D. P.

Laporta MD SMBD-JGH Dept of Adult Critical Care

SHOCK - OUTLINE
DEFINITION CAUSES

EFFECTS

OF INEFFECTIVE TREATMENT ASSESSMENT CLINICAL APPROACH

CASE

CASE

CASE

CASE

CASE

CASE

1. post Cardiac Surgery - same day - 1 week postop

SHOCK CASES

2. in MVA victim
3. In young male with Crohn s disease found febrile in shock 4. In drug addict, hospital worker

SHOCK DEFINITION

CAUSES EFFECTS OF INEFFECTIVE TREATMENT ASSESSMENT CLINICAL APPROACH

DEFINITION

A profound disturbance of the circulation and metabolism, leading to inadequate perfusion of vital organs, necessary to maintain homeostasis

SHOCK

DEFINITION

CAUSES

EFFECTS OF INEFFECTIVE TREATMENT ASSESSMENT CLINICAL APPROACH

HYPOPERFUSED STATES
RV
Venous
(capacitance)
PVR

LV
Arterial
(resistance)

EF End-Diastolic Volume
SVR

BP 60/30

Hypovolemic

HR 140/min
CVP 0 Lactate 10

Cardiogenic

BP 70/50

HR 130/min
CVP 18 Lactate 12

Obstructive

BP 70/50

HR 140/min
CVP 15 Lactate 12

VTED

OAD
DLD

Distributive

BP 70/40

HR 140/min
CVP 5 Lactate 12

SHOCK

DEFINITION CAUSES

EFFECTS

OF INEFFECTIVE TREATMENT
ASSESSMENT MEASUREMENT CLINICAL APPROACH

EFFECTS OF INEFFECTIVE TREATMENT

MISERY !!!
MODS
PO2/FiO2 ratio Serum creatinine Platelet count Glasgow coma score Serum bilirubin Pressure-adjusted heart rate (hr x CVP/MAP)

INFECTION

SHOCK

DEFINITION CAUSES EFFECTS OF INEFFECTIVE TREATMENT

ASSESSMENT

MEASUREMENT CLINICAL APPROACH

SHOCK: asssessment
Class

1&2 vs 3&4 needs blood or crystalloid ?

Sublingual capnometry:
A new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock
Max Harry Weil MD, PhD, FCCM - CCM 1999

hypercarbia is a universal indicator of critically reduced tissue perfusion.

Sublingual capnometry:
A new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock

Sublingual capnometry:
A new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock

Sublingual capnometry:
A new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock

P SL CO2 provides a prompt indication of the reversal of tissue hypercarbia when circulatory shock is reversed

SHOCK

DEFINITION CAUSES EFFECTS OF IEFFECTIVE TREATMENT MEASUREMENT

CLINICAL

APPROACH

SHOCK: an EMERGENCY !!!

GOAL:
RAPIDLY RESTORE TISSUE PERFUSION

Recognize

it !!!

Immediate stabilization: ABC

. SHOTGUN approach
ICU & Surgical consultation

Treat the cause

Management priorities
in hypoperfused states
Parameter to target
CVP 10-15 SBP? 100 or within 20-25 torr MBP ? 80 of patient's Nl Signs of perfusion DO2

Priority # Physiology to Intervention improve

1 2 Volume Pressure Fluids Vasopressor

PAC targets
DO2

Avoid
Low Sao2 See CXR Low SV, DO2 High HR, Resistances Low BP, SV, Resistances

Flow

Inotrope

BP potency: Dopamine...NEVasopressin/Phenylephrine