Transcript Shock Student version
Slide 1
Medical Student Small Group
Discussion Topics
Shock and Hemodynamic Management
Slide 2
Suggested Reading
Current Diagnosis and Treatment: Surgery
Chapter 12. Shock & Acute Pulmonary Failure in Surgical Patients
Schwartz's Principles of Surgery, 9e
Chapter 5. Shock
Current Diagnosis & Treatment: Surgery, Thirteenth Edition
Edited by Gerard M. Doherty
Copyright © 2010 by The McGraw-Hill Companies, Inc.
Schwartz's Principles of Surgery, 9e
F. Charles Brunicardi, Dana K. Andersen, Timothy R. Billiar, David L. Dunn, John G. Hunter, Jeffrey B.
Matthews, Raphael E. Pollock
Copyright © 2010, 2005, 1999, 1994, 1989, 1984, 1979, 1974, 1969 by The McGraw-Hill Companies, Inc.
Slide 3
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What is shock?
Slide 4
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What are the four principle
types of shock (Excluding
anaphylactic shock)?
Slide 5
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What physical examination
findings will help determine
the type of shock present?
Slide 6
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 32 year-old man was driving drunk and without his seatbelt
fastened when he was involved in a single-vehicle automobile
collision.
Slide 7
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 32 year-old man was driving drunk and without his seatbelt fastened when he was involved in a singlevehicle automobile collision.
When attended by EMT personnel, no information
was available about the time of the accident. He
was found agitated and complaining of abdominal
pain. His airway was patent. At the scene, he was
breathing at 20 per minute with a blood pressure
of 90/60 and a pulse of 130. He was placed in a
hard cervical collar and on a back board and
transported to your emergency room. Upon arrival
his vital signs are the same, with a temperature of
36°C. His abdomen is markedly distended. His
hands and feet are cold, his legs mottled. A
nasogastic tube reveals green liquid. A urinary
catheter reveals dark yellow urine. His hemoglobin
is 12. His abdominal lavage reveals gross blood.
Slide 8
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What type of shock does
this patient exhibit?
Slide 9
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
How do you explain the
patient’s normal
hemoglobin value?
Slide 10
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What are the normal
physiologic mechanisms to
compensate for blood loss?
Slide 11
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What would be the effect of this type of
shock on the following physiologic
measurements (low, normal, high)?
•Cardiac Output
•Systemic Vascular Resistance
•Central Venous Pressure
•Pulmonary Capillary Occlusion Pressure
(“Wedge Pressure”)
•Oxygen Delivery
•Mixed Venous Oxygen Saturation
•Oxygen Consumption
Slide 12
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What acid/base
disturbances might be
expected?
Slide 13
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What is the single most
important treatment for this
type of shock?
Slide 14
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
How would you manage the
patient until the primary goal is
accomplished?
Slide 15
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What is the role of vasopressors
in hypovolemic shock?
Slide 16
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 55 year-old man with stable angina undergoes an uneventful
sigmoid resection for diverticular disease.
Slide 17
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 55 year-old man with stable angina undergoes an uneventful sigmoid resection for diverticular disease.
The patient’s angina occurs twice a week while
walking uphill and is treated with nitoglycerin. On
postoperative day four he develops severe
substernal chest pain, sudden hypotension
(85/45), tachycardia (120), and becomes agitated.
Physical exam reveals body mottling, cold hands
and feet, distended neck veins and an S3 gallop.
ECG demonstrates elevated ST-T wave segments
in all of the anterior leads.
Slide 18
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What type of shock does
this patient exhibit?
Slide 19
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What are the normal
physiologic mechanisms to
compensate for this type of
shock?
Slide 20
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What would be the effect of this
type of shock on the following
physiologic measurements (low,
normal, high)?
•Cardiac Output
•Systemic Vascular Resistance
•Central Venous Pressure
•Pulmonary Capillary Occlusion
Pressure (“Wedge Pressure”)
•Oxygen Delivery
•Mixed Venous Oxygen Saturation
•Oxygen Consumption
Slide 21
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What acid/base
disturbances might be
expected?
Slide 22
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What are the potential causes
for this type of shock?
Slide 23
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
How would you manage
this patient’s shock for
each of the previously
listed causes?
Slide 24
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 35 year-old man dove into three feet of water at a swimming pool,
did not emerge and was rescued by friends who performed CPR.
Slide 25
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 35 year-old man dove into three feet of water at a swimming pool, did not emerge and was rescued by
friends who performed CPR.
When the EMTs arrived they found the patient to
have blood pressure of 80/50, pulse 60, and no
spontaneous respirations, although he was
opening his eyes. They began ambu bag
assistance of respiration and placed a hard
cervical collar. He was placed on a back board and
transported to your emergency room. Upon
arrival he has the same vital signs with warm
hands and feet and pink extremities. He is unable
to move any of his extremities. His anal sphincter
tone is lax and he has no deep tendon reflexes in
his extremities.
Slide 26
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What type of shock does
this patient exhibit?
Slide 27
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What is the significance of
the patient’s lack of anal
sphincter tone and loss of
reflexes?
Slide 28
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What are the physiologic
causes for the patient’s
hypotension?
Slide 29
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What acid/base
disturbances might be
expected?
Slide 30
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What would be the effect of this
type of shock on the following
physiologic measurements (low,
normal, high)?
•Cardiac Output
•Systemic Vascular Resistance
•Central Venous Pressure
•Pulmonary Capillary Occlusion
Pressure (“Wedge Pressure”)
•Oxygen Delivery
•Mixed Venous Oxygen Saturation
•Oxygen Consumption
Slide 31
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
How would you manage
this patient’s shock?
Slide 32
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 65 year-old man with known coronary artery disease is
admitted with acute left lower quadrant pain of six hours
duration.
Slide 33
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 65 year-old man with known coronary artery disease is admitted with acute left lower quadrant pain of six
hours duration.
The patient had a myocardial infarction three
years earlier and is currently taking beta-blockers.
His blood pressure is 90/50, pulse 120,
respiration 18, temperature 39°C. He is flushed
with warm hands and warm feet, his legs are
pink. Physical examination reveals findings
consistent with peritonitis in the left lower
quadrant.
Slide 34
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What type of shock does
this patient exhibit?
Slide 35
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What is responsible for the
pathophysiology of this
condition?
Slide 36
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What is the consequences
of this condition?
Slide 37
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What would be the effect of this
type of shock on the following
physiologic measurements (low,
normal, high)?
•Cardiac Output
•Systemic Vascular Resistance
•Central Venous Pressure
•Pulmonary Capillary Occlusion
Pressure (“Wedge Pressure”)
•Oxygen Delivery
•Mixed Venous Oxygen Saturation
•Oxygen Consumption
Slide 38
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What acid/base
disturbances might be
expected?
Slide 39
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
Given the effects of this
condition on Oxygen delivery,
what is the explanation for
this acid base disturbance?
Slide 40
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
How would you manage
this patient’s shock?
Slide 41
Medical Student Small Group
Discussion Topics
Shock and Hemodynamic Management
Slide 2
Suggested Reading
Current Diagnosis and Treatment: Surgery
Chapter 12. Shock & Acute Pulmonary Failure in Surgical Patients
Schwartz's Principles of Surgery, 9e
Chapter 5. Shock
Current Diagnosis & Treatment: Surgery, Thirteenth Edition
Edited by Gerard M. Doherty
Copyright © 2010 by The McGraw-Hill Companies, Inc.
Schwartz's Principles of Surgery, 9e
F. Charles Brunicardi, Dana K. Andersen, Timothy R. Billiar, David L. Dunn, John G. Hunter, Jeffrey B.
Matthews, Raphael E. Pollock
Copyright © 2010, 2005, 1999, 1994, 1989, 1984, 1979, 1974, 1969 by The McGraw-Hill Companies, Inc.
Slide 3
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What is shock?
Slide 4
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What are the four principle
types of shock (Excluding
anaphylactic shock)?
Slide 5
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What physical examination
findings will help determine
the type of shock present?
Slide 6
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 32 year-old man was driving drunk and without his seatbelt
fastened when he was involved in a single-vehicle automobile
collision.
Slide 7
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 32 year-old man was driving drunk and without his seatbelt fastened when he was involved in a singlevehicle automobile collision.
When attended by EMT personnel, no information
was available about the time of the accident. He
was found agitated and complaining of abdominal
pain. His airway was patent. At the scene, he was
breathing at 20 per minute with a blood pressure
of 90/60 and a pulse of 130. He was placed in a
hard cervical collar and on a back board and
transported to your emergency room. Upon arrival
his vital signs are the same, with a temperature of
36°C. His abdomen is markedly distended. His
hands and feet are cold, his legs mottled. A
nasogastic tube reveals green liquid. A urinary
catheter reveals dark yellow urine. His hemoglobin
is 12. His abdominal lavage reveals gross blood.
Slide 8
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What type of shock does
this patient exhibit?
Slide 9
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
How do you explain the
patient’s normal
hemoglobin value?
Slide 10
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What are the normal
physiologic mechanisms to
compensate for blood loss?
Slide 11
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What would be the effect of this type of
shock on the following physiologic
measurements (low, normal, high)?
•Cardiac Output
•Systemic Vascular Resistance
•Central Venous Pressure
•Pulmonary Capillary Occlusion Pressure
(“Wedge Pressure”)
•Oxygen Delivery
•Mixed Venous Oxygen Saturation
•Oxygen Consumption
Slide 12
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What acid/base
disturbances might be
expected?
Slide 13
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What is the single most
important treatment for this
type of shock?
Slide 14
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
How would you manage the
patient until the primary goal is
accomplished?
Slide 15
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What is the role of vasopressors
in hypovolemic shock?
Slide 16
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 55 year-old man with stable angina undergoes an uneventful
sigmoid resection for diverticular disease.
Slide 17
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 55 year-old man with stable angina undergoes an uneventful sigmoid resection for diverticular disease.
The patient’s angina occurs twice a week while
walking uphill and is treated with nitoglycerin. On
postoperative day four he develops severe
substernal chest pain, sudden hypotension
(85/45), tachycardia (120), and becomes agitated.
Physical exam reveals body mottling, cold hands
and feet, distended neck veins and an S3 gallop.
ECG demonstrates elevated ST-T wave segments
in all of the anterior leads.
Slide 18
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What type of shock does
this patient exhibit?
Slide 19
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What are the normal
physiologic mechanisms to
compensate for this type of
shock?
Slide 20
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What would be the effect of this
type of shock on the following
physiologic measurements (low,
normal, high)?
•Cardiac Output
•Systemic Vascular Resistance
•Central Venous Pressure
•Pulmonary Capillary Occlusion
Pressure (“Wedge Pressure”)
•Oxygen Delivery
•Mixed Venous Oxygen Saturation
•Oxygen Consumption
Slide 21
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What acid/base
disturbances might be
expected?
Slide 22
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What are the potential causes
for this type of shock?
Slide 23
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
How would you manage
this patient’s shock for
each of the previously
listed causes?
Slide 24
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 35 year-old man dove into three feet of water at a swimming pool,
did not emerge and was rescued by friends who performed CPR.
Slide 25
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 35 year-old man dove into three feet of water at a swimming pool, did not emerge and was rescued by
friends who performed CPR.
When the EMTs arrived they found the patient to
have blood pressure of 80/50, pulse 60, and no
spontaneous respirations, although he was
opening his eyes. They began ambu bag
assistance of respiration and placed a hard
cervical collar. He was placed on a back board and
transported to your emergency room. Upon
arrival he has the same vital signs with warm
hands and feet and pink extremities. He is unable
to move any of his extremities. His anal sphincter
tone is lax and he has no deep tendon reflexes in
his extremities.
Slide 26
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What type of shock does
this patient exhibit?
Slide 27
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What is the significance of
the patient’s lack of anal
sphincter tone and loss of
reflexes?
Slide 28
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What are the physiologic
causes for the patient’s
hypotension?
Slide 29
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What acid/base
disturbances might be
expected?
Slide 30
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What would be the effect of this
type of shock on the following
physiologic measurements (low,
normal, high)?
•Cardiac Output
•Systemic Vascular Resistance
•Central Venous Pressure
•Pulmonary Capillary Occlusion
Pressure (“Wedge Pressure”)
•Oxygen Delivery
•Mixed Venous Oxygen Saturation
•Oxygen Consumption
Slide 31
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
How would you manage
this patient’s shock?
Slide 32
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 65 year-old man with known coronary artery disease is
admitted with acute left lower quadrant pain of six hours
duration.
Slide 33
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
A 65 year-old man with known coronary artery disease is admitted with acute left lower quadrant pain of six
hours duration.
The patient had a myocardial infarction three
years earlier and is currently taking beta-blockers.
His blood pressure is 90/50, pulse 120,
respiration 18, temperature 39°C. He is flushed
with warm hands and warm feet, his legs are
pink. Physical examination reveals findings
consistent with peritonitis in the left lower
quadrant.
Slide 34
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What type of shock does
this patient exhibit?
Slide 35
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What is responsible for the
pathophysiology of this
condition?
Slide 36
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What is the consequences
of this condition?
Slide 37
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What would be the effect of this
type of shock on the following
physiologic measurements (low,
normal, high)?
•Cardiac Output
•Systemic Vascular Resistance
•Central Venous Pressure
•Pulmonary Capillary Occlusion
Pressure (“Wedge Pressure”)
•Oxygen Delivery
•Mixed Venous Oxygen Saturation
•Oxygen Consumption
Slide 38
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
What acid/base
disturbances might be
expected?
Slide 39
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
Given the effects of this
condition on Oxygen delivery,
what is the explanation for
this acid base disturbance?
Slide 40
Medical Student Small Group Discussion Topics
Shock and Hemodynamic Management
How would you manage
this patient’s shock?
Slide 41