DrVirgo
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Please help me make any changes or corrections... I'll send everyone who posts here a complete chart on the different types of shock for quick review after we have finished this discussion... All you have to do is say Increased, Decreased, or Normal, No change for each one.
This topic comes up a LOT on questions in both IM and Surgery so I think we need to know it well.
Thanks.
Hemorrhagic or Hypovolemic Shock:
MAP Dec
HR Inc
CO Dec
TPR Inc
LVEDV Dec
PCWP Dec
PCWP after fluid challenge: No change-Inc
Cardiogenic (LV Dysfunction). eg -Contusion, MI, Arrhythimia, Valve Rupture:
MAP Dec
HR Norm-Inc
CO
TPR
LVEDV
PCWP Inc
PCWP after fluid challenge: Further INC.
Cardiogenic Shock (RV Dysfunc): eg. Contusion or MI
MAP Dec
HR N-Inc
CO
TPR
LVEDV
PCWP Norm-Dec
PCWP after fluid challenge: No change-Inc
Systolic Heart Failure:
MAP Dec
HR Inc
CO Dec
TPR Inc
LVEDV Inc
PCWP Inc
PCWP after fluid challenge:
Diastolic Heart Failure:
MAP Dec
HR Inc
CO Dec
TPR Inc
LVEDV Norm or Dec???
PCWP
PCWP after fluid challenge:
Septic Shock:
MAP Dec
HR Inc
CO Inc?
TPR Dec?
LVEDV
PCWP Norm-Inc
PCWP after fluid challenge: Inc.
Tension PTX / Massive Hemothorax:
MAP Dec
HR Inc
CO Dec?
TPR
LVEDV
PCWP Norm-Dec
PCWP after fluid challenge: No Change-Inc
Pericardial Tamponade:
MAP Dec
HR Inc
CO
TPR
LVEDV
PCWP Inc
PCWP after fluid challenge: Further INC.
High Output Cardiac Failure:
MAP Dec
HR Inc
CO Norm or Inc?
TPR Dec
LVEDV Inc
PCWP
PCWP after fluid challenge:
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| DrVirgo
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 Doesn't anyone want to try these?
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| peter90036
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CVP = right atrial pressure (RAP) = right-ventricle end-diastolic press (RVEDP) (Right Ventricle Preload) = any neck vein catheter or jugular venous pressure.
PCWP = estimates left atrial pressure (LAP) = left-ventricular end-diastolic pressure (LVEDP) (Left Ventricular Preload) by Swan-Ganz
4 Categories of Shock
HYPOVOLEMIC ↓PCWP ↓CVP ↓ CO ↑SVR
= hemorrhage, fluid loss(GI/interstitial/3rd spacing (pancreatitis etc)).
Loss of volume --> decreased ventricular preload -->↓SV -->↓ CO.
Compensate: ↑HR & ↑SVR = cool & clammy.
Severity of Shock Depends on Amt, Rate of Blood Loss .
Loss of up to 10% of blood has almost no effect on CO, MAP, and no long-term consequences .
>20% loss reduces CO, MAP, though CO affected more b/c of SVR increase.
CARDIOGENIC ↑PCWP ↑CVP ↓ CO ↑ SVR
= massive MI, cardiomyopathy, acute valvular disease, tachycardia , Bradycardia.
Has preload.
Doesn’t have output --> compensate: ↑SVR = cold & clammy.
Sx: JVD, Pulm edema(usually when PCWP>19).
DISTRIBUTIVE aka vasodilatatory ↓ SVR ↑CO
= Sepsis, the systemic inflammatory response syndrome (SIRS) due to pancreatitis and massive trauma, and anaphylaxis.
= Neurogenic (Spinal Cord Injury, Spinal Anesthesia, Drug Overdose) neurogenic shock ↓PCWP ↓CVP ↓ CO ↓ SVR.
= Importantly, vasodilatory shock is a common endpoint of prolonged shock of any kind, or after cardiac arrest.
Has ↓ SVR (vasodilation) = warm and flushed.
Compensation= ↑CO (If hypovolemic ↓CO, with volume resuscitation compensation resumes as ↑CO).
Prolonged vasodilatory shock --> progressively diminished cardiac function (part due to myocardial underperfusion and circulating myocardial depressant factors).
typical vasodilatory shock: ↓ SVR ↑CO, CVP/ PCWP vary depending on volume.
OBSTRUCTIVE ↓CO ↑SVR ↑CVP ↑PCWP (N with PE)
= Obstruction of filling = tension pneumothorax, pericardial tamponade--> ↓CO
= Obstruction of Outflow = massive pulmonary embolism: normal PCWP
End Organ Dysfunction in Shock
Respiratory: tachypneic or respiratory distress, even if oxygenation is normal. -->pulm edema & ARDS
Renal: oliguria (<1/2 ml/kg/hr) is an important early sign of hypoperfusion. --> ARF, ATN
Metabolic: acidosis (lactate and other anions)
CNS: encephalopathy: agitation, obtundation
Tx:
- secure airway, resp distress/severe acidosis --> mechanical ventilation, hypoxemia --> O2
- foley, monitor urine out
- continuous EKG, pulseOx
- CVP/Swanganz if volume status/cardiac function unclear
- Prompt admin isotonic crystalloids NS/RL & reassess after each bolus – goal: BP & urine
- Prompt treatment of the underlying cause of the shock is essential:
- antibiotics,drainage of infected foci for sepsis, consider activated protein C for patients in septic shock
- thrombolysis for PE,
- pericardiocentesis for tamponade,
- control of bleeding, re-perfusion therapy in acute MI, cardioversion or pacing of arrhythmias
- tube thoracostomy for tension pneumothorax,
- placement of intra-aortic balloon pump or left ventricular assist device for refractory cardiogenic shock.
- etc
sources
http://www.med.cornell.edu/education/curriculum/f...
i just made this because i dont like tables, ya'll can download my PDF. here below:
Attached Files:
notes - Shock.pdf (87 KB, 9 downloads)
Edited by peter90036 on 04/05/08 - 10:31 AM
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| arlete
Intern in 2009!!!!!
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Posts: 2,212
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PCWP = Pulmonary Capillary Wedge Pressure = Left atrium pressure
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| inkspot
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Posts: 554
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This is from Goljan Rapid Review: so the source is accurate.
Hypovolemic :
CO: dec
TPR: inc
LVEDV: dec
Endotoxic Shock (septic)
CO: inc
TPR: dec
LVEDV: dec
Cardiogenic Shock:
CO: dec
TPR: Inc
LVEDV: inc
==========================================
Some stuff from Harrison Internal Medicine 16th ed.
====================================
To DrVirgo: Kindly update your first post using this data, so that we have a final list that we can print and vomit in exam
Take care
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| peter90036
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Posts: 315
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30. Fluid Challenge
Generally, it is not good to judge absolute values of PCWP or CVP as an index of optimum fluid volue for a given patient.
Practice is to give "fluid challenge" of 200 cc of fluid in a short period of time to determine what efect it has on CVP or PCWP. Since the vascular system is a compliant structure, volume increases will cause little change in pressure until it is stretched to elastic limit, then pressure will increase dramatically.
Challenge is tried only in hemodynamically unstable individuals, to see if more volume may improve cardiac output.
If volume causes < 3 mm Hg change in PCWP, then give more fluid.
If > than 7 mm Hg then do not give any more fluid.
>>>>>>>> from some yosemite hemodynamics website (didnt check if its humans or dogs...)
Fluid challenge in patients with suspected hypovolemia may be given.
>>>>>>>> from a nice shock PPT from U.Michigan
PCWP
Below 15, fluid may be an option
Between 15 and 18 need to jump to inotropes
an acp cardiac failure PPT.
Hypovolemic shock:
Generally, CVP or PCWP should not be raised > 12 to 15 mm Hg by fluid replacement.
>>>>>>>> from: weber.edu
>>> a nice PPT about INVASIVE HEMODYNAMIC MONITORING @ musc.edu
250ml bolus for cardiogenic shock, no evidence of pulm edema–Optimal PCWP ≈18-25
>>>> hemodynamic support PDF @uchsc.edu
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| peter90036
Forum Elite
Topics: 28
Posts: 315
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can't find anything more about fluid challenges... maybe someone with some physio/patho knowledge can infer the consequences for each situation
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| peter90036
Forum Elite
Topics: 28
Posts: 315
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High Output Cardiac Failure:
CO HIGH (as in the name)
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| DrVirgo
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peter90036 wrote:
(didnt check if its humans or dogs...)
 LOL  -I know... Sometimes when you google medical stuff it gives you vetinary things! 
Anyway, thanks for your help everyone... I am going to go through EVERTHING that you all posted. I will condense and compile it into ONE HUGE CHART... I'll post it by the end of this weekend, so look out!
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| DrVirgo
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Posts: 3,344
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Here it is again with some more blanks filled in.
I'm not sure about LVEDV and LVEDP in some of these.
I also didn't add CVP, but Peter summed it up nicely.
Just remember that in hemorrhagic/hypovolemic shock there are flat neck veins so decreased JVP and decreased CVP. But if there is a back up of blood like in MI, CHF, or trauma and Tension PTX or Cardiac tamponade, there will be JVD and Increased CVP.
-Most forms of shock have Decreased CO and Increased HR... Expept HIGH OUTPUT -which has Inc CO
-Most forms of shock have Inc TPR (think vasoconstriction to help maintain CO) so patient will will be cold and clammy. -The exeptions are Septic, Neurogenic, and High Output cardiac failure which will have Vasodilation. Septic shock, especially in the initial stages presents as warm and flushed.
-Another important point to rember is that if you have a patient who presents with shock, due to blunt trauma of the thorax, and you give fluids, and the PCWP increases but the patient remains hypotensive, his shock was probably not due to blood loss (hypovolemic/hemorrhagic)...
-PCWP elevation + Persistent Hypotention after fluids = LV Failure and cardiogenic shock. -Could be MI, arrhythmia, contusion, compression, tamponade. -ALL forms of cardiogenic shock should be treated with volume expansion till PCWP of 15-20. Inotropic meds like Dopamine/Dobutamine can be used to maintain CO and Increase HR.
-If anyone has anything else to add please post here! Thanks.
Hemorrhagic or Hypovolemic Shock:
MAP Dec
HR Inc
CO Dec
TPR Inc
LVEDV Dec
PCWP Dec
PCWP after fluid challenge: No change-Inc
Cardiogenic (LV Dysfunction). eg -Contusion, MI, Arrhythimia, Valve Rupture:
MAP Dec
HR Norm-Inc
CO Dec
TPR Norm/Inc
LVEDV
PCWP Inc
PCWP after fluid challenge: Further INC.
Cardiogenic Shock (RV Dysfunc): eg. Contusion or MI
MAP Dec
HR N-Inc
CO Dec
TPR Inc
LVEDV
PCWP Norm-Dec
PCWP after fluid challenge: No change-Inc
Systolic Heart Failure:
MAP Dec
HR Inc
CO Dec
TPR Inc
LVEDV Inc
PCWP Inc
PCWP after fluid challenge:
Diastolic Heart Failure:
MAP Dec
HR Inc
CO Dec
TPR Inc
LVEDV Norm or Dec???
PCWP Dec/Norm/Inc
PCWP after fluid challenge:
Septic Shock:
MAP Dec
HR Inc
CO Inc
TPR Dec
LVEDV Dec
PCWP Norm-Inc
PCWP after fluid challenge: Inc.
Tension PTX / Massive Hemothorax:
MAP Dec
HR Inc
CO Dec
TPR Inc
LVEDV
PCWP Norm-Dec
PCWP after fluid challenge: No Change-Inc
Pericardial Tamponade:
MAP Dec
HR Inc
CO Dec
TPR Inc
LVEDV
PCWP Inc
PCWP after fluid challenge: Further INC.
High Output Cardiac Failure:
MAP Dec
HR Inc
CO Norm or Inc?
TPR Dec
LVEDV Inc
PCWP
PCWP after fluid challenge:
Neurogenic Shock:
MAP Dec
HR Norm/Inc
CO dec
TPR Dec
LVEDV Inc
PCWP Normal/Dec
PCWP after fluid challenge: Inc
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Our greatest glory is not in never falling, but in rising every time we fall.
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