D. P. Laporta MD SMBD-JGH Dept of Adult Critical Care

D. P. Laporta MDD. P. Laporta MD

SMBD-JGH SMBD-JGH

Dept of Adult Critical CareDept of Adult Critical Care

SHOCK - SHOCK - OUTLINEOUTLINE

DEFINITIONDEFINITION CAUSESCAUSES EFFECTS OF INEFFECTIVE TREATMENTEFFECTS OF INEFFECTIVE TREATMENT ASSESSMENTASSESSMENT CLINICAL APPROACHCLINICAL APPROACH

CASECASE

CASECASE

CASECASE

CASECASE

CASECASE

CASECASE

SHOCK CASESSHOCK CASES1. post Cardiac Surgery1. post Cardiac Surgery- same day- same day- 1 week postop- 1 week postop

2. in MVA victim2. in MVA victim

3. In young male with Crohn ’s 3. In young male with Crohn ’s disease found febrile in shockdisease found febrile in shock

4. In drug addict, hospital 4. In drug addict, hospital workerworker

SHOCK -SHOCK -

DEFINITIONDEFINITION

CAUSESCAUSES EFFECTS OF INEFFECTIVE TREATMENTEFFECTS OF INEFFECTIVE TREATMENT ASSESSMENTASSESSMENT CLINICAL APPROACHCLINICAL APPROACH

A profound disturbance of the circulationA profound disturbance of the circulation

and metabolism, leading to and metabolism, leading to

inadequate perfusion of vital organs,inadequate perfusion of vital organs,

necessary to maintain homeostasisnecessary to maintain homeostasis

DEFINITION

SHOCK -SHOCK -

DEFINITIONDEFINITION

CAUSESCAUSES

EFFECTS OF INEFFECTIVE TREATMENTEFFECTS OF INEFFECTIVE TREATMENT ASSESSMENTASSESSMENT CLINICAL APPROACHCLINICAL APPROACH

HYPOPERFUSED STATESHYPOPERFUSED STATES

RVRV LVLVArterial Arterial (resistance)(resistance)

Venous Venous (capacitance)(capacitance)

PVRPVR

EF End-Diastolic Volume

SVRSVR

HypovolemicHypovolemicBP 60/30BP 60/30

HR 140/minHR 140/min

CVP 0CVP 0

Lactate 10Lactate 10

CardiogenicCardiogenicBP 70/50BP 70/50

HR 130/minHR 130/min

CVP 18CVP 18

Lactate 12Lactate 12

ObstructiveObstructiveBP 70/50BP 70/50

HR 140/minHR 140/min

CVP 15CVP 15

Lactate 12Lactate 12

VTED

OAD

DLD

DistributiveDistributiveBP 70/40BP 70/40

HR 140/minHR 140/min

CVP 5CVP 5

Lactate 12Lactate 12

SHOCK -SHOCK - DEFINITIONDEFINITION CAUSESCAUSES

EFFECTS OF INEFFECTIVE TREATMENTEFFECTS OF INEFFECTIVE TREATMENT

ASSESSMENTASSESSMENT MEASUREMENTMEASUREMENT CLINICAL APPROACHCLINICAL APPROACH

EFFECTS OF INEFFECTIVE TREATMENT

MISERY !!!MISERY !!!MODSMODS

• PO2/ FiO2 ratio

• Serum creatinine

• Platelet count

• Glasgow coma score

• Serum bilirubin

• Pressure-adjusted heart rate

(hr x CVP/MAP)

INFECTIONINFECTION

SHOCK -SHOCK - DEFINITIONDEFINITION CAUSESCAUSES EFFECTS OF INEFFECTIVE TREATMENTEFFECTS OF INEFFECTIVE TREATMENT

ASSESSMENTASSESSMENT

MEASUREMENTMEASUREMENT CLINICAL APPROACHCLINICAL APPROACH

SHOCK: asssessmentSHOCK: asssessment

Class 1&2 vs 3&4Class 1&2 vs 3&4 needs blood or crystalloid ?needs blood or crystalloid ?

hypercarbia is a universal indicator of critically reduced tissue perfusion.

Sublingual capnometrySublingual capnometry: : A new noninvasive measurement for diagnosis and A new noninvasive measurement for diagnosis and

quantitation of severity of circulatory shockquantitation of severity of circulatory shock

Max Harry Weil MD, PhD, FCCM - CCM 1999Max Harry Weil MD, PhD, FCCM - CCM 1999

Sublingual capnometrySublingual capnometry: : A new noninvasive measurement for diagnosis and A new noninvasive measurement for diagnosis and

quantitation of severity of circulatory shockquantitation of severity of circulatory shock

Sublingual capnometrySublingual capnometry: : A new noninvasive measurement for diagnosis and A new noninvasive measurement for diagnosis and

quantitation of severity of circulatory shockquantitation of severity of circulatory shock

Sublingual capnometrySublingual capnometry: : A new noninvasive measurement for diagnosis and A new noninvasive measurement for diagnosis and

quantitation of severity of circulatory shockquantitation of severity of circulatory shock

P P SLSL CO CO22

provides a prompt provides a prompt indication of the indication of the reversal of tissue reversal of tissue hypercarbia hypercarbia when circulatory when circulatory shock is reversedshock is reversed

SHOCK -SHOCK -

DEFINITIONDEFINITION CAUSESCAUSES EFFECTS OF IEFFECTIVE TREATMENTEFFECTS OF IEFFECTIVE TREATMENT MEASUREMENTMEASUREMENT

CLINICAL APPROACHCLINICAL APPROACH

SHOCK: an EMERGENCY !!!SHOCK: an EMERGENCY !!!

GOAL:GOAL:

RAPIDLY RESTORE TISSUE PERFUSIONRAPIDLY RESTORE TISSUE PERFUSION

• Recognize it !!!Recognize it !!!

•Immediate stabilization: ABCImmediate stabilization: ABC

…… ……. SHOTGUN approach. SHOTGUN approach

• ICU & Surgical consultationICU & Surgical consultation

•Treat the causeTreat the cause

Management Management prioritiespriorities

in hypoperfused statesin 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...NE…Vasopressin/Phenylephrine