Shock

53 y/o F 古 O 嫻
病歷號： 2579786
Information from patient and family
Chief complaint:
-Progressive nausea, vomiting and diarrhea for hours
Present illness:
- High fever
- Intermittent abdominal cramping
- Chillness
- No obvious URI sign or dysuria told
- Elevated Finger Sugar
Past history:
1. Hypertension
2. Diabetes mellitus
3. Left anterior cerebral artery ischemic infarction with right hemiplegia, onset on
2013/03
4. Psoriatic arthritis
5. Right elbow cellulitis with abscess formation, pus culture: group B Streptococcu
s 現狀用藥：
6. Urinary tract infection Atorvastatin 10mg/tab 1PC QD
Aspirin 100mg/cap 1PC QD
Mecobalamin (Vit.B12) 500mcg/cap 1PC BID
Amlodipine 5mg/tab 0.5PC QD
Flunarizine 5mg/cap 1PC PRN

家族史：血親無糖尿病、高血壓、高血脂、心血管、癌症疾病史
理學檢查 : 2020/11/19 02:11
T:38.9 P:104 R:19 SBP:94 DBP:48 General appearance : ill
E:4 V:5 M:6 Conscious : clear
HEENT: no anemic
Patient has pain. Chest: clear
Current intensity of pain is score 2 out Heart : RHB
of 10. Abdomen: hyperactive bowel sound
The location of pain is abdomen. no obvious tenderness showed
The pain character is colicky. Extremities: right side weakness as
baseline
The onset of pain is intermittent.
The duration of the latest pain episode CXR: No pneumonia patchy lesion
is >30 min’s.
Impression
• Suspect AGE
• r/o UTI
Lab data (2020/11/19 02:18)
BUN 25.5 WBC 21.7  Nucleated RBC   0.5
Creatinine 2.65               RBC   4.59  Segment   88.5
eGFR   19    Hemoglobin  13.9 Band  1.0           
Osmolality(B)    304 Hematocrit 43.0 Lymphocyte 4.5
Total Bilirubin 1.2 MCV 93.7  Monocyte 5.0 
ALT/GPT 37 MCH 30.3   Eosinophil 0.0
ALK-P 62 MCHC 32.3 Basophil  1.0
Na 136 RDW 13.1 P.T        13.2
K 4.0 Platelets 111  Nor.plasma mean 11.8
CRP 74.7 PDW  12.9 INR 1.1
Lactate(B) 45.5 MPV 10.5
BloodKetone 0.8
Blood culture: pending
Urine: ?
Vein gas (2020/11/19 02:18)

TEMP  37.0
PH 7.312 
PCO2 42.4               
PO2 25.0
HCO3 21.0
SBE -5.3
SAT 40.2
02:12 T:38.9 P:104 R:19 BP:94/48 E4V5M6
Þ IV challenge with NS 500ml stat
Þ IV with N/S 1000ML run 100ML/HR
Acetaminophen 500mg/tab 1 PC STAT/QID PO
Scopolamine 20mg/amp 1 PC STAT IM

03:06 T:38.4 P:124 R:16 BP:114/75 O2:97%

Þ IV challenge with NS 500ml
Þ Ceftriaxone 1GM/vial 2PC stat

03:33
Þ Metronidazole (IVF) 1 PC stat
Pinaverium bromide 50 mg/tab 1 PC TID PO
Dioctahedral Smectite powder 3gm/sachet 1 PK PO

05:11
Þ ICP + urine routine/sediment + urine culture
Urinalysis
Color Yellow Blood 3+
Turbidity  Cloudy              Hyaline cast      2             
SP.Gravity      1.018           Bacteria    Positive
pH 5.0 RBC 36
WBC esterase    1+ WBC     78
Nitrite Negative Epith-Cell  6 
Protein  1+ (30)                Renal Tub.Epi.  3            
Glucose 3+ (1000)             
Ketone Negative
Urobilinogen 1.0
Bilirubin Negative
05:30 T:40.2
Þ Acetaminophen

06:27 T:39.3 R:20 BP:67/40 O2:95%

Þ IV challenge with L-R 1000ml stat, on BP monitor, lab follow-up

07:00 T:38.3 R:30 BP:50/43 O2:99%

Þ 07:13 On CVC, IV challenge N/S 1000ML stat
IV with D5W 500ML + Levophed 4 amp run 20 CC/HR
Þ Shift antibiotics to Meropenem trihydrate 250mg/vial Q12H

07:33 P:115 BP:110/63, E3V5M6

Þ Abdomen CT
08:10 T:37.7 P:106 R:30 BP:59/34, O2:100%
08:18 T:36.4 P:111 R:27 BP:59/33, O2:85%, E3V4M6
Þ Levophed titrate to 40CC/HR
08:43 Albumin:
Þ Albumin 25%,50ml 2 PC STAT
Þ 08:47 Sat 85%(room air), Oxygen therapy-nasal cannula 3 L/M
Levophed titrate to 50CC/HR
Þ 08:59 Levophed titrate to 60CC/HR

09:20 P:112 R:22 BP:71/37 O2:95%

Þ IV with Vasopressin 1PC in 100ml NaCl run 10CC/HR

09:50 P:110 R:20 BP:76/44

10:08 T:36.4 P:110 R:20 BP:83/35 O2:95%
=> 10:21 Vasopressin titrate to 18CC/HR
IV Challenge with N/S 500ml stat
10:27 T:37.1 P:112 R:16 BP:89/50 O2:97%
=> ICU
Lab data follow-up (2020/11/19 07:45)
Lactate(B) 54.3
Cortisol  24.80             
Procalcitonin >100.00               
Albumin 2.90                  

Vein gas (2020/11/19 07:45)

TEMP  37.0
PH 7.361 
PCO2 29.6               
PO2 42.0
HCO3 16.4
SBE -9.0
SAT 76.6
CT of abdomen finding
1. Right perirenal fat stranding and Gerota's fascial thickening, suspicious
infection/inflammation.
2. Mild right hydronephrosis with tapering at right UPJ level.
3. No evidence of radiopaque stone in the urotract.
4. Fatty liver.
5. L5/S1 disc space narrowing and vacuum phenomenum.

Impression:
1. Right perirenal fat stranding, suspicious infection/inflammation.
2. Mild right hydronephrosis without urolithiasis.
Impression
• Severe septic shock, suspected right side APN related
• Suspected relative adrenal insufficiency
Classification of shock
• Distributive
• Cardiogenic
• Hypovolemic
• Obstructive
• Mixed/unknown
 Distributive shock Hypovolemic
septic shock about 55%-62%, and anaphylactic and neurogenic shock about 16%-27%
4%

• Relative hypovolemia due to redistributed circulating volum • Loss of intravascular volume causing inadequate organ
e (fluid shift) perfusion
• Subtypes • Subtypes
• Anaphylactic shock • hemorrhagic shock
severe vasodilation mediated by histamine release and fluid s • hypovolemic shock
hift to extravascular space − Gastrointestinal losses
• Septic shock (eg, diarrhea, vomiting, external drainage)
lactate > 2 mmol/L and persistent hypotension requiring vaso − skin losses
pressors to keep mean arterial pressure > 65 mm Hg (eg, heat stroke, burns, dermatologic conditions)
• Neurogenic shock − renal losses
− imbalance between sympathetic and parasympathetic r (eg, excessive drug-induced or osmotic diuresis,
egulation of cardiac and vascular smooth muscle functi salt-wasting nephropathies, hypoaldosteronism)
on − third space losses into the extravascular space or
− characterized by sudden drop in systolic arterial pressur body cavities
e to < 100 mmHg and heart rate to < 60 beats/minute w (eg, postoperative and trauma, intestinal
ith obtunded consciousness, and possibly loss of spinal obstruction, crush injury, pancreatitis, cirrhosis)
reflexes if patient has high spinal cord injury
 Obstructive Cardiogenic shock
1-2% 13%-16%

 Mechanical causes of obstruction of • Systolic or diastolic dysfunction causing critical reduction of

 the great vessels or heart resulting in reduced venous return (decr pumping capacity
eased preload) • Subtypes
 left ventricle outflow (excessive afterload), restricting forward flow
• Cardiomyopathic
 Subtype − Myocardial infarction
 Pulmonary vascular − Severe heart failure from dilated cardiomyopathy
− pulmonary embolus
− Stunned myocardium from prolonged ischemia
− severe pulmonary hypertension (eg, cardiac arrest, hypotension, cardiopulmonary bypass)
− severe or acute obstruction of the pulmonic or tricuspid valve
− Advanced septic shock
− venous air embolus
− Myocarditis
 Mechanical
− Myocardial contusion
− Tension pneumothorax or hemothorax
(eg, trauma, iatrogenic) − Drug-induced (eg, beta blockers)
− pericardial tamponade • Arrhythmogenic
− constrictive pericarditis − Tachyarrhythmia – Afib, AF, VT, VF
− restrictive cardiomyopathy − Bradyarrhythmia – Complete heart block, Mobitz type II
− severe dynamic hyperinflation second degree heart block
(eg, elevated intrinsic PEEP)
• Mechanical
− ventricular outflow tract obstruction
− Severe valvular insufficiency, acute valvular rupture, critical
− abdominal compartment syndrome
valvular stenosis, acute or severe ventricular septal wall
− aorto-caval compression defect ruptured ventricular wall aneurysm, atrial myxoma
(eg, positioning, surgical retraction)
Vasoactive agent:
Dopamine <5 mcg/kg/min→Vasodilator Norepinephrine Powerful vasoconstrictor
5-10 mcg/kg/min→Increase contractility, CO
>10 mcg/kg/min→Vasoconstrictor
Dobutamine Powerful inotropic, weak chronotropic agent Vasopressin Vasoconstrictor, 0.01-0.04U/min
Epinephrine Choice of anaphylactic Milrinone Inotrope, vasodilator to increase CO
Approach to shock patients-History
• Present illness
• Hypovolemic
• Hemorrhage: major, GI bleeding, ruptured ectopic pregnancy or bleeding from GYN source…
• Non-hemorrhage: vomiting, diarrhea, burn…
• Cardiogenic or obstructive: Chest pain, cold sweating, shortness or breath, leg swelling
• Distributive
• Allergy: exposure to trigger, pruritis, hives
• Infection focus
• Spinal cord injury
• Past history
• Underlying disease
• Medication, toxin, ingestion
• Hospitalization or surgical history
Approach to shock patients-PE
• Vital signs and GCS
• Hypotension alone should not be used as the sole determinant of shock
• Altered mental status is common
• HEENT
• JVP: flat (hypovolemia, distributive), distended (cardiogenic)
• Lung
• breathing sound: rales (pulmonary edema), wheezing (anaphylaxis)
• Air entry for evidence of pneumothorax or hydrothorax
• Heart
• Murmurs
• asymmetric pulse (dissection)/ paradoxical pulse
• Abdomen: tenderness, rigidity…
• Extremities: edema, peripheral pulse, DVT, delayed capillary refill
• Skin: temperature, wound, sores, rashes
• Volume: skin turgor, urine output
Approach to shock patients-lab
• Identifying the underlying etiology and determining if end-organ dama
ge is present
• CBC/DC; PT, APTT
• Cardiac markers
• Chem 7: Na, K, Cl, HCO3, BUN, Cr, Glucose
• Liver function tests
• Lactate
• Fecal occult blood
• Blood gas
• U/A
• Pregnancy test
 Approach to shock patients-exam
• CXR: cardiomegaly, pulmonary vessel congestion
• EKG: arrythmia, ischemia, PE
• US: RUSH protocol
Hypovolemic shock Cardiogenic shock Obstructive shock Distributive shock
The pump Hypercontractile heart Hypocontractile heart Hypercontractile heart Hypercontractile heart
(Cardiac) Small chambers Dilated heart Pericardial effusion ↓
Cardiac tamponade Hypocontractile heart
Cardiac thrombus
The tank Flat IVC Distended IVC Distended IVC Nl or small IVC
(IVC) Pleural, peritoneal fluid Pleural, peritoneal fluid Pneumothorax: Pleural, peritoneal fluid
Lung rockets (B line) no lung sliding
The pipes Aortic dissection Nl DVT Nl
(thoracic aorta & Abd aortic aneurysm
abdominal aorta)
Definition of septic shock
• SIRS (severe inflammatory response syndrome): >= 2 of the following
• T>38’C or T<36’C
• HR>90
• RR>20
• WBC>12000 or <4000; or band>10%
• Sepsis: SIRS + source infection
• Severe sepsis: sepsis + sepsis-induced hypoperfusion/ organ dysfunction
• Septic shock: severe sepsis + ↓BP despite adequate fluid resuscitation
Management of Septic Sh
ock