Circulatory Failure - Shock Case Presentation 56 year old man with a past history of type 2 diabetes and hypertension. Presented to the ER with a 12 hour history of epigastric pain, nausea and vomiting. He had recently eaten some fish at a questionable restaurant downtown. His vitals at the triage desk are 96/52, heart rate 119, respiratory rate 18, temperate 38.6 C and saturation 91% What is the differential diagnosis for his presentation? Is this man in shock? – What is the definition of shock? – What further information do you need to determine that he is in shock? After being taken to an examination room, the patient complains of being lightheaded and that the fire truck in the room is taking up too much space. On examination, he is in moderate respiratory distress, clammy, with tenderness in the epigastric area to palpation, scattered crackles in both bases and a faint S3. Lactate 5.9 on the first blood gas. What are the four main types of shock? – – – – Hypovolemic Cardiogenic Distributive Obstructive What is the differential diagnosis for each type of shock? Describe the characteristic findings in preload, afterload, cardiac output and tissue perfusion for each type of shock. What would be your initial approach to this patient? Over the course of the next 30 minutes, the patient’s level of consciousness continues to decline and his shortness of breath worsens. On examination, the crackles are higher up the chest and his oxygen saturations are 90% on flush oxygen. ECG demonstrates inferior wall ST segment elevation myocardial infarction. Describe the physiology and outline the management of shock due to: – Left ventricular failure – Anaphylaxis – Hemorrhage – Sepsis – Massive pulmonary embolism – Tension pneumothorax The patient is taken urgently to the angiography suite and undergoes PTCA of the right coronary artery. After the procedure, he remains hypotensive, lactating, and obtunded. He is started on a norepinephrine and dobutamine infusion while awaiting a balloon pump. What is the main mechanism of action and use for the following vasopressors/inotropes: – – – – – – Norepinephrine Vasopressin Phenylephrine Ephedrine Epinephrine Dobutamine What is the difference between a vasopressor and an inotrope? Questions?