Shock evaluation protocol
Shock definition
•Shock is the clinical syndrome that results from inadequate tissue perfusion.
•Symptoms and signs : Oliguria, decreased mental status, decrease peripheral pulses and
diaphoresis.
•Clinical hypotension is usually found, i.e., mean arterial pressure <60 mmHg or systolic
blood pressure < 90 mmHg in previously normotensive persons.
•Hypoperfusion-induced imbalance between the delivery of and requirements for oxygen
and substrate leads to cellular dysfunction.
•The cellular injury induces the production and release of inflammatory mediators that
further compromise perfusion through functional and structural changes within the
microvasculature.
•Survival from the shock is related to the adequate of the initial resuscitation and the
degree of subsequent organ system dysfunction.
•The main goal of therapy is rapid cardiovascular resuscitation with the re-establishment
of tissue perfusion using fluid therapy and vasoactive drugs.
Shock classification
•Hypovolemic or traumatic
•Cardiogenic
(1) Intrinsic (systolic CHF or RV failure)
(2) compressive (cardiac tamponade)
•Septic and anaphylactic
(1) Hypodynamic
(2) Hyperdynamic
•Others (Neurogenic or Hypoadrenal)
Hemodynamic profile In shock states
Diagnosis****
Hypovolemia
Cardiogenic
intrinsic
compressive**
Septic
*
**
PCWP(PAOP)
Decrease
Cardiac index
decrease
SVR
increase
increase*
increase
decrease
decrease
decrease
increase***
increase
increase
decrease
PCWP may be normal or decrease in RV infarction
Equalization of intracardiac diastolic pressure (cardiac tamponade or
pulmonary embolism)
*** CO may decrease in hypodynamic shock or inadequate volume
**** Normal PCWP<18 mmHg
Normal Cradiac index >2.3 L/min/m2
Normal SVRI 1800-2300 dynes.sec.m2/cm5
Indication of PA catheter (swan-ganz)
1. Differentiate between various shock states.
2. Acute myocardial infarction complicated with shock.
3. Assess volume status.
4. Severe left ventricular failure.
5. Cardiac tamponade.
6. Severe pulmonary hypertension
7. Differentiate between constrictive and restrictive cardiac physiology.
8. Severe Adult respiratory distress syndrome.
9. High-risk cardiac patients during pre, intra, and post operative periods.
Resuscitation principles
1. Fluid resuscitation
•Usually is
the first treatment, base on arterial BP, urine output, cardiac filling pressure ,
and CO.
(1) Crystalloid fluid
•0.9% normal saline or ringer,s lactate
•The infusion of 2 to 3 L over 10 to 30 min should restore normal hemodynamics in
hypovolemic shock. Continued hemodynamic instability implies that shock has not been
reversed and/or that there are significant ongoing blood or volume losses.
•If cardiogenic shock, normal saline challenge no more than 200 millliter, and further
central venous pressure monitor was considered.
(2) Colloid solution
•5% and 25% albumin , 6% hetastarch, dextran 40, and dextran 70
•Keep hematocrits over 30%
•Blood products for significant anemia or active bleeding.
2 vasopressors and inotropes
•Requires monitor with intra-arterial line and PA catheter
(1)Dopamine
2-3 ug/kg/min as vasodilator, increasing renal and splanchnic blood flow.
4-8 ug/kg/min increase cardiac contractivity via beta-1 receptors
>10 ug/kg/min increase BP by activation of peripheral alpha-1 receptors
(2)Dobutamine (1-10 ug/kg/min)
Inotropic agent and indirect peripheral vasodilatation. (beta1>beta2>alpha1)
(3)Epinephrine
Has alpha and beta-adernergic receptors, choice for anaphylactic shock.
(beta1=beta2>>alpha1)
(4)Norepinephrine (2-8 ug/kg/min)
Has alpha and beta receptors, is potent vaso-constricting agents
(beta1>alpha1>beta2)
(5) Milrinone (0.375-0.75 ug/kg/min)
Non-catecholamine inhibitors of phophodiesterase III as inotropic and direct
vasodilator.
(6)Vasopressin (0.01-0.04 U/min)
Used in refractory septic shock.
(7) Phenylepherine (20-200 ug/kg/min)
Potential vasoconstrictor without inotropic effect.
Treatment guideline
1.clinical sign evaluation
•shock, (Cardiogenic or non-Cardiogenic)
•hypotension, (Hypovolemia or non-Hypovolemia)
•congestive heart failure, (Systolic/Diastolic; Acute/Chronic; Left-side/Right-side)
•acute pulmonary edema,
•which is most likely problem?
2.differential diagnosis
•A acute pulmonary edema
•B volume problem
•C pump problem
•D rate problem (tachycardia or bradycardia)
•A. acute pulmonary edema-first line
•Furosemide IV 0.5 to 1.0 mg/kg
•Morphine IV 2 to 4 mg
•Nitroglycerin SL
•Oxygen/intubation as needed
•B. volume problem
•Administer: fluids, blood transfusion, cause-specific interventions
•Consider vasopressors
•C. pump problem (cardiogenic failure)
•Check blood pressure serial exam and further differential diagnosis
•Further pump problem differential diagnosis
•According to systolic blood pressure level, divided to 5 conditions
•If acute pulmonary edema-second line
•Nitroglycerin/nitroprusside if BP>100 mmHg
•Dopamine if BP=70-100 mmHg, signs/symptoms of shock
•Dobutamine if BP>100 Hg, no signs/symptoms of shock
•If systolic BP<70 mmHg, signs/symptoms of shock
•Norepinephrine 0.5 to 30 ug/min IV
•If systolic BP 70 to 100 mmHg, signs/symptoms of shock
•Dopamine 5 to 15 ug/kg/min IV
•If systolic BP 70 to 100 mmHg , no signs/symptoms of shock
•Dobutamine 2 to 20 ug/kg/min IV
•If systolic BP >100 mmHg
•Nitroglycerin 10 to 20 ug/min IV
•Nitroprusside 0.1 to 5.0 ug/kg/min IV
•D. If rate problem
•Tachycardia evaluation treatment
Anti-arrhythmia drugs or rate control, consider DC shock for hemodynamic unstable.
•Bradycardia underlying diagnosis and treatment
Atropine or TCP or temporary pacemaker.
• further therapeutic considerations
•Pulmonary artery catheter.
•Intra-aortic balloon pump.
•Angiography for AMI/ischemia.
•Emergent CABG or other surgery.
•Additional diagnosis studies.
Indication of intra-aortic balloon counterpulsation
1. Cardiogenic shock.
2. Refractory unstable angina.
3. Acute MI catheter-based reperfusion.
4. High-risk percutaneous revascularization.
5. End-stage cardiomyopathy/bridge to cardiac transplantation.
6. Support during noncardiac surgery.
7. Mechanical complications of acute MI.
8. Decompensated aortic stenosis.
9. Refractory ventricular arrhythmias.
10 weaning from cardiopulmonary bypass/postoperative pump failure.
Contraindication of intra-aortic balloon counterpulsation
1. Aortic dissection.
2. Abnormal of thoracic aneurysm.
3. Severe peripheral vascular disease.
4. Descending aortic and peripheral vascular grafts.
5. Coagulopathy of contraindication to heparin of LMWH.
6. Moderate to severe aortic insufficiency.
supplement
•Adrenal insufficiency if patient has septic shock with fulminant N.meningitis infection,
refractory hypotension, recent glucosteroid use, disseminated TB of AIDS.
•Use hydrocortisone 50 mg IV q6h
Case sample 1
•CHF with acute pulmonary edema, without cardiogenic shock (SBP>90 mmHg)
•=> Tridil
•=> Lasix, record I/O keep negative balance
•=> diet salt control and water restriction
•=> O2 therapy, keep SPO2>90%
•=> Dobutamine use if systolic dysfunction or EF<45%
•=> treat underlying organic heart disease or arrhythmia.
Case sample 2
•CHF with acute pulmonary edema, and cardiogenic shock (SBP<90 mmHg)
•=> Dopamine
•=> Dobutamine (C.I.<2.3 or LVEF<45%, adjusted by PA catheter data).
•=> Lasix keep I/O neative balance if SBP>90 mmHg
•=> Nor-epinephrine even epinephrine use if refractory shock.
•=> consider IABP and PA catheter. Surgical ECMO for severe cardiogenic shock
•=> consider ACS possibility, further angioplasty or thrombolytic drugs if necessary.
•=> treat nuderlying organic heart disease of arrhythmia.
•=> O2 therapy keep SpO2>90%.
Case sample 3
•AMI, inferior wall infarction with RV infarction
•=> IV fluid challenge or hydration if hypotension of shock.
•=> avoid overuse nitrate, lasix and morphine.
•=> anticoagulant drugs and antiplatelet drugs.
•=> consider angioplasty or thrombolytic drug use.
•=> inotropic drugs use (Dopamine or Dobutamine)
•=> watch out high-degree AV block and TCP or TPM if necessary .
Case sample 4
•Massive pulmonary embolism or cardiac tamponade compressive cardiogenic shock
•=> emergent heart echo followed up
•=> IV fluid hydration
•=> inotropic agent use (dopamine or levophed) if necessary
•=> pericardiocentesis for tamponade
•=> thrombolysis for massive pulmonary embolism or consult CVS for thrombectomy.
•=> O2 therapy keep Spo2 >90%
•=> Anti-coagulant drugs use for pulmonary embolism.
Case sample 5
•Severe inflammatory refractory sepsis with septic shock
•=> on CVP or PA catheter
•=> fluid supplement
•=>Dopamine
•=>Levophed
•=> Broad-spectrum antibiotic drugs use.
•=> Find out infection source and species