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

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

EFFECTS OF INEFFECTIVE TREATMENT
ASSESSMENT
CLINICAL APPROACH
HYPOPERFUSED STATES
RV LV
Arterial
(resistance)
Venous
(capacitance)
PVR
EF End-Diastolic Volume
SVR
Hypovolemic
BP 60/30
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 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 ?
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
Max Harry Weil MD, PhD, FCCM - CCM 1999
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
CO
2

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
Priority # Physiology to
improve
Intervention Parameter to target PAC
targets
Avoid
1 Volume Fluids CVP 10-15 DO2 Low Sao2
See CXR
2 Pressure Vasopressor SBP
?
100 or within 20-25
torr
MBP
?
80 of patient's Nl

Low SV, DO2
High HR,
Resistances
3 Flow Inotrope Signs of perfusion DO2 Low BP, SV,
Resistances

BP potency: Dopamine...NEVasopressin/Phenylephrine