1What are the four types of shock?
- Cardiogenic Shock: Acute MI, valvular disease, arrhythmias
- Hypovolemic shock: Blood volume loss
- Obstructive Shock: Cardiac tamponade, PE
- Distributive Shock: Anaphylaxis, neurogenic, sepsis
2Types of Shock
Which type is associated with decreased afterload with normal or high CO?
Distributive
3Types of Shock
Which type is associated with decreased preload with low CO?
Hypovolemic
4Types of Shock
Which type is associated with decreased CO and high CVP?
- Cardiogenic
- Obstructive
5Cardiogenic Shock
Main causes?
- Myocardial Infarction = Rule out rupture
- Left Ventricular Failure = Myocarditis / Cardiomyopathies
- Valvular disease = Usually leading to LV failure
- Arrhythmias
6Cardiogenic Shock
Diagnostics?
- SBP<80-90mmHg or MAP drop 30mmHg from baseline
- Significant reduction in cardiac index or cardiac output
- Adequate filling pressure
7Cardiogenic Shock
What is often used to diagnose and then guide therapy?
Pulmonary artery catheter
8Cardiogenic Shock
After the underlying condition or cause has been ruled out, what drugs are the main treatment?
Inotropic therapy:
- First line = Dobutamine
- Second line = Milrinone
9Cardiogenic Shock
What are inotropic agents used over vasopressors?
Inotropic agents will increase CO, vasopressors will increase BP. The issue is cardiac, not vasodilation or hypotension.
10Hypovolemic Shock
In addition to acute blood loss, what other complications are seen with hypovolemic shock?
- Lactic acidosis
- Coagulopathy
- Hypothermia
11Hypovolemic Shock
Causes?
- Abdominal aortic aneurysm
- PUD
- Trauma
- Maternal disorder
12Hypovolemic Shock
What are the main components to pre-hospital care?
- Hemorrhage identification
- Physical control of bleeding
- Large volume parenteral (LVP) administration for hemodynamic support
- Prevent hypothermia
- Getting patient to appropriate medical facility FAST
13Hypovolemic Shock
What are the main components to in-hospital care?
- Definitive identification of source and diagnosis of shock
- LVP and hemodynamic support
- 'Massive Transfusion Protocol' if patients meet criteria
- Stop the bleeding
- If the patient is on anticoag and needs reversal
14Hypovolemic Shock
What do "Massive Transfusion Protocols" consist of?
Usually 1:1:1 with plasma:platelets:RBCs +/- cryoprecipitate
15Hypovolemic Shock
What agent is sometimes used in hypovolemic shock that blocks the conversion of plasminogen to plasmin in acute major bleeding?
Tranexamic acid
16Distributive Shock
Three main types?
- Anaphylaxis
- Neurogenic
- Sepsis = Most common
17Distributive Shock
Mechanism?
Systemic vasodilation leading to initial decreased afterload and eventually will affect preload
18Distributive Shock
Which type is NOT associated with CNS dysfunction or infection and typically associated with an allergen?
Anaphylaxis
19Distributive Shock
Anaphylaxis treatment regimen?
1. Airway, Breathing, Circulation, Consciousness
2. Epinephrine 1:1000 (1mg/mL) 0.2-0.5mL IM STAT
3. Diphenhydramine 25-50mg IV STAT
4. Consider H2-antagonist (ranitidine or famotidine)
5. Consider albuterol inhalation
6. Glucocorticoids not helpful acutely but sometimes used
20Sepsis / Septic Shock
Systemic inflammation due to a source of _______________. Results in what 3 things?
- Infection
- Systemic vasodilation leads to hypoperfusion
- Decreased anticoagulation leads to thrombus formation
- Organ dysfunction leads to eventual failure and increased risk of mortality
21Sepsis / Septic Shock
Explain the pathophysiology?
- When a systemic inflammatory process is stimulated, pro-inflammatory cytokines are released and NO pathway stimulated
- Increases vascular permeability to recruit immune cells to 'source'
- Causes fluid to go out of vasculature and into extravascular space
**Decreased fluid in vasculature + systemic vasodilation = Hypotension**
22Sepsis / Septic Shock
Which type of organisms are the most common causes of sepsis?
Which type of organisms are twice as likely to lead to septic shock + higher mortality?
- Gram positives = More common
- Gram negatives = More septic shock and mortality
23Sepsis / Septic Shock - Dx
How do we diagnose sepsis?
Presence of infection + 2/4 SIRS criteria
- HR > 90 beats per minute
- RR > 20 per minute OR pCO2<32
- Temp. > 38◦C or <36◦C
- WBC >12,000, <4,000 OR >10% bands
24Sepsis / Septic Shock - Dx
How do we diagnose septic shock?
Sepsis + hypotension requiring vasopressors to maintain MAP > 65
25Sepsis / Septic Shock - Dx
What is used to quickly identify organ dysfunction?
qSOFA = Need 1/3
- RR > 22
- Altered mentation
- SBP < 100
26Septic Shock Tx
Acute goals of treatment?
- Increase intravascular volume
- Increase tissue perfusion and oxygen delivery
- Get treatment for infection started immediately
27Septic Shock Tx
Long-term goals of treatment?
- Treat infection with de-escalation
- Decrease time in ICU
- Decrease morbidity and mortality
28Septic Shock Tx
What are the components to initial resuscitation?
- 30mL/kg of IV crystalloid (LRs) within first 3 hrs
- Recommend goal MAP target of 65mmHg
- Recommend treating to normalize serum lactate concentrations
29Septic Shock Tx
T/F: For every hour of delay in starting antimicrobials after hypotension, survival decreases by 7.6%
TRUE
30Septic Shock Tx
T/F: Serum lactate is commonly used to diagnoses septic shock.
FALSE -- Used to guide treatment effectiveness. AS lactate trends down, that means treatment is working
31Septic Shock Tx
What are the most common sources of infection?
- Lung is the most commonly identified site of infection (37.2%)
- Intra-abdominal - 29%
- Genitourinary - 10%
- Bloodstream (primary) - 4%
32Septic Shock Tx
What are the components of antimicrobial therapy?
- Start IV antibiotics as soon as possible after recognition and within one hour
- Recommend empiric broad spectrum therapy with one or more (usually 2) antimicrobials that cover all likely pathogens
- Narrow broad spectrum therapy based on clinical course and/or culture results
- Guidelines are NOT strongly in favor of double-coverage for likely pathogens as part of empiric coverage
- Treatment for 7-10 days (longer for specific causes)
- SOURCE CONTROL!!
33Septic Shock Tx
What are the common broad spectrum antimicrobials used?
Anti-MRSA:
- Vancomycin
Gram negative:
- Zosyn
- Cefepime
Anaerobic coverage PRN: (GI, GU sources)
- Zosyn
- Carbapenem
- Metronidazole
34Septic Shock Tx
What is the preferred fluid? Why?
Lactated Ringers
- More closely related to normal plasma
- Less acidosis and chloride elevations
35Septic Shock Tx
What are the components of vasopressor therapy?
- NE as first-choice vasopressor
- Add either vasopressin or epinephrine as second agent to increase MAP to goal (or vasopressin added to decrease norepinephrine dose)
- Dopamine as an alternative ONLY in select patients (bradycardic or low risk of tachyarrhythmias)
- 'Low-dose' dopamine not recommended for renal protection
- Dobutamine recommended only if persistent hypoperfusion despite adequate fluid resuscitation AND vasopressor use
36Septic Shock Tx - Vasopressors
What is the DOC in septic shock?
What type of activity does it have?
AE associated with prolonged use?
- NE
- Alpha 1 and Beta 1 activity = Increase SVR
- extremity ischemia
37Septic Shock Tx - Vasopressors
Second line after NE has been used?
What type of activity does it have?
Common AEs?
- Epi
- Alpha 1, beta 1, beta 2 = Increase CO, increase SVR
- Tachycardia and HTN
38Septic Shock Tx - Vasopressors
Which agent is not recommended for use in septic shock due to high risk of tachyarrhythmias?
Dopamine
39Septic Shock Tx - Vasopressors
3rd line for septic shock?
What type of activity does it have?
What other type of shock is it commonly used in?
- Phenylephrine
- Alpha only = Increase SVR only
- Neurogenic
40Septic Shock Tx - Vasopressors
What agent is used as adjunct to NE in septic shock and should never be used as monotherapy?
Vasopressin
41Septic Shock Tx - Vasopressors
What is the general order that each of the pressors should be used?
1. NE
2. MAP < 65 = Add vasopressin
3. MAP < 65 = Add epi
4. MAP < 65 = Add phenylephrine
42Septic Shock Tx
What is the place in therapy for IV hydrocortisone in septic shock?
Only recommended if septic shock patient is unable to achieve adequate hemodynamic stability after fluid resuscitation AND vasopressors
43Septic Shock Tx
Why is hydrocortisone used over other corticosteroids?
It has mineralocorticoid activity = Fluid retention = Increased BP
44Septic Shock Tx
What is the goal blood glucose of septic shock patients?
< 180mg/dL
- Avoid hypoglycemia due to increased mortality
**recommend insulin therapy when two consecutive glucose results >180mg/dL**