximized
Fluid ResuscitationFluid Resuscitation
How do we determine when an animal is How do we determine when an animal is cardiovascularly stable?cardiovascularly stable?
Fluid ResuscitationFluid Resuscitation
Assess parameters that indicated the animal Assess parameters that indicated the animal was unstablewas unstable
Fluid ResuscitationFluid Resuscitation
Assess parameters that indicated the animal Assess parameters that indicated the animal was unstablewas unstable
Try to re-establish normal values for those Try to re-establish normal values for those parameters that indicated the patients was parameters that indicated the patients was unstableunstable
End Points of ResuscitationEnd Points of Resuscitation
Zola: Initial ResuscitationZola: Initial Resuscitation
7.5% hypertonic saline : 4-6 ml/kg IV7.5% hypertonic saline : 4-6 ml/kg IV
Zola: Initial ResuscitationZola: Initial Resuscitation
7.5% hypertonic saline : 4-6 ml/kg IV7.5% hypertonic saline : 4-6 ml/kg IV Concerns for concurrent cerebral or pulmonary edemaConcerns for concurrent cerebral or pulmonary edema
Zola: Initial ResuscitationZola: Initial Resuscitation
7.5% hypertonic saline : 4-6 ml/kg IV7.5% hypertonic saline : 4-6 ml/kg IV Concerns for concurrent cerebral or pulmonary edemaConcerns for concurrent cerebral or pulmonary edema
Search for causeSearch for cause low TS, low normal PCV: search for hemorrhagelow TS, low normal PCV: search for hemorrhage
ZolaZola
AbdominocentesisAbdominocentesis
Abdominal PCV 33%Abdominal PCV 33% Peripheral PCV 32%Peripheral PCV 32%
Abdominal CounterpressureAbdominal Counterpressure
T 0 HR 186 bpm
ZolaZola
ZolaZola
T10 HR 154 bpmHypertonic SalineHydromophone
Recheck: Hct 28% TS 3.8 mg/dl, Lactate 7.1mmol /LABP: 86 mmHg
ZolaZola
T10 HR 154 bpmHypertonic SalineHydromophone
30 ml/kg bolus LRS
ZolaZola
T10 HR 154 bpmHypertonic SalineHydromophone
30 ml/kg bolus LRS
PCV 21% TS 2.4 mg/dLABP 98 mmHg
ZolaZola
T10 HR 154 bpmHypertonic SalineHydromophone
30 ml/kg bolus LRS
2 units PRB’s
Fluid ResuscitationFluid Resuscitation
Animal remains unstable - how much fluid Animal remains unstable - how much fluid can be given before edema occurs?can be given before edema occurs?
Fluid ResuscitationFluid Resuscitation
Measure central venous pressureMeasure central venous pressure (N = <5cm H(N = <5cm H220)0)
Risk of edema increases around 10 cm HRisk of edema increases around 10 cm H2200
Fluid ResuscitationFluid Resuscitation
How do you determine intravascular volume How do you determine intravascular volume without a manometer?without a manometer?
Fluid ResuscitationFluid Resuscitation
How do you determine intravascular volume How do you determine intravascular volume without a manometer?without a manometer?
Estimating CVPEstimating CVP
Positioning is importantPositioning is importantSternal recumbencySternal recumbencyHead elevatedHead elevatedNeck gently extendedNeck gently extendedShaving to visualize Shaving to visualize
the jugular furrowthe jugular furrow
Estimating CVPEstimating CVP
Normal animalsNormal animals
Jugular pulse < 1/3 of the way up the neckJugular pulse < 1/3 of the way up the neck
Jugular distension < 1/3 of the way up the Jugular distension < 1/3 of the way up the neckneck
Estimating CVPEstimating CVP
Estimating CVPEstimating CVP
Fluid ResuscitationFluid Resuscitation
What if the animal remains unstable but What if the animal remains unstable but Intravascular volume is maximized?Intravascular volume is maximized?
Fluid ResuscitationFluid Resuscitation
What if the animal remains unstable but What if the animal remains unstable but Intravascular volume is maximized?Intravascular volume is maximized?Search for an underlying cause Search for an underlying cause
Myocardial depression, electrolytes, acid base, Myocardial depression, electrolytes, acid base, glucose, glucose, on going hemorrhage,on going hemorrhage, relative adrenal relative adrenal insufficiency? insufficiency?
Consider vasopressorsConsider vasopressorsConsider emergency surgeryConsider emergency surgery
After resuscitative efforts have been exhaustedAfter resuscitative efforts have been exhausted
Why differentiate forms Why differentiate forms of shock?of shock?
Tailored TherapiesTailored Therapies
Cardiogenic shock: Cardiogenic shock: Reduce preload : furosemideReduce preload : furosemide Reduce afteroad: arterial/venous vasodilatorsReduce afteroad: arterial/venous vasodilators Antiarrhythmia medications: lidocaine, procainomideAntiarrhythmia medications: lidocaine, procainomide Heart rate reducers (beta blockers, digoxin, calcium channel)Heart rate reducers (beta blockers, digoxin, calcium channel) Positive ionotropes: Dobutamine, pimobendanPositive ionotropes: Dobutamine, pimobendan
Tailored TherapiesTailored Therapies
Sepsis: Sepsis: AntibioticsAntibiotics Blood glucose concentrationsBlood glucose concentrations Surgical excision and debridementSurgical excision and debridement Relative adrenal insufficiency: physiologic steroidsRelative adrenal insufficiency: physiologic steroids
Tailored TherapiesTailored Therapies
Vasodilatory shockVasodilatory shock Vasopressor supportVasopressor support Epinephrine for anaphylactic shockEpinephrine for anaphylactic shock
Tailored TherapiesTailored Therapies
Hemorrhagic shockHemorrhagic shock Transfusion therapyTransfusion therapy Possible surgical control of hemorrhagePossible surgical control of hemorrhage
SummarySummary
Consider the factors contributing to Consider the factors contributing to decreased oxygen deliverydecreased oxygen delivery
Rule out cardiogenic shockRule out cardiogenic shock Start fluid resuscitation while underlying Start fluid resuscitation while underlying
cause is soughtcause is sought Tailor therapies once underlying cause is Tailor therapies once underlying cause is
identifiedidentified
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Questions?Questions?