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FCA 0611 - Shock
- 1. A State of Shock Veronica Bonales, M.D. CEPAmerica, Emergency Medicine Redwood Memorial Hospital
- 2. I am shocked, shocked...
- 3. Objectives What is Shock? Types of Shock Stages and Symptoms of Shock Treatment of Shock
- 6. What is Shock? Inadequate tissue perfusion
- 7. What is Shock? Oxygen to lungs Oxygen to RBC’s Oxygen to tissues CO2 in tissues CO2 to RBC’s CO2 to lungs
- 8. What is Shock? Red Blood Cells Hemoglobin molecules Carry O2 to the tissues and CO2 away from the tissues
- 9. What is Shock? CO2 is a by-product of cellular respiration
- 10. What is Shock? CO2 is a by-product of cellular respiration
- 11. What is Shock?
- 12. What is Shock? Anaerobic Metabolism Leads to build up of Lactic Acid Creates energy debt
- 13. What is Shock?
- 14. What is Shock? Kidneys Sense fall in blood pressure Release renin Leads to increased blood pressure
- 15. What is Shock? Carotid bodies Sense pH, O2 levels, CO2
- 16. What is Shock? If pH decreased, O2 decreased, or CO2 increased Signals sent via Vagus nerve Decreased parasympathetic input Heart rate increases Increased sympathetic input Vessels contract increasing BP
- 17. Types of Shock
- 19. Types of Shock
- 20. Types of Shock Cardiogenic Shock
- 21. Types of Shock Cardiogenic Shock Some condition doesn’t allow heart to pump effectively
- 22. Types of Shock Cardiogenic Shock Some condition doesn’t allow heart to pump effectively Arrhythmia, MI, CHF, valvular problem, CM
- 23. Types of Shock Heart not pumping properly Vessels compensate by increasing tone Less blood to end organs Increased venous pressure
- 24. Types of Shock CHF Hypertensive Tachycardic Diaphoretic Crackles
- 25. Types of Shock Distributive Shock Anaphylactic Neurogenic Septic
- 26. Types of Shock “Relative hypovolemia” Vasodilation Leaky capillaries Tissue edema
- 27. Types of Shock Anaphylaxis Severe allergic reaction Histamine release leads to vasodilation & capillary leakage
- 28. Types of Shock Anaphylaxis Severe allergic reaction Histamine release leads to vasodilation & capillary leakage
- 29. Types of Shock Neurogenic Spinal cord damage Leads to loss of sympathetic tone
- 30. Types of Shock Septic Shock Usually Gram negative bacteria Release toxins Release of cellular chemicals Cytokines Free radicals
- 31. Types of Shock Septic Shock Usually Gram negative bacteria Release toxins Release of cellular chemicals Cytokines Free radicals
- 32. Types of Shock Cause vasodilation Cause capillary leakage Increase in lactate Increase heart rate
- 33. Types of Shock Hypovolemic Shock Trauma GI bleeds Dehydration Diabetes Burns
- 34. Types of Shock
- 35. Types of Shock Obstructive
- 36. Stages & Symptoms of Shock
- 37. Shock Stages & Symptoms
- 38. Shock Stages & Symptoms
- 39. Shock Stages & Symptoms
- 40. Shock Stages & Symptoms Grade 1 - 15% (750ml) Mild tachycardia
- 41. Shock Stages & Symptoms Grade 1 - 15% (750ml) Mild tachycardia Grade 2 - 15 - 30% (750 - 1500ml) Moderate tachycardia, prolonged cap refill
- 42. Shock Stages & Symptoms Grade 1 - 15% (750ml) Mild tachycardia Grade 2 - 15 - 30% (750 - 1500ml) Moderate tachycardia, prolonged cap refill Grade 3 - 30 - 40% (1500 - 2000ml) Hypotension, tachycardia, low urine output
- 43. Shock Stages & Symptoms Grade 1 - 15% (750ml) Mild tachycardia Grade 2 - 15 - 30% (750 - 1500ml) Moderate tachycardia, prolonged cap refill Grade 3 - 30 - 40% (1500 - 2000ml) Hypotension, tachycardia, low urine output Grade 4 - 40 - 50% (2000 - 2500ml) Profound hypotension, end-organ damage, death
- 44. Shock Stages & Symptoms
- 45. Shock Stages & Symptoms Initial Stage
- 46. Shock Stages & Symptoms Initial Stage Hypoperfusion --> hypoxia
- 47. Shock Stages & Symptoms Initial Stage Hypoperfusion --> hypoxia Hypoxia --> no ATP produced --> anaerobic metabolism --> increased lactate
- 48. Shock Stages & Symptoms Initial Stage Hypoperfusion --> hypoxia Hypoxia --> no ATP produced --> anaerobic metabolism --> increased lactate No energy --> cell damage --> leaky walls --> loss of fluid
- 49. Shock Stages & Symptoms Initial Stage Hypoperfusion --> hypoxia Hypoxia --> no ATP produced --> anaerobic metabolism --> increased lactate No energy --> cell damage --> leaky walls --> loss of fluid No energy --> cells can’t function
- 50. Shock Stages & Symptoms
- 51. Shock Stages & Symptoms Compensatory Stage
- 52. Shock Stages & Symptoms Compensatory Stage Acidosis
- 53. Shock Stages & Symptoms Compensatory Stage Acidosis Hypervent- ilation
- 54. Shock Stages & Symptoms Compensatory Stage Acidosis Hypervent- ilation Hypotension
- 55. Shock Stages & Symptoms Compensatory Stage Acidosis Hypervent- ilation Hypotension Tachycardia
- 56. Shock Stages & Symptoms Compensatory Stage Acidosis Hypervent- ilation Hypotension Tachycardia Vasoconstric- tion
- 57. Shock Stages & Symptoms Compensatory Stage Blood shunted to heart, Acidosis brain, lungs Hypervent- ilation Hypotension Tachycardia Vasoconstric- tion
- 58. Shock Stages & Symptoms Compensatory Stage Blood shunted to heart, Acidosis brain, lungs Hypervent- Diaphoresis ilation Hypotension Tachycardia Vasoconstric- tion
- 59. Shock Stages & Symptoms Compensatory Stage Blood shunted to heart, Acidosis brain, lungs Hypervent- Diaphoresis ilation Kidneys Hypotension Tachycardia Vasoconstric- tion
- 60. Shock Stages & Symptoms Compensatory Stage Blood shunted to heart, Acidosis brain, lungs Hypervent- Diaphoresis ilation Kidneys Hypotension Increase Tachycardia volume by Vasoconstric- decreased tion UOP, Na+
- 61. Shock Stages & Symptoms Progressive (Decompensating) Stage Increased acidosis --> vasodilation & capillary leak --> edema Blood sludges --> microinfarcts Increasing loss of perfusion and end-organ damage
- 62. Shock Stages & Symptoms Refractory (Irreversible) Stage Multi-system organ failure Brain death occurs Death imminent
- 63. Shock Treatment
- 65. Treatment of Shock Cardiogenic - fix the underlying problem (angio, surgery, ECV)
- 66. Treatment of Shock Cardiogenic - fix the underlying problem (angio, surgery, ECV) Anaphylactic - Epinephrine, anti- histamines, steroids
- 67. Treatment of Shock Cardiogenic - fix the underlying problem (angio, surgery, ECV) Anaphylactic - Epinephrine, anti- histamines, steroids Neurogenic - most difficult, steroids or surgery
- 69. Treatment of Shock Septic - massive amounts of fluids, antibiotics, pressor support, end-organ support (ventilator, dialysis)
- 70. Treatment of Shock Septic - massive amounts of fluids, antibiotics, pressor support, end-organ support (ventilator, dialysis) Hypovolemic - aggressive fluids, blood products, treatment of underlying cause
- 71. Treatment of Shock Septic - massive amounts of fluids, antibiotics, pressor support, end-organ support (ventilator, dialysis) Hypovolemic - aggressive fluids, blood products, treatment of underlying cause Obstructive - treatment of underlying cause (needle decompression, pericardiocentesis)
- 72. Questions..?
- 73. Questions..?
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