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Diagnosis and Management

of Shock
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Objectives
Define the major types of shock and principles
of management
Review fluid resuscitation, vasopressors and
inotropes
Address the balance of O
2
supply and demand
Discuss the differential diagnosis of oliguria
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Shock
Always a symptom of its cause
Abnormally low organ perfusion
usually associated with decreased
blood pressure
Signs of organ hypoperfusion: mental
status change, oliguria, acidosis
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Shock Categories
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Cardiogenic
Hypovolemic
Distributive
Obstructive

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Cardiogenic Shock
Decreased contractility
Increased filling pressures,
decreased LV stroke work,
decreased cardiac output
Increased systemic
vascular resistance
compensatory
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Hypovolemic Shock
Decreased cardiac output
Decreased filling pressures
Compensatory increase in
systemic vascular resistance
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Distributive Shock
Normal or increased cardiac output
Low systemic vascular resistance
Low to normal filling pressures
Sepsis, anaphylaxis, neurogenic,
and acute adrenal insufficiency
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Obstructive Shock
Decreased cardiac output
Increased systemic vascular
resistance
Variable filling pressures
etiology dependent
Cardiac tamponade, tension
pneumothorax, massive
pulmonary embolus
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Cardiogenic Shock Management
Treat arrhythmias
Diastolic dysfunction may
require increased filling
pressures
Vasodilators if not hypotensive
Inotrope administration
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Cardiogenic Shock Management
Vasopressors if hypotensive to
raise aortic diastolic pressure
Mechanical assistance
Consultation
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Hypovolemic Shock
Volume resuscitation crystalloid,
colloid
Initial crystalloid choices
Lactated Ringers solution
Normal saline (high chloride may
produce hyperchloremic acidosis)
Match fluid given to fluid lost
Blood, crystalloid, colloid

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Distributive Shock Therapy
Expand intravascular volume
Hypotension despite volume therapy
Inotropes
Vasopressors for MAP < 60 mm Hg
Adjunctive antibiotics in sepsis
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Obstructive Shock Treatment
Relieve obstruction
Pericardiocentesis
Tube thoracostomy
Treat pulmonary embolus
Temporary benefit from fluid
or inotrope administration
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Therapeutic Goals in Shock
Increase O
2
delivery
Optimize O
2
content of blood
Improve cardiac output and
blood pressure
Match systemic O
2
needs with O
2
delivery
Reverse/prevent organ hypoperfusion

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Fluid Therapy
Crystalloids
Lactated Ringers solution
Normal saline
Colloids
Hetastarch
Albumin
Packed red blood cells
Infuse to physiologic endpoints

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Fluid Therapy
Correct hypotension first
Decrease heart rate
Correct hypoperfusion abnormalities
Monitor for deterioration of
oxygenation
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Inotropic / Vasopressor Agent
Dopamine
Low dose (2-3 g/kg/min) mild inotrope
plus renal effect
Intermediate dose (4-10 g/kg/min)
inotropic effect
High dose ( >10 g/kg/min) vasoconstriction
Chronotropic effect
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Inotropic Agent
Dobutamine
5-20 g/kg/min
Inotropic and variable chronotropic
effect
Decrease in systemic vascular
resistance
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Inotropic / Vasopressor Agent
Norepinephrine
0.05 g/kg/min and titrate
Inotropic and vasopressor effects
Potent vasopressor at high doses
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Epinephrine
Both and actions for inotropic
and vasopressor effects
0.1 g/kg/min and titrate
Increases myocardial O
2

consumption
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Oliguria
Marker of hypoperfusion
Urine output in adults
<0.5 mL/kg/hr for 2 hrs
Etiologies
Prerenal
Renal
Postrenal
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Evaluation of Oliguria
History and physical examination
Laboratory evaluation
Urine sodium
Urine osmolality or specific gravity
BUN, creatinine
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Evaluation of Oliguria
Laboratory Test Prerenal ATN
Blood Urea Nitrogen/ >20 1020
Creatinine Ratio
Urine Specific Gravity >1.020 <1.010
Urine Osmolality (mOsm/L) >500 <350
Urinary Sodium (mEq/L) <20 >40
Fractional Excretion of Sodium (%) <1 >2
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Therapy in Acute Renal Insufficiency
Correct underlying cause
Monitor urine output
Assure euvolemia
Diuretics not therapeutic
Low-dose dopamine?
Adjust dosages of other drugs
Monitor electrolytes, BUN, creatinine
Consider dialysis
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Pediatric Considerations
BP not good indication of hypoperfusion
Capillary refill, extremity temperature better
signs of poor systemic perfusion
Epinephrine preferable to norepinephrine due to
more chronotropic benefit from epinephrine
Fluid boluses of 20 mL/kg titrated to BP or total
60 mL/kg, before inotropes or vasopressors
Pediatric dosages in text
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Pediatric Considerations
Neonates consider congenital
obstructive left heart syndrome as
cause of obstructive shock
Oliguria
< 2 yrs old, urine volume <2 mL/kg/hr
Older children, urine volume
<1 mL/kg/hr
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Key Points