1. Approach to a case of
Hypotension and Shock
Introductory Lecture Series
Department of Medicine
Dr C Khati
2. Shock is an Emergency
Assessment and resuscitation go hand in hand
because time is critical
3. Learning Objectives
• To learn definition and meanings of related
terms
• To be able to list the steps in pathogenesis of
shock
• To be able to list the 3 major categories of
shock, and 3 others
• To be able to enumerate common causes of
shock in each of the 3 major categories
4. Learning Objectives
• To comprehend that more than one
mechanisms may operate in a given patient
• To list steps in rapid initial assessment
• To enumerate broad steps in resuscitation of
shock
5. Definitions and Meanings
• Stroke Volume (SV): Amount of blood
pumped out with each systole. Pulse pressure
correlates well with SV
• Heart Rate (HR): Number of ventricular
contractions per minute
• Cardiac Output(CO): Amount of blood
pumped out in each minute.
CO = SV X HR
6. Definitions and Meanings
• Stroke Volume (SV): Amount of blood
pumped out with each systole. Pulse pressure
correlates well with SV
• Heart Rate (HR): Number of ventricular
contractions per minute
• Cardiac Output(CO): Amount of blood
pumped out in each minute.
CO = SV X HR
7. Definitions and Meanings
• Stroke Volume (SV): Amount of blood
pumped out with each systole. Pulse pressure
correlates well with SV
• Heart Rate (HR): Number of ventricular
contractions per minute
• Cardiac Output(CO): Amount of blood
pumped out in each minute.
CO = SV X HR
8. Definitions and Meanings
• Stroke Volume (SV): Amount of blood
pumped out with each systole. Pulse pressure
correlates well with SV
• Heart Rate (HR): Number of ventricular
contractions per minute
• Cardiac Output(CO): Amount of blood
pumped out in each minute.
CO = SV X HR
10. Definitions and Meanings
Pulse Pressure (PP): SBP – DBP correlates well
with Stroke Volume .
Mean Arterial Pressure (MAP): DBP + 1/3 PP
11. Definition and Meanings
• Hypotension is diagnosed if blood pressure falls
below 90/50 mmHg in adults.
• Hypotension may also be diagnosed if an individual
has a sudden drop in SBP of 30 - 40 mmHg or more
from their baseline, or
• An orthostatic (postural) drop in DBP of 15 mm Hg
12. Definition and Meanings
• Hypotension is diagnosed if blood pressure falls
below 90/50 mmHg in adults.
• Hypotension may also be diagnosed if an individual
has a sudden drop in SBP of 30 - 40 mmHg or more
from their baseline, or
• An orthostatic (postural) drop in DBP of 15 mm Hg
13. Definition and Meanings
• Hypotension is diagnosed if blood pressure falls
below 90/50 mmHg in adults.
• Hypotension may also be diagnosed if an individual
has a sudden drop in SBP of 30 - 40 mmHg or more
from their baseline, or
• An orthostatic (postural) drop in DBP of 15 mm Hg
15. Definitions and Meanings
• The Jugular Venous Pressure (JVP) is an
observed pressure over the jugular veins
• The Central Venous Pressure (CVP) is a
measured pressure in the right atrium by
means of a catheter attached to a manometer
16. Definitions and Meanings
• The Jugular Venous Pressure (JVP) is an
observed pressure over the jugular veins
• The Central Venous Pressure (CVP) is a
measured pressure in the right atrium by
means of a catheter attached to a manometer
17. Definitions and Meanings
• The Jugular Venous Pressure (JVP) is an
observed pressure over the jugular veins
• The Central Venous Pressure (CVP) is a
measured pressure in the right atrium by
means of a catheter attached to a manometer
18. Definitions and Meanings
Capillary Nail Refill Test
• Pressure is applied to the nail bed until it turns white
(blanching). Then pressure is removed.
• Time taken for return of pink colour to the nail is
considered (capillary refill).
• Blanch time > 2 seconds is a delayed response.
–Dehydration
–Shock
– Peripheral vascular disease (PVD)
– Hypothermia
19. Definitions and Meanings
Capillary Nail Refill Test
• Pressure is applied to the nail bed until it turns
white (blanching). Then pressure is removed.
• Time taken for return of pink colour to the nail is
considered (capillary refill).
• Blanch time > 2 seconds is a delayed response.
–Dehydration
–Shock
–Peripheral vascular disease (PVD)
–Hypothermia
20. Definitions and Meanings
Shock or circulatory failure is the clinical syndrome that
results from generalized inadequate tissue perfusion
lasting for some time. Where oxygen delivery fails to
meet metabolic requirements of the tissues.
It is defined by the presence of multisystem, end organ
hypo perfusion causing cellular injury.
Cellular injury further compromises perfusion through
functional and structural changes in the
microvasculature through mediators
Thus, setting up a vicious cycle.
21. Definitions and Meanings
Shock or circulatory failure is the clinical syndrome that
results from generalized inadequate tissue perfusion
lasting for some time. Where oxygen delivery fails to
meet metabolic requirements of the tissues.
It is defined by the presence of multisystem, end organ
hypo perfusion causing cellular injury.
Cellular injury further compromises perfusion through
functional and structural changes in the
microvasculature through mediators
Thus, setting up a vicious cycle.
22. Definitions and Meanings
Shock or circulatory failure is the clinical syndrome that
results from generalized inadequate tissue perfusion
lasting for some time. Where oxygen delivery fails to
meet metabolic requirements of the tissues.
It is defined by the presence of multisystem, end organ
hypo perfusion causing cellular injury.
Cellular injury further compromises perfusion through
functional and structural changes in the
microvasculature through mediators
Thus, setting up a vicious cycle.
27. Definition and Meanings
• Early Shock
• No significant organ failure
• Late Shock
• Multi-organ failure. > 80% mortality
28. Definition and Meanings
• Early Shock
• No significant organ failure
• Late Shock
• Multi-organ failure. > 80% mortality
29. Definition and Meanings
• Early Shock
• No significant organ failure
• Late Shock
• Multi-organ failure. > 80% mortality
30. Definitions and Meanings
• Systemic Vascular Resistance (SVR): An index
of arteriolar constriction throughout the body
• Calculated by dividing the blood pressure by
the cardiac output. MAP/ CO = SVR
• Pulmonary Vascular Resistance (PVR): An
index of arteriolar constriction in the
pulmonary circulation
31. Definitions and Meanings
• Systemic Vascular Resistance (SVR): An index
of arteriolar constriction throughout the body
• Calculated by dividing the blood pressure by
the cardiac output. MAP/ CO = SVR
• Pulmonary Vascular Resistance (PVR): An
index of arteriolar constriction in the
pulmonary circulation
32. Definitions and Meanings
• Systemic Vascular Resistance (SVR): An index
of arteriolar constriction throughout the body
• Calculated by dividing the blood pressure by
the cardiac output. MAP/ CO = SVR
• Pulmonary Vascular Resistance (PVR): An
index of arteriolar constriction in the
pulmonary circulation
33. Definitions and Meanings
• Systemic Vascular Resistance (SVR): An index
of arteriolar constriction throughout the body
• Calculated by dividing the blood pressure by
the cardiac output. MAP/ CO = SVR
• Pulmonary Vascular Resistance (PVR): An
index of arteriolar constriction in the
pulmonary circulation
45. Pathogenesis of Shock ( CO)
MAP = CO X SVR
or
MAP/ CO = SVR
• If an hypotensive patient has high CO, it can
be inferred that reduced BP is a result of
decreased SVR
46. Pathogenesis of Shock ( CO)
MAP = CO X SVR
or
MAP/ CO = SVR
• If a hypotensive patient has high CO, it can be
inferred that reduced BP is a result of
decreased SVR
47. Pathogenesis of Shock ( CO)
• Low Intravascular and Cardiac Volume
• Increased Intravascular and Cardiac Volume
49. Pathogenesis of Shock ( CO)
Low Intravascular and Cardiac Volume
• Hemorrhage
• Volume Losses (vomiting, diarrhea, Polyuria)
• JVP/ CVP is reduced
• What do you think the other findings will be?
50. Pathogenesis of Shock ( CO)
Low Intravascular and Cardiac Volume
• Hemorrhage
• Volume Losses (vomiting, diarrhea, Polyuria)
• JVP/ CVP is reduced
• What do you think the other findings will be?
51. Pathogenesis of Shock( CO)
Increased Intravascular and Cardiac Volume
• Increased JVP/ CVP
• Extremity edema
• S3/ S4 gallops
• Basal crepitations
• X Ray
– Cardiomegaly
– Widened vascular pedicles, Kerley B Lines
– Pulmonary edema
52. Common Categories of Shock
1. Cardiogenic
2. Hypovolemic
3. High CO with decreased SVR (Warm Shock)
4. Neurogenic- Major brain or spinal injury-
5. Hypoadrenal- Refractory Shock
6. Obstructive- Tamponade, Pulmonary
Embolism, Tension Pneumothorax
53. Common Categories of Shock
1. Cardiogenic
2. Hypovolemic
3. High CO with decreased SVR (Warm Shock)
4. Neurogenic- Major brain or spinal injury-
5. Hypoadrenal- Refractory Shock
6. Obstructive- Tamponade, Pulmonary
Embolism, Tension Pneumothorax
54. Basic Changes in Each Category
Cardiogenic Hypovolemic High CO with
decreased SVR
CO Low Low High
55. Basic Changes in Each Category
Cardiogenic Hypovolemic High CO with
decreased SVR
CO Low Low High
SVR High High Low/ High (late)
56. Basic Changes in Each Category
Cardiogenic Hypovolemic High CO with
decreased SVR
CO Low Low High
SVR High High Low/ High (late)
MAP Low Low Normal/ Low
57. Basic Changes in Each Category
Cardiogenic Hypovolemic High CO with
decreased SVR
CO Low Low High
SVR High High Low/ High (late)
MAP Low Low Normal/ Low
CVP High Low Low/ High (late)
58. Basic Changes in Each Category
Cardiogenic Hypovolemic High CO with
decreased SVR
CO Low Low High
SVR High High Low/ High (late)
MAP Low Low Normal/ Low
CVP High Low Low/ High (late)
Venous Oxygen
saturation
Low Low High
59. Common Causes of Shock
Cardiogenic Hypovolemic High CO with
decreased SVR
MI GI Losses SIRS
Arrhythmias Heat stroke Sepsis
Myocarditis Hemorrhage Pancreatitis
Anaphylaxis
Tamponade Trauma Thyrotoxicosis (storm)
Injuries Burns Burns
AV Shunts
Liver Failure
60. Steps in rapid initial assessment
• Confirm shock and assess severity
• Assess category of shock
• Low CO or high CO
(Heart empty or full)
• Start resuscitation simultaneously
61. Steps in rapid initial assessment
• Confirm shock and assess severity
• Assess category of shock
• Low CO or high CO
(Heart empty or full)
• Start resuscitation simultaneously
62. Steps in rapid initial assessment
• Confirm shock and assess severity
• Assess category of shock
• Low CO or high CO
(Heart empty or full)
• Start resuscitation simultaneously
63. Goal of Resuscitation ?
• Re establish adequate tissue perfusion to
prevent or minimize end- organ injury
64. Goal of Resuscitation
• Re establish adequate tissue perfusion to
prevent or minimize end- organ injury
65. Resuscitation is different in each category
Cardiogenic Hypovolemic High CO with decreased
SVR
Treatment for
Ischemia
IV Fluids Antibiotics
Ionotropes Colloids EGDT*
After load
reduction
Low dose steroids
Activated Protein C
66. Steps in rapid initial assessment
• Patient and clinical situation assessment
• Vitals and quick examination to assess category
of shock-
• Core temperature
• Cold or warm peripheries
• Pulse- bounding or low volume
• Capillary filling- slow/ rapid
• Raised JVP, S3 and basal crepts in cardiogenic
• Respiration
• Urine Output
67. Steps in rapid initial assessment
• Patient and clinical situation assessment
• Vitals and quick examination to assess
category of shock-
–Core temperature
–Cold or warm peripheries
–Pulse- bounding or low volume
–Capillary filling- slow/ rapid
–Raised JVP, S3 and basal crepts in
cardiogenic
–Respiration
–Urine Output
68. Terms in Assessment/ Treatment
• APACHE II Score- Acute Physiology and
Chronic Health Evaluation II (with points for
age and co-morbidity)
• Glasgow Coma Score
• ACLS- Advanced Cardiac Life Support
• Old acronym- ABC (still valid)
69. General Features of Shock
• Hypotension (SBP < 100)
• Tachycardia (>100)
• Cold clammy skin (Low CO)
• Rapid shallow respiration
• Drowsiness, confusion and irritability
• Oliguria (<30ml/hr)
• Elevated / reduced CVP
• Multi- organ failure
70. Steps in Resuscitation
• Airway and Respiration
• Circulation
• Early Goal Directed Therapy (EGDT)
• Multisystem organ support
71. 32 year old young lady, on NSAIDS
• Dyspepsia X 5 days
• Dark tarry stools X 2 days
• Profound weakness X 2 days
• Syncope this morning
• Cold clammy and sweating, Poor capp refill
• BP 70/50 mm Hg lying; 60/ 35 mm standing
• Pulse 140/ min, thready
• Resp- 36/ min
• Pallor
72. 40 year busy doctor, HT
• Chest Pain X 1 Hour
• Sweating, palpitations and breathlessness
• Restless, sweating, cold and clammy
• BP 100/76 mm, Pulse 110/ min, low volume
• Resp- 26/ min, prefers to be propped up
• Poor capillary refill
• JVP/ CVP raised
73. 45 year old diabetic male
• Fever, cough and rusty sputum X 2 days
• Weakness X 1 day
• No urine X12 hours
• Temp- 40 degrees C, warm extremities
• Pulse 120/ min, good volume
• BP 108/30 mm, Resp rate 40/ min
• Cyanosis +, JVP not raised
• Capp refill good
74. Take Home Messages
• Shock is an Emergency. Assessment and
resuscitation go hand in hand because time is
critical
• Hypotension is a late feature of shock. Do not
wait for hypotension before starting treatment
• Clinical setting and simple examination of MAP,
pulse pressure, heart rate, JVP and nail cappillary
bed refill can give vital clues. Tachypnea and
sweating should also make you alert.
75. Take Home Messages
• Urine output is a good indicator of renal (tissue)
perfusion
• Goal of resucitatation is to re establish adequate
tissue perfusion to prevent or minimize end-
organ injury