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Shock Pathophysiology and Management

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Andrew Ferguson
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Anand Kumar, MD Section of Critical Care Medicine Section of Infectious Diseases University of Manitoba, Winnipeg, Canada UMDNJ-Robert Wood Johnson Medical School Cooper Hospital, NJ Shock Pathophysiology, Classification, and Approach to Management
Shock ,[object Object],[object Object],[object Object]
Shock: Definitions ,[object Object]
Shock: Classification ,[object Object],[object Object],[object Object],[object Object]
Classification of Circulatory Shock ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Kumar and Parrillo, 2001
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Classification of Circulatory Shock Kumar and Parrillo, 2001
Classification of Circulatory Shock ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Kumar and Parrillo, 2001
Classification of Circulatory Shock ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Kumar and Parrillo, 2001
Shock Hemodynamics ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Hypovolemic Shock ,[object Object],[object Object],[object Object],[object Object]
Class I ClassII Class III Class IV Clinical Correlates of Hemorrhage American College of Surgeons, 1989 ↓ >75% ↓ 50-75% ↓ 20-50% ↓ 0-10% CI (L/min) Confused/lethargic Anxious/confused Mild anxiety Slight anxiety CNS mental status < 5 5 - 15 20 - 30 > 30 UO (mL/hr) > 34 30 - 40 20 - 30 14 - 20 Resp rate Delayed Delayed Delayed Normal Capillary refill Marked Marked Minimal Absent Orthostasis ↓ ↓ ↓ Normal or ↑ Pulse pressure ↓ ↓ Normal Normal Blood pressure > 140 > 120 > 100 < 100 Pulse rate > 40% 30 - 40% 15 - 30% > 15% Blood loss (% total) > 2000 1500 - 2000 750 - 1500 > 750 Blood loss (mL)
Hypovolemic Shock ,[object Object],[object Object],[object Object],[object Object]
Cardiogenic Shock ,[object Object],[object Object],[object Object],[object Object]
Cardiogenic Shock ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Cardiogenic Shock ,[object Object],[object Object],[object Object],[object Object],[object Object]
Obstructive Shock ,[object Object],[object Object],[object Object],[object Object]
Distributive Shock ,[object Object],[object Object],[object Object]
Distributive Shock ,[object Object],[object Object],[object Object],[object Object]
Distributive Shock ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Hypodynamic Shock: Perfusion ,[object Object],[object Object],[object Object],[object Object]
Hyperdynamic Shock: Perfusion ,[object Object],[object Object],[object Object],[object Object]
Cardiovascular Performance Cardiac Function Venous Return Vascular Performance Microvascular Function Oxygen Unloading and Diffusion Cellular Energy Metabolism Determinants of Effective Tissue Perfusion
Preload Afterload Contractility Arterial pressure Cardiac output Peripheral resistance Heart rate Stroke volume Left ventricular size Myocardial fiber shortening Cardiac Performance
Organ Blood Flow in Shock ,[object Object],[object Object],[object Object]
Vascular Failure: Potential Causes ,[object Object],[object Object],[object Object],[object Object],[object Object]
Microvasculature in Shock ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RBC = Red blood cells DPG = Diphosphoglycerate Determinants of Effective Tissue Perfusion (cont) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Mechanisms of Cellular Injury in Shock ,[object Object],[object Object],[object Object]
Mizock BA. Crit Care Med. 1992;20:80-93. Oxygen Consumption Oxygen Delivery Critical Delivery Threshold Lactic Acidosis Physiologic Oxygen Supply Dependency
Mizock BA. Crit Care Med. 1992;20:80-93. Oxygen Consumption Oxygen Delivery Pathologic Physiologic Pathologic Oxygen Supply Dependency
Cellular Ischemia in Shock ,[object Object],[object Object],[object Object],Evidence
 
 
Kumar and Parrillo, 2001
 
 
Diagnosis and Evaluation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Clinical Signs
Diagnosis and Evaluation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Laboratory
Diagnosis and Evaluation ,[object Object],[object Object],[object Object],[object Object],[object Object],2 2 2 Invasive Monitoring
[object Object],[object Object],[object Object],[object Object],[object Object],A Clinical Approach to Shock Diagnosis and Management Initial Diagnostic Steps
Initial Therapeutic Steps A Clinical Approach to Shock Diagnosis and Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnosis Remains Undefined or Hemodynamic Status Requires Repeated Fluid Challenges of Vasopressors A Clinical Approach to Shock Diagnosis and Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
 
Immediate Goals in Shock Hemodynamic support MAP > 60mmHg PAOP = 12 - 18 mmHg Cardiac Index > 2.2 L/min/m 2 Maintain oxygen delivery Hemoglobin > 9 g/dL Arterial saturation > 92% Supplemental oxygen and mechanical ventilation Reversal of oxygen dysfunction Decreasing lactate (< 2.2 mM/L) Maintain urine output ` Reverse encephalopathy Improving renal, liver function tests MAP = mean arterial pressure; PAOP = pulmonary artery occlusion pressure. A Clinical Approach to Shock Diagnosis and Management
Hypovolemic Shock A Clinical Approach to Shock Diagnosis and Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Cardiogenic Shock A Clinical Approach to Shock Diagnosis and Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Extra-cardiac Obstructive Shock A Clinical Approach to Shock Diagnosis and Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Distributive Shock A Clinical Approach to Shock Diagnosis and Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Fluid Therapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Fluid Therapy ,[object Object],[object Object],[object Object],[object Object]
Therapy: Resuscitation Fluids ,[object Object],[object Object],[object Object],[object Object],[object Object]
 

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Shock Pathophysiology and Management

  • 1. Anand Kumar, MD Section of Critical Care Medicine Section of Infectious Diseases University of Manitoba, Winnipeg, Canada UMDNJ-Robert Wood Johnson Medical School Cooper Hospital, NJ Shock Pathophysiology, Classification, and Approach to Management
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  • 12. Class I ClassII Class III Class IV Clinical Correlates of Hemorrhage American College of Surgeons, 1989 ↓ >75% ↓ 50-75% ↓ 20-50% ↓ 0-10% CI (L/min) Confused/lethargic Anxious/confused Mild anxiety Slight anxiety CNS mental status < 5 5 - 15 20 - 30 > 30 UO (mL/hr) > 34 30 - 40 20 - 30 14 - 20 Resp rate Delayed Delayed Delayed Normal Capillary refill Marked Marked Minimal Absent Orthostasis ↓ ↓ ↓ Normal or ↑ Pulse pressure ↓ ↓ Normal Normal Blood pressure > 140 > 120 > 100 < 100 Pulse rate > 40% 30 - 40% 15 - 30% > 15% Blood loss (% total) > 2000 1500 - 2000 750 - 1500 > 750 Blood loss (mL)
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  • 23. Cardiovascular Performance Cardiac Function Venous Return Vascular Performance Microvascular Function Oxygen Unloading and Diffusion Cellular Energy Metabolism Determinants of Effective Tissue Perfusion
  • 24. Preload Afterload Contractility Arterial pressure Cardiac output Peripheral resistance Heart rate Stroke volume Left ventricular size Myocardial fiber shortening Cardiac Performance
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  • 30. Mizock BA. Crit Care Med. 1992;20:80-93. Oxygen Consumption Oxygen Delivery Critical Delivery Threshold Lactic Acidosis Physiologic Oxygen Supply Dependency
  • 31. Mizock BA. Crit Care Med. 1992;20:80-93. Oxygen Consumption Oxygen Delivery Pathologic Physiologic Pathologic Oxygen Supply Dependency
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  • 47. Immediate Goals in Shock Hemodynamic support MAP > 60mmHg PAOP = 12 - 18 mmHg Cardiac Index > 2.2 L/min/m 2 Maintain oxygen delivery Hemoglobin > 9 g/dL Arterial saturation > 92% Supplemental oxygen and mechanical ventilation Reversal of oxygen dysfunction Decreasing lactate (< 2.2 mM/L) Maintain urine output ` Reverse encephalopathy Improving renal, liver function tests MAP = mean arterial pressure; PAOP = pulmonary artery occlusion pressure. A Clinical Approach to Shock Diagnosis and Management
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