Field Care Audit, RMH 06/15/11

1. A State of Shock
Veronica Bonales, M.D.
CEPAmerica, Emergency Medicine
Redwood Memorial Hospital

2. I am shocked, shocked...

3. Objectives
What is Shock?
Types of Shock
Stages and Symptoms of Shock
Treatment of Shock

4. What is Shock?

5. What is Shock?

6. What is Shock?
Inadequate tissue perfusion

7. What is Shock?
Oxygen to lungs
Oxygen to RBC’s
Oxygen to tissues
CO2 in tissues
CO2 to RBC’s
CO2 to lungs

8. What is Shock?
Red Blood Cells
Hemoglobin
molecules
Carry O2 to
the tissues
and CO2 away
from the
tissues

9. What is Shock?
CO2 is a by-product of
cellular respiration

10. What is Shock?
CO2 is a by-product of
cellular respiration

11. What is Shock?

12. What is Shock?
Anaerobic
Metabolism
Leads to build
up of Lactic
Acid
Creates energy
debt

13. What is Shock?

14. What is Shock?
Kidneys
Sense fall in
blood pressure
Release renin
Leads to
increased
blood pressure

15. What is Shock?
Carotid bodies
Sense
pH, O2 levels,
CO2

16. What is Shock?
If pH decreased, O2 decreased, or CO2 increased
Signals sent via Vagus nerve
Decreased parasympathetic input
Heart rate increases
Increased sympathetic input
Vessels contract increasing BP

17. Types of Shock

18. Types of Shock
Cardiogenic
Distributive
Hypovolemic
Obstructive

19. Types of Shock

20. Types of Shock
Cardiogenic Shock

21. Types of Shock
Cardiogenic Shock
Some condition doesn’t allow heart
to pump effectively

22. Types of Shock
Cardiogenic Shock
Some condition doesn’t allow heart
to pump effectively
Arrhythmia, MI, CHF, valvular
problem, CM

23. Types of Shock
Heart not pumping
properly
Vessels compensate
by increasing tone
Less blood to end
organs
Increased venous
pressure

24. Types of Shock
CHF
Hypertensive
Tachycardic
Diaphoretic
Crackles

25. Types of Shock
Distributive Shock
Anaphylactic
Neurogenic
Septic

26. Types of Shock
“Relative hypovolemia”
Vasodilation
Leaky capillaries
Tissue edema

27. Types of Shock
Anaphylaxis
Severe allergic
reaction
Histamine release
leads to
vasodilation &
capillary leakage

28. Types of Shock
Anaphylaxis
Severe allergic
reaction
Histamine release
leads to
vasodilation &
capillary leakage

29. Types of Shock
Neurogenic
Spinal cord
damage
Leads to loss
of sympathetic
tone

30. Types of Shock
Septic Shock
Usually Gram negative
bacteria
Release toxins
Release of cellular
chemicals
Cytokines
Free radicals

31. Types of Shock
Septic Shock
Usually Gram negative
bacteria
Release toxins
Release of cellular
chemicals
Cytokines
Free radicals

32. Types of Shock
Cause vasodilation
Cause capillary leakage
Increase in lactate
Increase heart rate

33. Types of Shock
Hypovolemic Shock
Trauma
GI bleeds
Dehydration
Diabetes
Burns

34. Types of Shock

35. Types of Shock
Obstructive

36. Stages & Symptoms
of Shock

37. Shock Stages &
Symptoms

38. Shock Stages &
Symptoms

39. Shock Stages &
Symptoms

40. Shock Stages &
Symptoms
Grade 1 - 15% (750ml)
Mild tachycardia

41. Shock Stages &
Symptoms
Grade 1 - 15% (750ml)
Mild tachycardia
Grade 2 - 15 - 30% (750 - 1500ml)
Moderate tachycardia, prolonged cap refill

42. Shock Stages &
Symptoms
Grade 1 - 15% (750ml)
Mild tachycardia
Grade 2 - 15 - 30% (750 - 1500ml)
Moderate tachycardia, prolonged cap refill
Grade 3 - 30 - 40% (1500 - 2000ml)
Hypotension, tachycardia, low urine output

43. Shock Stages &
Symptoms
Grade 1 - 15% (750ml)
Mild tachycardia
Grade 2 - 15 - 30% (750 - 1500ml)
Moderate tachycardia, prolonged cap refill
Grade 3 - 30 - 40% (1500 - 2000ml)
Hypotension, tachycardia, low urine output
Grade 4 - 40 - 50% (2000 - 2500ml)
Profound hypotension, end-organ damage, death

44. Shock Stages &
Symptoms

45. Shock Stages &
Symptoms
Initial Stage

46. Shock Stages &
Symptoms
Initial Stage
Hypoperfusion --> hypoxia

47. Shock Stages &
Symptoms
Initial Stage
Hypoperfusion --> hypoxia
Hypoxia --> no ATP produced -->
anaerobic metabolism --> increased
lactate

48. Shock Stages &
Symptoms
Initial Stage
Hypoperfusion --> hypoxia
Hypoxia --> no ATP produced -->
anaerobic metabolism --> increased
lactate
No energy --> cell damage --> leaky
walls --> loss of fluid

49. Shock Stages &
Symptoms
Initial Stage
Hypoperfusion --> hypoxia
Hypoxia --> no ATP produced -->
anaerobic metabolism --> increased
lactate
No energy --> cell damage --> leaky
walls --> loss of fluid
No energy --> cells can’t function

50. Shock Stages &
Symptoms

51. Shock Stages &
Symptoms
Compensatory Stage

52. Shock Stages &
Symptoms
Compensatory Stage
Acidosis

53. Shock Stages &
Symptoms
Compensatory Stage
Acidosis
Hypervent-
ilation

54. Shock Stages &
Symptoms
Compensatory Stage
Acidosis
Hypervent-
ilation
Hypotension

55. Shock Stages &
Symptoms
Compensatory Stage
Acidosis
Hypervent-
ilation
Hypotension
Tachycardia

56. Shock Stages &
Symptoms
Compensatory Stage
Acidosis
Hypervent-
ilation
Hypotension
Tachycardia
Vasoconstric-
tion

57. Shock Stages &
Symptoms
Compensatory Stage Blood shunted
to heart,
Acidosis
brain, lungs
Hypervent-
ilation
Hypotension
Tachycardia
Vasoconstric-
tion

58. Shock Stages &
Symptoms
Compensatory Stage Blood shunted
to heart,
Acidosis
brain, lungs
Hypervent-
Diaphoresis
ilation
Hypotension
Tachycardia
Vasoconstric-
tion

59. Shock Stages &
Symptoms
Compensatory Stage Blood shunted
to heart,
Acidosis
brain, lungs
Hypervent-
Diaphoresis
ilation
Kidneys
Hypotension
Tachycardia
Vasoconstric-
tion

60. Shock Stages &
Symptoms
Compensatory Stage Blood shunted
to heart,
Acidosis
brain, lungs
Hypervent-
Diaphoresis
ilation
Kidneys
Hypotension
Increase
Tachycardia
volume by
Vasoconstric- decreased
tion UOP, Na+

61. Shock Stages &
Symptoms
Progressive (Decompensating) Stage
Increased acidosis -->
vasodilation & capillary leak -->
edema
Blood sludges --> microinfarcts
Increasing loss of perfusion and
end-organ damage

62. Shock Stages &
Symptoms
Refractory (Irreversible) Stage
Multi-system organ failure
Brain death occurs
Death imminent

63. Shock Treatment

64. Treatment of Shock

65. Treatment of Shock
Cardiogenic - fix the underlying
problem (angio, surgery, ECV)

66. Treatment of Shock
Cardiogenic - fix the underlying
problem (angio, surgery, ECV)
Anaphylactic - Epinephrine, anti-
histamines, steroids

67. Treatment of Shock
Cardiogenic - fix the underlying
problem (angio, surgery, ECV)
Anaphylactic - Epinephrine, anti-
histamines, steroids
Neurogenic - most difficult, steroids
or surgery

68. Treatment of Shock

69. Treatment of Shock
Septic - massive amounts of fluids,
antibiotics, pressor support, end-organ
support (ventilator, dialysis)

70. Treatment of Shock
Septic - massive amounts of fluids,
antibiotics, pressor support, end-organ
support (ventilator, dialysis)
Hypovolemic - aggressive fluids, blood
products, treatment of underlying cause

71. Treatment of Shock
Septic - massive amounts of fluids,
antibiotics, pressor support, end-organ
support (ventilator, dialysis)
Hypovolemic - aggressive fluids, blood
products, treatment of underlying cause
Obstructive - treatment of underlying
cause (needle decompression,
pericardiocentesis)

72. Questions..?

73. Questions..?