Systolic BP <90mmHg or a decrease of at least 40mmHg from baseline. 

Perfusion abnormalities despite fluid resuscitation.

Pump- the heart

Tubing- veins, capillaries, arteries

Fluid- plasma, blood

CO=SV x HR

cardiac output= stroke volume X heart rate

Total Vascular Resistance

(Systemic Vascular Resistance- SVR)

1. failure of circulation

2. failure of compensation

SV Starlings Law

HR

Vasoconstriction

hypovolemic

cardiogenic

distributive

Hemorrhagic

third spacing

fluid losses

"Relative Hypovolemia"/Vasodilation

anaphylaxis, neurogenic, septic, drugs

hemorrhage

diarrhea/vomiting

sweating

diabetes insipidus

3rd spacing

poor atrial filling

obstruction of contraction

increased afterload

PE

valvular stenosis

MI

ischemia

cardiac hypertrophy

drugs w/negative inotropic effect (BB, CCB)

bacterial toxins

distributive (predominant)

cardiogenic

distributive

hypovolemic

distributive

hypovolemic

cardiogenic

Airway, Breathing, Circulation

early recognition/determination of cause of shock

rapidly restore perfusion (prevent ongoing cellular injury & development of end-organ failure)

Restore circulating volume

Restore oxygen perfusion to tissues

Stop any ongoing bleeding/hemorrhage (may require surgical intervention)

Fluid resuscitation

vasoactive drug

urgent echocardiography

Cardiogenic shock

alternative treatment option

Distributive/Vasodilatory Shock

Goals of Therapy

maintain ABC

identify/address source of inflammation

maintain perfusion pressure (MAP >/=65mmHg)

Distributive/Vasodilatory 

Septic Shock

Initial Approach to Treatment

fill the tank- fluid resuscitation

antibiotics

squeeze the tank- vasopressor agent

Distributive/Vasodilatory

Anaphylaxis

Initial Approach to Treatment

Relax airway muscles- epinephrine

Squeeze the tank- epi

address histamine release- diphenhydramine

3 choices for fluid resuscitation

Crystalloid 500-1000ml

Colloids 300-500 ml

Blood Products

500-100ml

Normal Saline

3% Hypertonic Saline

Lactated Ringers

300-500ml

Albumin 5% or 25%

6% Hetastarch

Common Adverse Effects of

Fluid Resuscitation

Fluid Overload

Dilutional Coagulopathy

isotonic, 154 mEq/L Na & 154 mEq/L Cl

volume required= 3-4 X volume of deficit

rare ADE:hyperchloremic metabolic acidosis

hypertonic, 513 mEq/L Na & 513 mEq/L Cl

(displaces water from intracellular space)

requires smaller volumes

Rapid expansion assoc with ongoing hemorrhage and clot disruption

Requires more volume

physiologic composition- approx interstitial fluid

130 mEq/L Na

109 mEq/L Cl

28 mEq/L lactate

4 mEq/L K

3mEq/L Ca

less likely to cause hyperchloremic metabolic acidosis

Lactated Ringers

Precautions

May cause hyponatremia

May worsen existing hyperkalemia

contains lactate (not for distributive shock)

calcium may bind some IV meds

Plasma expander

Requires 1/3 volume of NS for equal volume expansion

25 grams= 2 units (500ml FFP)

preferred over 25%

equal volume of citrated plasma

hypovolemic shock

hypertonic

can draw 3.5X volume into vascular space from well-hydrated extravascular space

May lead to excessive volume expansion

May be diluted with D5W to 5% albumin

DO NOT DILUTE WITH WATER d/t HEMOLYSIS

comparable plasma expansion to 5% albumin

may increase volume up to 230% infused volume

Dose- 20ml/kg/hr max 1500ml/day

risk of coagulopathy- esp with higher doses (by decreasing factor VIII)

increase oxygen carrying capacity

restore circulating volume

reverse deficiency of clotting proteins or platelets

Hemoglobin is <7-10 gm/dL

Contains all blood factors

used for acute hemorrhage- emergent restoration of volume & oxygen carrying capacity in massively bleeding patients

May Cause fluid overload in cases of euvolemia

Anticoagulant preservative (Citrate) toxicity

<6-8 hrs

unless its fresh, it is a poor source of clotting factors and platelets

Component Blood Therapy

Packed Red Blood Cells (PRBC)

RBCs, leukocytes, and small amt of plasma

1 unit (200-300ml) will increase hematocrit by approx 3%

Shelf-life 5-6 weeks, can be frozen up to 10 years

Component Blood Therapy

Fresh Frozen Plasma (FFP)

replacement of clotting factors

Shelf-life 5 days

Treats: ongoing hemorrhage PT/PTT >1.5X normal

severe hepatic disease

coagulopathies (warfarin)

other bleeding disorders

Component Blood Therapy

Platelets (Plts)

admin of 5-packs or 6-packs will increase plt ct by approx 25,000-50,000 plts/mm³

shelf life 5 days

treats: bleeding or risk of bleeding from thrombocytopenia

Component Blood Therapy

Platelets

When to treat

Plts <100,000k/mm³--only if actively bleeding

Plts 20,000-5000/mm³---prophylactic to prevent spontaneous hemorrhage

Plts <5,000/mm³- almost all patients

ongoing hemorrhage may increase plt requirement

Anaphylaxis

Immunologic rxn

Transfusion-related infections

hemolytic reactions

greater than 10 units or 50% pt's blood volume/24 hrs

endogenous catecholamine

alpha & beta1 stimulation

predominant alpha stim:

    vasoconstriction/increase in MAP &

mild increase in CO, SV & HR

beta stim: inotropy (can increase CO- mostly at low doses)

coronary vasodilation

Norepinephrine is first line therapy

for _____________ shock

titrate to effect

start at 5 mcg/min

extravasation, bradycardia, arrythmias

considerations: ischemia of kidneys, GI tract or limbs

&

risk increases in prevalence of hypovolemia

Endogenous catecholamine, immediate precursor to NE & can stimulate NE release from sympathetic nerves

DA follows dose-dependent pharmacology.  Doses are <5mcg/kg/min; 5-10 mcg/kg/min, and >10mcg/kg/min

avoid doses >20mcg/kg/min

septic

good for pts with compromised systolic function

avoid use for renal protection

effectiveness is decreased in presence of acidosis.

endogenous catecholamine

Shock: Initial: 0.05 mcg/kg/min; Range: 1-10 mcg/min or 0.024-0.1 mcg/kg/min

Selective alpha1 agonist-peripheral vasoconstriction

little or no effect on heart (may dec CO, SV & HR)

endogenous peptide (made by hypothalamus, stored in pituitary)

decrease HR & CO, increase MAP & SVR (vasoconstriction)

pulmonary vascular dilation

platelet aggregation

synthetic catecholamine

Initial: 5 mcg/kg/min

Max: 20 mcg/kg/min

it is a pure b1 and b2 agonist- increases HR, it is helpful in respiratory problems

#1 problem: tachycardia and hypotension

****good drug, good beta 1 effects,  to use to increase HR in patients with a heart transplant

Decrease as tolerated no more often than every 10 minutes. This is to prevent precipitating worsened hemodynamic parameters. 

Does not apply to vasopressin!

It can cause ischemia or necrosis to GI, limbs, skin and other poorly perfused areas. 

There is an increased risk with hypovolemia.

Shock First Line Primary Alternative

Hypovolemic vol. resus.   ??

Cardiogenic ? ??

Distrib/Vaso ?? ????

Anaphylactic  Epi

Shock First Line Primary Alternative