Shock, Sepsis, MODS PPT-1

Shock Overview

  • Definition: Shock is a clinical syndrome characterized by inadequate tissue perfusion, leading to cellular, hemodynamic, and metabolic issues.

  • Consequences: Imbalance in cellular oxygen supply/demand, resulting in cell death, multiple organ dysfunction syndrome (MODS), or death.

Hemodynamic Review

  • Key Parameters: MAP, CVP, PAWP, CI, CO, SVR, Pao2, SvO2

Types of Shock

  1. Hypovolemic: Inadequate intravascular volume.

  2. Cardiogenic: Heart fails to pump effectively.

  3. Obstructive: Impairment in blood flow.

  4. Distributive: Widespread vasodilation leading to relative hypovolemia.

    • Subtypes: Neurogenic, anaphylactic, septic.

Stages of Shock

  • Stage I: Initial compensatory mechanisms begin, barely detectable signs.

  • Stage II: Symptoms manifest; interventions can reverse shock.

    • Neural Compensation: Epi and norepinephrine release leading to increased heart rate and vascular response.

    • Endocrine Compensation: Increased glucose, sodium, and water resorption, raising blood volume.

    • Chemical Compensation: Low oxygen and rise in respiratory rate, leading to respiratory alkalosis.

  • Stage III: Progressive shock, severe hypoperfusion, tissue ischemia, metabolic acidosis.

  • Stage IV: Refractory shock, irreversible damage, and organ failure.

Assessment of Shock

  • Cardiovascular Signs: Tissue Perfusion (color, temp, pulses, capillary refill), blood pressure (Initial compensatory VS. Late), heart rate variations.

  • Pulmonary Signs: Rapid and deep respirations (early); shallow and poor gas exchange (late).

  • Renal Signs: Oliguria or anuria indicating decreased perfusion. Increased BUN and CRT

  • Gastrointestinal Symptoms: Decreased bowel activity = abd distention, nausea, constipation

  • Lab Changes: Serum lactate levels for shock indication AND adequacy of fluid resuscitation.

Management Strategies

  • Key Goals: Maintain tissue perfusion, improve oxygen delivery.

  • Treatments: Fluid resuscitation, pharmacotherapy, mechanical therapy (oxygenation, dialysis, etc.)

Specific Shock Types

Hypovolemic Shock

  • Causes: dehydration, hemorrhage, GI bleed, DI, Diuresis, Intestinal obstruction, DIC, Surgery, Dissected aortic aneurysm

  • Assessment: Increased HR, decreased BP, decreased LOC, decreased UOP, decreased HCT, HGB, RBCs, and PLTs (if bleeding is main cause), Pale/Cool skin

  • Hemodynamics: Increased SVR, decreased CVP, PAOP, CO, CI

  • TX: ID cause, replace IV fluids, Oxygen, and PRBCs

Cardiogenic Shock

  • Causes: Myocardial infarction, heart failure, cardiac arrest, decreased myocardial contractility, dysrhythmias

  • Assessment: increased HR, decreased BP, cold/pale skin, EKG changes, S/S of fluid overload, increased CK/CKMB/Troponin

  • Hemodynamics: Increased PAWP, CVP, SVR, decreased CO and CI

  • TX: Oxygen, medication (e.g., inotropes), PCI, IABP, VAD.

Obstructive Shock

  • Causes: Cardiac tamponade, pulmonary embolism, pulmonary HTN, Pleural Effusion, Thoracic tumor

  • Assessment: increased HR, decreased BP, cool/clammy skin, muffled heart sounds, S/S of fluid overload

  • Hemodynamics: increased CVP, PAOP, SVR; decreased CO and CI

  • TX: treat the obstruction, oxygen, inotropic drugs (until you can get pt to OR)

Neurogenic Shock

  • Causes: Head or spinal cord trauma, anesthesia

  • Assessment: Bradycardia, hypotension, warm/dry/flushed skin BUT hypothermic

  • Hemodynamics: decreased CO, CVP, PAOP, SVR.

  • TX: maintain MAP and HR (vasoactive meds: Nor-epi, Epi. Dopamine, phenylephrine), IVF, Atropine, Pacing.

Anaphylactic Shock

  • Causes: Severe allergic reaction

  • Assessment: decreased BP, increased HR and RR, dyspnea, coughing, stridor, wheezing, swelling, rash

  • Hemodynamics: decreased CO, CVP, PAWP, and SVR

  • Management: REMOVE stinger, IM epi, AIRWAY, Fluids, Other drugs (antihistamines, steroids, bronchodilators, etc.)

Septic Shock

  • Causes: Severe infection leading to a systemic response.

  • Assesment:

    EARLY SIGNS: decreased UOP, confusion, rapid bounding pulses, increased temp and HR, warm flushed skin, high SvO2 (due to increase in CO2), decreased BP


    LATE SIGNS: increased HR and lactic acid, decreased BP, skin pallor, cyanosis, mottling, cool, absent UOP, weak peripheral pulses, lethargy, coma, decreased SvO2

  • Hemodynamics:

    EARLY: increased CO, decreased SVR, CVP, PAOP


    LATE: decreased CO, SVR, PAOP, CVP

  • TX: organ support (dialysis, ventilation), hemo monitoring, antibiotics, fluids, pressors.

Multiple Organ Dysfunction Syndrome (MODS)

  • Definition: Failure of two or more organ systems due to uncontrolled inflammatory response.

  • Assessment: tachypnea/hypoxemia, petechiae/bleeding, jaundice, abd distention, oliguria that leads to anuria, tachycardia, hypotension, change in LOC

  • TX: ventilator, inotropic meds or vasopressors, CRRT or hemodialysis, enteral feedings.

Disseminated Intravascular Coagulation (DIC)

  • Definition: Coagulopathy causing simultaneous clot formation and hemorrhage.

  • Assessment: bleeding from all openings, petechiae, ecchymosis, hemtomas, GI bleeds, decreased PLTS and fibrinogen, increased fibrin degradation products, prolonged PT and PTT, D-Dimer POSITIVE

  • TX: treat underlying cause, IVF (LR or NS), PRBCs, FFP, PLTs.