Shock

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Case A

73 year old woman

History of BP,
diabetes
Total hip replacement
6 days ago
Now oliguric
BP 130/100
Confused
Shock

State in which there is inadequate

blood flow to the tissues to meet
demand
Hypotension need not be
present
 Homeostasis
Vasodilatation High Low Vasoconstriction
Mean arterial pressure?
HR HR

Failure of compensation
Very severe disease
Shock

Hypoperfusion
Conscious state
Temperature of
limbs
Skin mottling
Urine output
pH
Lactate
Case A

73 year old woman

Shocked
Oliguric
Confused
Skin mottling
What next?
Global haemodynamic
relationships

MAP CO TPR
Global haemodynamic
relationships
Peripheral
perfusion

MAP CO TPR
Global haemodynamic
relationships
Peripheral
perfusion

MAP CO TPR

HR SV
Global haemodynamic
relationships
Peripheral
perfusion

MAP CO TPR

HR SV
JVP,CVP,
PAOP
Preload Afterload Contractility
Case A

HR 104/min regular, small volume

JVP 4 cm above sternal angle
Cold peripheries
 Causes of shock
HR JVP or CVP Peripheries

Cardiac or or Cold

Hypovolaemic Cold

Distributive -N Warm

Obstructive* Cold

* Obstructive shock due to cardiac tamponade, tension pneumothorax or massive PE

Case A

Differential diagnosis
Cardiogenic shock
Obstructive shock due to pulmonary
embolus
What next?
Immediate resuscitation of
the shocked patient
Immediately life threatening hypotension
Epinephrine 0.1 mg boluses
Vasopressor infusion

Usually fluid
BUT how much?
Cause
Treatment goals
Treatment goals

cardiac output
blood pressure
Blood flow

Perfusion pressure
Treatment goals

cardiac output
blood pressure
Blood flow

Perfusion pressure
Case A

Start fluid infusion

Give oxygen
Oxygenation status unclear at the
moment
Investigations
ABG
ECG
Biochemistry, complete blood count
Increasing cardiac output

Starling relationship
Cardiac output

Volume loading
Cardiogenic shock
End diastolic pressure

Pulmonary
oedema

End diastolic volume

What if fluids arent
enough?
Inadequate cardiac output
Inotrope
Inadequate blood pressure
Vasopressor
Dopamine

Inotrope
Vasopressor
Positive chronotrope
Concentration-dependent effects
Dobutamine

Inotrope
Vasodilator
Positive chronotrope
Norepinephrine

Vasopressor
Increases cardiac output in
hypotensive patients
Increases coronary perfusion and
hence cardiac function
Cardiogenic

Coronary perfusion to LV dependent

on diastolic blood pressure
LV function dependent on coronary
perfusion
Tachycardia decreases duration of
diastole
Cardiogenic

Aims:
Adequate diastolic pressure without
tachycardia
Increase cardiac output
Normotensive patient with poor
peripheral perfusion
Dobutamine infusion
Hypotensive patient
Norepinephrine infusion
How much?
Altered dose-
response curve in
critically ill,
particularly sepsis

Response

Dose
Dosage
Altered dose-
response curve in
critically ill,
particularly sepsis

Response
Titrate against
effect
Short half-life
Frequent
assessment 0 5 10 15 20

Mins
Titrate
Initial
dose

Increase Too low Too high Decrease

Target BP?
dose dose
Cardiogenic

Early referral
Revascularization
Intra-aortic balloon pump
Treat cause
Hypovolaemic
Hypovolaemic

Vasopressors
Life threatening hypotension
Distributive shock phase
Treat underlying cause
Septic

Pathophysiology
Vasodilatation
Capillary leak
Septic

Norepinephrine or dopamine
Dobutamine
Tissue hypoperfusion despite
normotension
Source control
Antibiotics
Obstructive

More complicated
Initial treatment depends on
pathophysiology of underlying
cause
Tension pneumothorax
Emergency thoracostomy
Massive pulmonary embolus
Fluid bolus 100-250 ml
Obstructive

Complex, call for help

Early relief of obstruction
Dobutamine-induced vasodilatation
may severe hypotension due to
relatively fixed cardiac output
Norepinephrine probably drug of
choice for initial management
Summary

Resuscitation
Restore tissue perfusion
Conscious state
Temperature of limbs
Skin perfusion
Urine output
pH
Lactate
Summary

Resuscitation
Fluid
Vasopressor to restore BP
Inotrope to increase cardiac output
Titrate against patient response
Summary

Initial cardiovascular assessment

JVP, peripheries, HR
BP
Treat underlying cause
Any questions?