Management of Hypovolemic Shock by cgb19383

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Management of Hypovolemic Shock document sample

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									SHOCK
             DEFINITION
• Profound hemodyamic and metabolic
  disturbance characterized by failure of the
  circulatory system to maintain adequate
  perfusion of vital organs
              Types of Shock
• Cardiogenic (intracardiac vs extracardiac)
• Hypovolemic
• Distributive
  –   sepsis****
  –   neurogenic (spinal shock)
  –   adrenal insufficiency
  –   anaphylaxis
 Cardiogenic Shock, intracardiac
• Myocardial Injury or Obstruction to Flow
  –   Arrythymias
  –   valvular lesions
  –   AMI
  –   Severe CHF
  –   VSD
  –   Hypertrophic Cardiomyopathy
     Presentation of Cardiogenic
                Shock
•   Pulmonary Edema
•   JVD
•   hypotensive
•   weak pulses
•   oliguria
    Cardiogenic Shock, extracardiac
            (Obstructive)
•   Pulmonary Embolism
•   Cardiac Tamponade
•   Tension Pneumothorax
•   Presentation will be according to underlying
    disease process.
           Hypovolemic Shock
• Reduced circulating blood volume with
  secondary decreased cardiac output
  –   Acute hemorrhage
  –   Vomiting/Diarrhea
  –   Dehydration
  –   Burns
  –   Peritonitis/Pancreatitis
     Presentation of Hypovolemic
                Shock
•   Hypotensive
•   flat neck veins
•   clear lungs
•   cool, cyanotic extremities
•   evidence of bleeding?
    – Anticoagulant use
    – trauma, bruising
• oliguria
          Distributive Shock
• Peripheral Vasodilation secondary to disruption
  of cellular metabolism by the effects of
  inflammatory mediators.
• Gram negative or other overwhelming infection.
• Results in decreased Peripheral Vascular
  Resistance.
Distributive Shock: Presentation
•   Febrile
•   Tachycardic
•   clear lungs, evidence of pneumonia
•   warm extremities
•   flat neck veins
•   oliguria
            Diagnosing Shock
•   Response to fluids
•   Echo/EKG
•   CXR
•   Evidence of infection
•   Swan-Ganz Catheter?
         Swan-Ganz Catheter
• Utilized to differentiate types of shock and
  assist in treatment response.

• Probably overused by physicians. Studies
  documenting increased mortality in patients
  with catheters versus no catheters, although
  somewhat swayed by selection bias.
Swan-Ganz Catheter
        Swan-Ganz Interpretation
Etiology           CO        PCWP         SVR
cardiogenic      decreased   increased   increased

hypovolemic      decreased   decreased   increased

distributive     increased   decreased   decreased

obstructive      decreased   Increased   increased
              Management
• Correct underlying disorder if possible and
  then direct efforts at increasing the blood
  pressure to increase oxygen delivery to the
  tissues.
• Maintain a mean arterial pressure of 60
  (1/3 systolic + 2/3 diastolic)
• Keep O2 sats >92%, intubate if neccesary
     Correction of hypotension
• Normal Saline should be administered
  anytime a patient is hypotensive. If
  hypotension exists give more NS. ***
• If possible give blood as it replaces colloid.
• Vasopressors
• Inotropic agents for cardiogenic shock
• Intra-aortic Balloon Pump for cardiogenic
             Autonomic Drugs in Shock

Drug             Indication        Dose              MOA            Principal actions
Dopamine         Renal perfusion   2-5 mcg/kg/min    Dopaminergic   Renal a. dilation
                 hypotension       5-10 mcg/kg/min   1 &           + inotrope
                                                     dopaminergic
                 Hypotension       >10 mcg/kg/min    1             vasoconstriction
Dobutamine       Cardiogenic shock 2.5-25 mcg/kg/min Selective 1   + inotrope
Norepinephrine   Hypotension       2-4 mcg/min       1 & 1        Vasoconstriction
Phenylephrine    Hypotension       40-180 mcg/min    Selective 1   Vasoconstriction
   Management of Cardiogenic
           Shock
• Attempt to correct problem and increase
  cardiac output by diuresing and providing
  inotropic support. IABP is utilized if
  medical therapy is ineffective.
  Catheterization if ongoing ischemia
• Cardiogenic shock is the exception to the
  rule that NS is always given for hypotension
  NS will exacerbate cardiac shock.
Intra-Aortic Balloon Pump
     Management of Septic Shock
•   Early goal directed therapy
•   Identification of source of infection
•   Broad Spectrum Antibiotics
•   IV fluids
•   Vasopressors
•   Steroids ??
•   Recombinant human activated protein C ( Xygris)
•   Bicarbonate if pH < 7.1
  Management of Hypovolemic
           Shock
• Correct bleeding abnormality
• If PT or PTT elevated then FFP
• Aggressive Fluid replacement with 2 large
  bore IV’s or central line.
• Pressors are last line, but commonly
  required.
         Addison’s Disease
• Deficiency of cortisol and aldosterone
  production in the adrenal glands
• This is suspected when patient is non-
  responsive to fluids and antibiotics.
• Electrolytes may reveal hyponatremia and
  hyperkalemia
• Hydrocortisone 100 mg IV immediately
  then taper appropriately

								
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