Transcript Shock Management Erin Burrell, ACNP-BC Surgical ICU Nurse Practitioner

Shock Management
Erin Burrell, ACNP-BC
Surgical ICU Nurse Practitioner
Objectives
• Understand the definition of the three
different types of shock
• Be able to recognize the different types of
shock in patient scenarios
• Understand and apply treatment guidelines
for the different types of shock
What is Shock?
• Shock is the “physiologic state characterized
by significant reduction of systemic tissue
perfusion, resulting in decreased tissue
oxygen delivery.”
– Tissue perfusion is dependent on SVR and CO
– Imbalance between oxygen delivery and oxygen
consumption which leads to cell death, end organ
damage, multi-system organ failure, and death
Gaieski et al. 2009 (Online accessed 22 August 2013)
URL: http://lijhs.sandi.net/faculty/rtenenbaum/ap-biology-folder/Links/Shock.utd.pdf
Three Types of Shock
• Cardiogenic
• Hypovolemic
• Distributive
– Septic
– Anaphylactic
– Neurogenic
• Combined
Case Study
• Mrs. C is a 61yo F who presents to ED
complaining of fatigue and SOB. She has
significant PMHx: DM, obesity, HTN. Husband
also states she has become slightly confused.
• Vitals: HR 46, BP 68/32, RR 23, SpO2 95% on
RA, Afebrile.
• Labs: WBC 8.1, Hgb 12.1, BUN 12, Creat 1.0,
Troponin 3.1, BG 121.
• EKG shows ST elevation in II, III, aVF
What kind of shock does this patient have?
A. Cardiogenic
B. Hypovolemic
C. Distributive
Cardiogenic Shock
• Shock caused as a result of cardiac pump
failure
– Results in a decrease in CO
– SVR is increased in an effort to compensate to
maintain organ perfusion
– Causes:
• Myocardial Infarction
• Arrythmias (Atrial fibrillation, ventricular tachycardias,
bradycardias, etc)
• Mechanical abnormalities (valvular defects)
• Extracardiac abnormalities (PE, pulm HTN, tension pneumothorax)
Medscape Reference. 1994 (Online accessed 22 August 2013)
URL: http://emedicine.medscape.com/article/152191-treatment#showall
What information do you have to suggest that
Mrs. C has cardiogenic shock?
A. Hypotension
B. Evidence of MI
C. Altered Mental
Status
D. All of the above
E. Both A. and B.
Treatment of Cardiogenic Shock
• Correct hypotension:
– Fluid resuscitation to correct hypovolemia
– Inotropic or Vasopressor support:
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Dobutamine
Milrinone
Norepinephrine
Dopamine
Epinephrine
Oxygenation
If MI – ASA, Heparin, and Revascularization
If arrthymia – correct arrthymia
If extracardiac abnormality – reverse or treat cause
Case Study
• Mr. H is a 18yo M who presents to ED after
suffering a MCC into a tree. He was
unhelmeted and has an obvious left femur fx.
He was intubated for a GCS of 8 in the field
and given 1L NS en route for hypotension.
• Vitals: HR 145, BP 71/38, Intubated with SpO2
100%, Afebrile.
• Labs: WBC 12.3, Hgb 6.7, Plts 72, INR 2.1.
• Traumagram shows Grade III liver lac.
What kind of shock does this patient have?
A. Cardiogenic
B. Hypovolemic
C. Distributive
Hypovolemic Shock
• Shock caused by decreased preload due to
intravascular volume loss (1/5 of blood
volume)
– Results in decreased CO
– SVR is typically increased in an effort to
compensate
– Causes:
• Hemorrhagic – trauma, GI bleed, hemorrhagic
pancreatitis, fractures
• Fluid loss induced – Diarrhea, vomiting, burns
Medscape LLC. 2013 (Online access on 22 August 2013)
URL: http://emedicine.medscape.com/article/760145-treatment#2
What information do you have to suggest that
Mr. H has hypovolemic shock?
A.
B.
C.
D.
E.
Recent trauma
WBC 12.3
Hgb 6.7
All of the above
Both A. and C.
Treatment of Hypovolemic Shock
• Maximize oxygen delivery
• Control further blood loss
– Tourniquets
– Surgical intervention
• Fluid resuscitation
– NS fluid boluses
– Blood product administration
Case Study
• Mr. S is a 59yo M presents to ED with
worsening abdominal pain and N&V
• He is POD#8 s/p ex-lap, SBR with primary
anastamosis for chronic SBO at OSH
• Vitals: HR 128, BP 78/45, RR28, SpO2 94% on
4L NC, Fever 103.1
• Labs: WBC 20.1, Hgb 9.5, BUN 34, Creat 2.1
• CT scan of ABD shows anastamotic leak
What kind of shock does this patient have?
A. Cardiogenic
B. Hypovolemic
C. Distributive
Distributive Shock
• Shock as a result of severely diminished SVR
– CO is typically increased in an effort to maintain
perfusion
– Subtypes:
• Septic – secondary to an overwhelming infection
• Anaphylactic – secondary to a life-threatening allergic
reaction
• Neurogenic – secondary to a sudden loss of the
autonomic nervous system function
Gaieski et al. 2009 (Online accessed 22 August 2013)
URL: http://lijhs.sandi.net/faculty/rtenenbaum/ap-biology-folder/Links/Shock.utd.pdf
What information do you have to suggest Mr. S
has distributive shock?
A. SpO2 94% on 4 L NC
B. Anastamotic leak on
CT scan
C. WBC 20.1
D. All of the above
E. Both B. and C.
Treatment of Septic Shock
• Resuscitate
– 30cc/kg of NS bolus
• Identify Source
– Pan cultures
– CT scan
– Line removal
– Foley removal
– Surgical exploration
• Antibiotics
Dellinger, R et al. Surviving Sepsis Campaign: International Guidelines for Management
of Severe Sepsis and Septic Shock:2012, 41: 580-637, 2013.
Treatment of Anaphylactic Shock
• Remove offending agent
• Establish an airway and return circulation
• Pharmacologic support:
– Epinephrine – reverses peripheral vasodilation, dilates
bronchial airways, increases myocardial contractility, and
suppresses histamine/ leukotriene release
– Antihistamine (benadryl) – may help counter histaminemediated vasodilation and bronchoconstriction
– Corticosteroids (hydrocortisone) – may help shorten
reaction
– Bronchodilators
Soar, J et al. 2013 (Online Accessed on 22 August 2013) URL:
http://www.resus.org.uk/pages/reaction.pdf
Treatment of Neurogenic Shock
• Establish an airway to maintain adequate
oxygenation and ventilation
• Fluid resuscitation for MAP>65mmHg
• Inotropic support
– Dobutamine
– Dopamine
• Atropine for severe bradycardia
• High dose methylprednisolone therapy
Emergency Medicine. 2009 (Online Accessed on 22 August 2013)
URL: http://emergencymed.wordpress.com/2009/03/11/neurogenic-shock/
All three types of shock can occur
at the same time to have a
combined shock picture.
Case Study
• Mrs. D is a 71yo F who presented to ED after a
3 day h/o N&V with inability to tolerate PO
intake. She is now POD0 s/p exlap,
pancretectomy for necrotizing pancreatitis.
She presents to the Surgical ICU postop.
• Vitals: HR 121, BP 82/41, Intubated on 100%
FiO2, Fever 102.8
• Labs: WBC 1.1, Hgb 8.4, BUN 61, Creat 2.82,
Lactate 3.7
Case Study cont..
• The Surgical ICU team places a MAC with PAC
to obtain further data about the patient’s
hemodynamic status.
• PAC numbers: PAP 18/6, CVP 1, PCWP 2, CI
1.7, SVR 615
What type of shock does this patient have?
A.
B.
C.
D.
Cardiogenic
Hypovolemic
Distributive
All of the Above
What information leads you to believe Mrs. D
has a component of cardiogenic shock?
A.
B.
C.
D.
BP 82/41
Temp 102.8
CI 1.7 L/min
Cr 2.82
What information demonstrates a component of
hypovolemic shock?
A. CVP 1 mmHg
B. PCWP 2 mmHg
C. SVR 615
dynes/sec/cm-5
D. PAP 18/6 mmHg
E. Both A. B. and D.
What information indicates a degree of
distributive shock?
A. PCWP 2 mmHg
B. SVR 615
dynes/sec/cm-5
C. PAP 18.16 mmHg
D. WBC 1.1
Mrs. S is suffering from distributive septic shock
along with cardiogenic and hypovolemic shock.
A. True
B. False
Case Study cont..
• The Surgical ICU team starts by giving Mrs. S a
2L NS bolus and 1L 5% Albumin bolus
• Vitals: HR 114, BP 89/45, Remains intubated
on SIMV/PRVC 60% FiO2, Febrile 101.7
• Labs: WBC 3.4, Hgb 7.4, BUN 72, Creat 3.21,
Lactate 2.1
• Broad spectrum ABX are started immediately
upon arrival
• PAC numbers after the initial resuscitation:
– PAP 22/10, CVP 9, PCWP 11, CI 1.5, SVR 682
Mrs. S. continues to have a combined shock of
hypovolemic, distributive, and cardiogenic
shock.
A. True
B. False
Mrs. S continues to suffer from cardiogenic and
distributive septic shock as evidence by the
following:
A. CI 1.5 L/min
B. SVR 682
dynes/sec/cm-5
C. Both A. and B.
As an intensivist, what treatment should be
implemented next?
A. More fluid resuscitation
B. Initiate vasopressor
support
C. Initiate inotropic
support
D. No change in current
therapy
E. Both B. and C.
Case study cont..
• After initiating milrinone and levophed
therapy, Mrs. S improves.
• Vitals: HR 93, BP 122/61, Intubated on
PS/CPAP 40%, Afebrile. Levophed at 4mcg/min
and Milrinone at 0.375mcg/kg/min
• PA numbers: PAP 24/10, CVP 12, PCWP 14, CI
3.6, SVR 1120
Case study cont..
• The Surgical ICU team decides to attempt to
wean vasopressor support first.
• Mrs. S is successfully weaned off levophed
support after approximately 12 hours.
• Vitals: HR 87, BP 117/58, Intubated on
PS/CPAP 40%, Afebrile. Levophed is off and
Milrinone at 0.375mcg/kg/min
• PA numbers: PAP 22/14, CVP 12, PCWP 14, CI
3.4, SVR 1068
Case Study cont..
• After an additional 12 hours, Mrs. S is
successfully weaned off milrinone support as
well.
• She is extubated the next day and progressing
well.
• On HOD 6, Mrs. S is complaining of a HA and
would prefer not to take narcotics.
• Ibuprofen 200mg q6h PRN is added to HA
pain.
Case Study cont..
• After approximately 15 min of her first dose of
Ibuprofen, Mrs S starts to complain of difficult
breathing, flushing, and airway edema.
• The bedside RN notices a new onset of hives
around Mrs. S’s neck and mouth.
• Vitals: HR 147, BP 54/31, SpO2 91% on 100%
NRB, Febrile 102.6.
What kind of shock is Mrs. S exhibiting?
A. Cardiogenic
B. Hypovolemic
C. Distributive
What would you include in your treatment plan?
A. Benadryl 25 mg IV
B. Reintubation
C. Hydrocortisone 100
mg IV
D. Epinephrine 50 mcg
IV
E. All of the above
Case Study cont..
• Mrs. S is successfully intubated and
administered treatment for her anaphylaxis.
After approximately 12hours, her symptoms
have resolved. She is again extubated and
progressing well.
• Mrs. S goes on to rehab and eventually home!
Summary
Survival and outcomes improve
with early perfusion, adequate
oxygenation, and identification
with appropriate treatment of the
cause of shock.
Questions?
References
• Dellinger, R et al. Surviving Sepsis Campaign: International Guidelines for
Management of Severe Sepsis and Septic Shock:2012, 41: 580-637, 2013.
• Emergency Medicine. 2009 (Online Accessed on 22 August 2013) URL:
http://emergencymed.wordpress.com/2009/03/11/neurogenic-shock/
• Gaieski et al. 2009 (Online accessed 22 August 2013)
URL:http://lijhs.sandi.net/faculty/rtenenbaum/ap-biologyfolder/Links/Shock.utd.pdf
• Medscape Reference. 1994 (Online accessed 22 August 2013) URL:
http://emedicine.medscape.com/article/152191-treatment#showall
• Medscape LLC. 2013 (Online access on 22 August 2013) URL:
http://emedicine.medscape.com/article/760145-treatment#2
• Soar, J et al. 2013 (Online Accessed on 22 August 2013) URL:
http://www.resus.org.uk/pages/reaction.pdf