Shock

Primarily from IBCC and Emcrit

6 causes

A. Pump 

  1. Arrhythmogenic Shock- <45, >150
  2. LV Shock- Inotropy (MI, myocarditis, OD B-blocker), Valve (AI or MR), 
  3. RV Shock- PE, decompensated pulm htn, RV MI
  4. Obstructive Shock(Tamponade, PTX, Elevated intrathoracic pressure from auto PEEP or abdominal compartment syndrome)

B. Tank

  1. Hypovolemic/Hemorrhagic Shock

C. Pipes 

  1. Vasodilatory/Distributive Shock
    1. Severe systemic inflammation 
      1. Septic shock
      2. Pancreatitis
      3. Post-cardiac arrest SIRS
      4. Post-MI SIRS
    2. Anaphylaxis
    3. Endocrine
      1. Adrenal Crisis
      2. Thyroid Storm
    4. Neurogenic 
      1. Trauma
      2. Spinal Anesthesia
    5. Liver failure
    6. Excess vasodilatory Drugs

Diagnosis

A. Pump

  1. Cold extremities
  2. Narrow Pulse Pressure suggests low cardiac output. if Syst-Diast is < 25% of systolic this is considered narrow.
  3. Loud AI murmur (SI space S2 with loud murmur bump baaaaa) left lat sternal border during diastole
  4. Loud MR murmur heard at apex during systole
  5. Poor EF
  6. Enlarged RV, poor RV contractility
  7. R/o pericardial effusion
  8. Confirm lung sliding and breath sounds bilaterally

Treatment

Specific Scenarios

Septic Shock

  1. Norepi
  2. Epi if need more inotropy- 0.01-0.08 mcg/kg/min (for a 70 kg pt, this is 1-5 mcg/min) 
  3. Add Vaso if need more vasoconstriction .03-.04 units/min, add early bc an infusion without a loading dose may take 30 min to show effect
  4. If ionized calcium low, replace it, will give significant improvement in inotropy and blood pressure
  5. Serious

Cardiogenic Shock without hypotension

  1. Milrinone low dose 

Cardiogenic Shock with hypotension

  1. Norepi
  2. Epi if need more inotropy- 0.01-0.08 mcg/kg/min (for a 70 kg pt, this is 1-5 mcg/min)
  3. If ionized calcium low, replace it, will give significant improvement in inotropy and blood pressure

Right Heart Failure (or PE induced RHF)

  1. Start with the vasopressor to protect coronary perfusion but 
  2. Vaso .03-.04 units/min
  3. Epi 0.01-0.08 mcg/kg/min (for a 70 kg pt, this is 1-5 mcg/min) 
  4. Norepi if you need more squeeze

Atrial Fibrillation with RVR and Shock (EMCRIT Episode 20 Feb12, 2010)

  1. Sync Cardioversion 200j Biphasic AP pads- usually won’t work so proceed to 2. Best sedative meds 5-7 mg Etomidate and 10-15 mg Ketamine.
  2. Screen for WPW (wide complex tachy 250-300, shock early shock often, light them up!
  3. Amiodarone 150mg bolus followed by infusion 1mg/min OR
  4. Diltiazem 2.5mg/min until HR<100 or you max out at 50mg
  5. Magnesium 2g IV over 20 minutes may repeat x 1 in 1 hour

Bradycardic Shock

  1. Initiate Medical and Electrical treatment arms simultaneously
  2. Transcutaneous pacing
  3. Atropine and Epinephrine
  4. Atropine 1mg
  5. Epinephrine drip or push dose 
  6. Calcium 3g IV over 5-10min
  7. Isoproterenol great for bradycardia but very expensive so pharmacy may not carry it
  8. Dobutamine helps increase HR but may cause hypotension

Anaphylaxic Shock

  1. IM Epi 0.5mg (not 0.3) Q5 min until you start the IV drip 
  2. Clean Epi drip 5-20ug/min If No Clean Epi rapidly available then do dirty epi drip
  3. Dirty Epi drip Push 1mg in 1000cc NS and then run wide open which in a 18g IV is usually between 20-30ml/min or if you can set it on the pump it is 1ug/10ml/min which for a 10ug/min infusion is 600ml per hour.
  4. Decadron 10mg IV (no steroid taper necessary)