1. Shock
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
1

2. Is This Patient in Shock?
•
Patient looks ill
•
Altered mental status
•
Skin cool and mottled or hot
and flushed
•
Weak or absent peripheral
pulses
•
SBP <90
•
Yes!
These are all signs and
symptoms of shock
Tachycardia
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
2

3. Case
•
A 68 yo M with presents to the ED with abrupt onset of
diffuse abdominal pain with radiation to his low back. The pt
is hypotensive, tachycardic, afebrile (no fever), with cool but
dry skin.
•
An 81 yo F ED with altered mental status. She is febrile to
39.4, hypotensive with a widened pulse pressure, tachycardic,
with warm extremities
Dr Mai Duc Thao. ED. Friendship
Hospital. Ha noi 2013

4. Case
•
A 41 yo M presents to the ED after an MVC complaining of
decreased sensation below his waist and is now hypotensive,
bradycardic, with warm extremities
•
A 55 yo M DM presents with “crushing” substernal chest
pain, diaphoresis, hypotension, tachycardia and cool,
clammy extremities
Dr Mai Duc Thao. ED. Friendship
Hospital. Ha noi 2013
4

5. Objectives




Definition
Approach to the hypotensive patient
Types
Specific treatments
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
5

6. Definition of Shock
•
•
•
•
A complex clinical syndrome caused by an acute
failure of circulatory function and characterized
by inadequate tissue and organ perfusion.
Inadequate oxygen delivery to meet metabolic
demands
Results in global tissue hypoperfusion and
metabolic acidosis
Shock can occur with a normal blood pressure
and hypotension can occur without shock
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
6

7. DEFINATION
Shock give rise to systemic hypoperfusion caused by reduction either in
cardiac output or in effective circulatory blood volume.
End results are :
Hypotension
Tissue hypoperfusion
Cellular hypoxia
Reversible injury
Irreversible injury with persistent of shock
End organ dysfunction
Death

8. Determinants of Oxygen Delivery
Oxygen
Delivery = Content (CaO2) x Cardiac output (CO)
 CaO2 = 1.34 (Hgb x SaO2) + (PaO2 x 0.003)

SaO2: Oxygen saturation

Hgb: Hemoglobin concentration

PaO2: partial pressure Oxygen in plasma
↳ To improve Oxygen content
 Increase Hemoglobin concentration
 Increase saturation

CaO2 is arterial oxygen content (in milliliters per deciliter), Hb is hemoglobin concentration (in
grams per deciliter), SaO2 is hemoglobin saturation of arterial blood (in percent), and PaO2 is
partial pressure of dissolved oxygen in arterial blood (in millimeters of mercury).
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
8

9. Determinants of Oxygen Delivery

Cardiac output

C.O = Heart rate x stroke volume
↳ To improve Cardiac output

Increase Heart rate

Increase Stroke Volume

Preload – volume of blood in the ventricle

Afterload – resistance to contraction

Contractility – force applied
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
9

10. Understanding Shock autonomic responses ?
•
Inadequate systemic oxygen delivery activates autonomic
responses to maintain systemic oxygen delivery
Sympathetic nervous system:
•
Epinephrine, dopamine, and cortisol release
•
Causes vasoconstriction, increase in HR, and
increase of cardiac contractility (cardiac output)
Renin-angiotensin axis
•
Water and sodium conservation and vasoconstriction
•
Increase in blood volume and blood pressure
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
10

11. Understanding Shock
Myocardial
Contractility
Stroke Volume
Cardiac Output
Blood
Pressure
Preload
Afterload
Heart Rate
Systemic Vascular
Resistance
Textbook of Pediatric Advanced Life Support, 1988
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
11

12. Understanding Shock
•
Cellular responses to decreased systemic oxygen delivery
•
•
Cellular edema
•
•
ATP depletion → ion pump dysfunction (Na+, K+ATPase)
Hydrolysis of cellular membranes and cellular death
Goal is to maintain cerebral and cardiac perfusion
•
Vasoconstriction of splanchnic, musculoskeletal, and renal
blood flow
Leads
to
systemic
metabolic
lactic
acidosis
that
overcomes the body’s compensatory mechanisms
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
12

13. Global Tissue Hypoxia
•
Endothelial inflammation and disruption
•
Inability of O2 delivery to meet demand, Anaerobic
respiration
Result:
•
Lactic acidosis
•
Cardiovascular insufficiency
•
Increased metabolic demands
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
13

14. Multiorgan Dysfunction
Syndrome (MODS)
•
Progression of physiologic effects as shock ensues
•
•
Respiratory distress
•
Renal failure
•
•
Cardiac depression
DIC
Result is end organ failure
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
14

15. Approach to the Patient in Shock
•
ABCs
•
Cardiorespiratory monitor
•
Pulse oximetry
•
Supplemental oxygen
•
IV access
•
ABG, labs
•
Foley catheter
•
Vital signs including rectal temperature
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
15

16. Approach to the Patient in
Shock
•
History
•
Recent illness
•
Fever
•
Chest pain, SOB
•
Abdominal pain
•
Comorbidities
•
Medications
•
Toxins/Ingestions
•
Recent hospitalization or
surgery
•
Baseline mental status
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
•
Physical examination
•
Vital Signs
•
CNS – mental status
•
Skin – color, temp, rashes,
sores
•
Heart sounds
•
Resp – lung sounds, RR,
oxygen sat, ABG
•
GI – abd pain…
•
Renal – urine output
16

17. Diagnosis
•
•
•
Physical exam (VS, mental status, skin color, temperature,
pulses, etc)
Infectious source
Labs:
•
CBC
•
Chemistries
•
Lactate
•
Coagulation studies
•
Cultures
•
ABG
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
17

18. Further Evaluation
•
CT of head/sinuses
•
Lumbar puncture
•
Wound cultures
•
Acute abdominal series
•
Abdominal/pelvic CT or US
•
Cortisol level
•
Fibrinogen, FDPs, D-dimer
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
18

19. Treatment
•
ABCDE
•
Airway
•
control work of Breathing
•
optimize Circulation
•
assure adequate oxygen Delivery
•
achieve End points of resuscitation
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
19

20. Airway
•
Determine need for intubation but remember: intubation
can worsen hypotension
•
Sedatives can lower blood pressure
•
Positive pressure ventilation decreases preload
May need volume resuscitation prior to intubation to
avoid hemodynamic collapse
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
20

21. Control Work of Breathing
•
Respiratory muscles consume a significant amount of
oxygen
•
Tachypnea can contribute to lactic acidosis
•
Mechanical ventilation and sedation decrease WOB and
improves survival
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
21

22. Optimizing Circulation
•
Isotonic crystalloids
•
Titrated to:
•
CVP 8-12 mm Hg
•
Urine output 0.5 ml/kg/hr (30 ml/hr)
•
Improving heart rate
•
May require 4-6 L of fluids
•
No outcome benefit from colloids
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
22

23. Maintaining Oxygen Delivery
•
Decrease oxygen demands
•
Provide analgesia and anxiolytics to relax muscles and
avoid shivering
•
Maintain arterial oxygen saturation/content
•
•
•
Give supplemental oxygen
Maintain Hemoglobin > 10 g/dL
Serial lactate levels or central venous oxygen saturations to
assess tissue oxygen extraction
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
23

24. End Points of Resuscitation
•
Goal of resuscitation is to maximize survival and minimize
morbidity
•
Use objective hemodynamic and physiologic values to guide
therapy
•
Goal directed approach
•
Urine output > 0.5 mL/kg/hr
•
CVP 8-12 mmHg
•
MAP 65 to 90 mmHg
•
Central venous oxygen concentration > 70%
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
24

25. Persistent Hypotension
•
Inadequate volume resuscitation
•
Pneumothorax
•
Cardiac tamponade
•
Hidden bleeding
•
Adrenal insufficiency
•
Medication allergy
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
25

26. Practically Speaking….
•
Keep one eye on these patients
•
Frequent vitals signs:
•
•
•
Monitor success of therapies
Watch for decompensated shock
Let your nurses know that these patients are sick!
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
26

27. First aid
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
27

28. First aid
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
28

29. Types of Shock
•
Hypovolemic
•
Septic
•
Cardiogenic
•
Anaphylactic
•
Neurogenic, trauma
•
Obstructive
•
poison
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
29

30. Classification of Shock
Hypovolemic Shock (#1 cause world wide)
Dehydration, hemorrhagic (Hemorrhagic, nonhemorrhagic)
 Cardiogenic Shock
 Pump failure, obstructive, L-R shunt
 Ischemic, Myopathic, Mechanical, Arrhythmia
 Distributive Shock
 Neurogenic (spinal shock), Anaphylaxis, septic
 Obstructive
Massive Pulmonary embolism, Tension pneumothorax
Cardiac tamponade, Constrictive pericarditis
 Septic Shock – All of the above

Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
30

31. Classification of Shock
An Introduction to
Clinical
Emergency
Medicine
Sw aminatha V. M ahadevan,
M D , FA CEP FA A EM
,
Associate Chief, Division of Emer gency Medicine
Assistant Pr ofessor of Surgery (Emergency Medicine)
Stanford University School of Medicine
Emergency Department Medical Dir ector
Medical Student Clerkship Dir ector
Stanford University Medical Center , Stanford, CA
G us M . G armel,
M D , FA CEP FA A EM
,
Co-Program Director, Stanford/Kaiser Emergency Medicine Residency
Clinical Associate Professor of Surgery (Emergency Medicine)
Stanford University School of Medicine
Senior Staff Emergency Physician, The Permanente Medical Gr oup
Clerkship Dir ector for Medical Students and Rotating Interns
Kaiser Permanente Medical Center , Santa Clara, CA
Cambridge University Press 2005
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
31

32. Physiologic parameters in shock states
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
32

33. What Type of Shock is This?
•
68 yo M with presents to the ED with abrupt onset of diffuse
abdominal pain with radiation to his low back. The pt is
hypotensive, tachycardic, afebrile (no fever), with cool but
dry skin.
Hypovolemic Shock
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
33

34. 34

35. ESSENTIALS OF DIAGNOSIS
• Tachycardia and hypotension.
• Cool and frequently cyanotic extremities.
• Collapsed neck veins.
• Oliguria or anuria.
• Rapid correction of signs with volume infusio
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
35

36. Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
36

37. Hypovolemic Shock
Mild (<20%)
Moderate(20-40%)
Severe(>40%)
Cold extremities
Same +
Same +
Diaphoresis
Tachycardia
Hypotension
Anxiety
Tachypnoea
Mental status
deterioration
Oliguria
Postural
-hypotension
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
37

38. What Type of Shock is This?
•
An 81 yo F ED with altered mental status. She is febrile to
39.4, hypotensive with a widened pulse pressure, tachycardic,
with warm extremities
Septic
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
38

39. Septic shock
Manifestation of excessive & inflammatory response of
endogenous immune mechanism two or more of the following:
– T >38 or <36 C
– HR >90 bpm
– RR >20/min or PaCO2 <32 mmHg
– WBC >12,000 or <4,000 cells/ or >10% bands
 Sepsis is SIRS with established focus of infection
 Septic shock - severe sepsis unresponsive to continuous fluid
infusion and inotropes
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
39

40. Definition by American College of Chest Physicians/Society
of Critical Care Medicine
SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference, Levy MM et al., Crit. Care Med. 2003, 31(4): 1250-1256)

41. A clinician, armed with the sepsis bundles, attacks the three heads of severe sepsis:
hypotension, hypoperfusion, and organ dysfunction.
Crit Care Med. 2004;320(Suppl):S595-S597

42. What Type of Shock is This?
•
A 55 yo M DM presents with “crushing” substernal chest
pain, diaphoresis, hypotension, tachycardia and cool,
clammy extremities
Cardiogenic shock
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
42

43. ESSENTIALS OF DIAGNOSIS
•
Decreased urine output.
•
Impaired mental function.
•
Cool extremities.
•
Distended neck veins.
•
Hypotension with evidence of peripheral and pulmonary
venous congestion.
•
Acute myocardial infarction most common cause
Dr Mai Duc Thao. ED. Friendship
Hospital. Ha noi 2013
43

44. Cardiogenic shock
 Circulatory pump failure in setting of adequate
vascular volume
 Sustained hypotension SBP < 90 mm Hg for at least
30 minutes
CI < 2.2 L/min/m2
PAWP >15mmHg
Surgical importance in patients with chest trauma for
Tamponade
Tension pneumothorax
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
44

45. Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
45

46. What Type of Shock is This?
•
A 34 yo F presents to the ED after dining at a restaurant where
shortly after eating the first few bites of her meal, became anxious,
diaphoretic, began wheezing, noted diffuse pruritic rash, nausea,
and a sensation of her “throat closing off”.
She is currently
hypotensive, tachycardic and ill appearing.
Anaphalactic
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
46

47. ESSENTIALS OF DIAGNOSIS
•Cutaneous flushing, pruritus.
•Abdominal distention, nausea, vomiting, diarrhea.
•Airway obstruction owing to laryngeal edema.
•Bronchospasm, bronchorrhea, pulmonary edema.
•Tachycardia, syncope, hypotension.
•Cardiovascular collapse.
Dr Mai Duc Thao. ED. Friendship
Hospital. Ha noi 2013
47

48. Management of anaphylaxis

Anaphylaxis is an acute medical emergency. The
immediate management includes:







preventing further contact with the allergen (e.g. removal of
bee sting)
ensuring airway patency
administration of oxygen
restoration of blood pressure (laying the patient flat,
intravenous fluids)
prompt administration of adrenaline (epinephrine).
Intravenous antihistamines (chlorphenamine 10-20 mg i.m.
or slow i.v. injection), which limit ongoing inflammation.
Corticosteroids (hydrocortisone 100-300 mg) prevent latephase symptoms in severely affected patients.
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013

49. What Type of Shock is This?
•
A 41 yo M presents to the ED after an MVC complaining of
decreased sensation below his waist and is now hypotensive,
bradycardic, with warm extremities
Neurogenic shock
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
49

50. ESSENTIALS OF DIAGNOSIS
• Preceded by trauma or spinal anesthesia.
• Hypotension with tachycardia.
• Cutaneous warmth and flushing in the
denervated area.
• Venous pooling.
Dr Mai Duc Thao. ED. Friendship
Hospital. Ha noi 2013
50

51. Neurogenic Shock
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
51

52. What Type of Shock is This?
•
A 24 yo M presents to the ED after an MVC c/o chest pain and
difficulty breathing. On PE, you note the pt to be tachycardic,
hypotensive, hypoxic, and with decreased breath sounds on left
Obstructive
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
52

53. Obstructive Shock

54. Narcotic - toxic






Hypothermia
Bradycardia
Hypotension
Respiratory depression
Constricted pupils
CNS depression
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
54

55. General Management



ABC
Consider thiamine, dextrose, naloxone if depressed GCS
Prevent further absorption



Decontaminate eyes, clothes, skin, hair if appropriate
Activated charcoal + sorbitol (if < 1 hour from ingestion)
Gastric lavage (if < 1 hour from ingestion and life-threatening drug or dose)


Whole bowel irrigation for “body packing” illicit drugs


In general not used
In general not used
Enhance elimination


Forced diuresis and urinary alkalinisation (salicylates and barbiturates)
Multiple dose activated charcoal 0.5 g/kg every 2-4 hours



binds toxin and interrupts enterohepatic recirculation
mainly life-threatening ingestion of carbamazepine, dapsone, phenobarbital, quinine or theophylline
Extracorporeal removal (for active metabolites, delayed toxicity or poor organ clearance)

Haemodialysis - low MW (<500 d), soluble, low Vd (< 1L/kg) e.g. methanol, ethylene glycol,
salicylates, lithium



Haemoperfusion - e.g theophylline, phenobarbital, phenytoin, carbamazepine, paraquat
Haemofiltration for large Vd and extensive tissue bound toxins but removes virtually all drugs
Antidotes
Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
55

56. Dr Mai Duc Thao. ED. Friendship Hospital.
Ha noi 2013
56

57. Dr Mai Duc Thao. ED. Friendship
Hospital. Ha noi 2013
57

58. Dr Mai Duc Thao. ED. Friendship
Hospital. Ha noi 2013
58

59. References


Tintinalli. Emergency Medicine. 6th
edition
Rivers et al. Early Goal-Directed
Therapy in the Treatment of Severe
Sepsis and Septic Shock. NEJM 2001;
345(19):1368.
Dr Mai Duc Thao. ED. Friendship
Hospital. Ha noi 2013
59