Shock: Principles of Management: Nathan W. Mick, MD Massachusetts General Hospital Brigham and Women's Hospital

Shock: Principles of
Management
Nathan W. Mick, MD
Massachusetts General Hospital
Brigham and Women’s Hospital
Definition
 Inadequate end-organ perfusion

Stages of shock
Parameter Class 1 Class 2 Class 3 Class 4
%Blood Loss <15% 15-30% 30-40% >40%
Pulse <100 >100 >120 >140
BP Normal Normal Decreased Decreased
UOP (ml/h) >30 20-30 5-15 <5
Mental Anxious Agitated Confused Lethargic

Status
Cases:
 22 yo male with single gunshot wound to

the left chest. Vitals: P 160, BP 60/p, Sat
100%, RR 26, T 37.0
Cases:
 90 year old female with fever, cough

productive of green sputum and altered
mental status. Vitals: P 120, BP 75/45,
Sat 90%, RR 28, T 101.0
Cases:
 66 yo male with anterolateral myocardial

infarction 2 weeks ago now with
progressive dyspnea, pedal edema and
hypotension. Vitals P 110, BP 70/40, Sat
90%, RR 28, T 37.0
Initial Management
Initial Management:
 A:
 B:
 C:
 IV:
 Oxygen:
 Monitor
Airway
 Intubate the damn patient!

Intravenous Access
 the rate of volume infusion is determined by the
dimensions of the vascular catheter, not by the
size of the vein
 cannulation of the large central veins requires
catheters that are at least 5 inches in length,
whereas cannulation of peripheral veins can be
accomplished with catheters that are 2 inches in
length
Intravenous Access
Intravenous Access
 central venous cannulation is reserved for
monitoring cardiac filling pressures and venous O2
saturation unless very-large-bore introducer
catheters are used for volume resuscitation
 central venous catheters are 3 to 4 times longer
than peripheral venous catheters, the infusion
rate through central catheters will be as much
as 75% less than the infusion rate through
peripheral catheters (of equal diameter)
Labs
 "Use of the hematocrit to estimate

acute blood loss is unreliable and
inappropriate"
Resuscitation Endpoints
 The following are common endpoints of

volume resuscitation:
1. CVP = 15 mm Hg
2. Wedge pressure = 10 to 12 mmHg
3. Cardiac index > 3 L/min/m2
4. Blood lactate < 4 mmol/L
5. Base deficit -3 to +3 mmol/L
Base Deficit
 the base deficit (millimoles of base needed to correct
the pH of 1 L of whole blood to 7.40) has been shown
to correlate with volume deficits and with mortality in
trauma victims
 The normal range for the base deficit is 3 mmol/L on
either side of zero. Elevations in base deficit can be
classified as mild (2 to 5 mmol/L), moderate (6 to 14
mmol/L), or severe (> 15 mmol/L)
 the base deficit that remains elevated during volume
infusion is an indication of ongoing tissue ischemia
Fluid Composition
 Normal Saline
 154 meq sodium
 154 meq chloride
 308 mOsm
 pH 5.6
Fluid Composition
 Lactated Ringer’s
 130 meq sodium
 109 meq chloride
 4 meq potassium
 3 meq calcium
 28 meq lactate
 273 mOsms
 pH 6.6
 Can’t use LR while infusing blood!
Dopamine
 Dopamine receptor activation at low

doses-”splanchnic dilation” (2-5
mcg/kg/min)
 Beta receptor activation-increase cardiac
output (5-10 mcg/kg/min)
 Alpha receptor activation-vasoconstriction
(>10 mcg/kg/min)
Dobutamine
 primarily a 1-receptor agonist (cardiac
stimulation), but it also has mild -2 effects
(vasodilation)
 causes a dose-dependent increase in stroke
volume
 decrease in cardiac filling pressures
 an alkaline pH inactivates catecholamines such as
dobutamine
 Dose 2-20 mcg/kg/min
Dobutamine
 dobutamine is the preferred inotropic

agent for the acute management of low
output states due to systolic heart failure.
Because dobutamine does not usually
raise the arterial blood pressure, it is not
indicated as monotherapy in patients
with cardiogenic shock
Norepinephrine
 -receptor agonist that promotes

widespread vasoconstriction
 administration of any vasoconstrictor
agent carries a risk of hypoperfusion and
ischemia involving any tissue bed or vital
organ
 Dose 8-12 mcg/min

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Shock: Principles of

 Inadequate end-organ perfusion

%Blood Loss <15% 15-30% 30-40% >40%

Pulse <100 >100 >120 >140

BP Normal Normal Decreased Decreased

UOP (ml/h) >30 20-30 5-15 <5

Mental Anxious Agitated Confused Lethargic

 22 yo male with single gunshot wound to

 90 year old female with fever, cough

 66 yo male with anterolateral myocardial

 Intubate the damn patient!

 "Use of the hematocrit to estimate

 The following are common endpoints of

 Dopamine receptor activation at low

 dobutamine is the preferred inotropic

 -receptor agonist that promotes

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