Difference between revisions of "Undifferentiated shock"

(Undifferentiated Hypotension Algorithm)
(Causes of non-response to vasopressorsAnand Swaminathan, "Occult Causes of Non-Response to Vasopressors", REBEL EM blog, July 13, 2017. Available at: https://rebelem.com/occult-causes-of-non-response-to-vasopressors/.)
 
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== Definition ==
+
{{Adult top}} [[undifferentiated shock]].''
#SBP <90 in normal pt
+
==Overview==
#SBP <100 with h/o HTN or age >60
+
*Inadequate perfusion of the tissues
#Lactate > 4 or base def < -4
+
*Goal to increase the flow of oxygenated blood to the tissues
 +
*MAP<50 in dog studies brain will become ischemic and patients might presents as an altered mental status <ref>Plöchl, W, D J Cook, T A Orszulak, and R C Daly. 1998. Critical cerebral perfusion pressure during tepid heart operations in dogs. The Annals of thoracic surgery, no. 1. http://www.ncbi.nlm.nih.gov/pubmed/9692450</ref>
  
== Types ==
+
==Undifferentiated [[Hypotension]] Algorithm<ref>Morchi R. Diagnosis Deconstructed: Solving [[Hypotension]]in 30 Seconds. Emergency Medicine News. 2015.</ref>==
 +
Check/manage the following in order:
  
{| border="1"
+
[[File:Hypotension.png|thumbnail|Algorithm for the Evaluation of [[Hypotension]](By Dr. Ravi Morchi)]]
|-
 
| '''Type'''
 
| '''Skin'''
 
| '''HR'''
 
| '''Oth'''
 
|-
 
| Hypovolemic
 
| cold
 
| inc
 
| <br/>
 
|-
 
| Obstructive
 
| cold
 
| inc
 
| <br/>
 
|-
 
| Cardiogenic
 
| cold
 
| inc/dec
 
| &nbsp;?dysth
 
|-
 
| Distributive
 
| warm
 
| inc
 
| <br/>
 
|-
 
| Neurogenic
 
| warm
 
| dec
 
| <br/>
 
|}
 
  
== Undifferentiated Hypotension Algorithm ==
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*Pulse (assess based on patient's age)
*Which of the following is the main cause?
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**Too [[bradycardia|slow]] or too [[tachycardia|fast]] (to the point where CO is affected)?
*Which of the following is contributing?
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***If so, HR is likely primary etiology of hypotension
 +
***Pace or cardiovert
 +
*Volume status
 +
**What is the LV end-diastolic volume?
 +
***Approximated by the [[IVC ultrasound|IVC diameter]] or CVP
 +
***If low:
 +
****Assess for [[hemorrhage|blood]] loss versus [[hypovolemia|fluid loss]]
 +
*****[[FAST exam|FAST]] for intra-abdominal bleed
 +
*****US for ruptured [[Aortic ultrasound|AAA]]
 +
*****Guaiac for [[GI bleed]]
 +
*****[[CXR]] for [[hemothorax]]
 +
****Treat with [[IVF]] and/or [[pRBCs]] depending on cause
 +
*Contractility
 +
**Is the myocardium severely depressed in its contractile function ([[cardiogenic shock]])?
 +
***Assess via [[Ultrasound: In Shock and Hypotension|ultrasound]]
 +
***Treat with inotrope (e.g. [[epinephrine]], [[dopamine]]
 +
**Is forward flow occurring?
 +
***Assess for valvular dysfunction ([[mitral regurgitation|MR]], [[aortic regurgitation|AR]])
 +
***Assess for obstruction ([[PE]], [[tamponade]])
 +
*Systemic Vascular Resistance
 +
**Pathologic vasodilation (decreased SVR) suggested by:
 +
***Warm extremities
 +
***Bounding pulse
 +
**Treated based on likely etiology of distributive shock (see below)
  
Check the following in order:
+
==Differential Diagnosis==
 +
{{Shock DDX}}
  
#HR (assess based on pt's age)
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==Evaluation==
##Too slow or too fast? (to the point where CO is affected)
+
{{Shock index}}
###If so HR is likely primary etiology of hypotension
 
###Pace or cardiovert
 
  
#Volume Status
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===Consider RUSH to CVS===
##What is the LV end-diastolic volume?
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*[[RUSH exam]]
###Approximated by the CVP, IVC diameter
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*[[calcium chloride|Calcium]] bolus as inotrope
##If low must rule-out occult blood loss:
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*[[Vasopressin]]
###FAST for intra-abdominal source
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*[[Steroids]], stress-dose, mineralocorticoids
###US to rule-out AAA
 
###Guaiac to rule-out GI bleed
 
###CXR to rule-out hemothorax
 
  
 +
==Management==
 +
*Treat underlying type
  
 +
{{Vasopressor table}}
  
 
+
===Causes of non-response to vasopressors<ref>Anand Swaminathan, "Occult Causes of Non-Response to Vasopressors", REBEL EM blog, July 13, 2017. Available at: https://rebelem.com/occult-causes-of-non-response-to-vasopressors/.</ref>===
#Contractility
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*[[Acidosis]]
##Is the myocardium severely decreased in its contractile function?
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**Dx: Blood gas, BMP
###Poor contractility on ultrasound, bounding/thready pulse, hyperdynamic precordium
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**Tx: treat underlying cause, consider bicarbonate gtt
##Is forward flow occurring?
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*[[Hypothyroidism]]
###Assess for valvular dysfunction (MR, AR)
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**Dx: Clinical, TSH
###Assess for obstruction (PE, HOCM)
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**Tx: [[levothyroxine]]
 
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*[[Anaphylaxis]]
#Systemic Vascular Resistance
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**Dx: History
##Pathologic vasodilation (decreased SVR) suggested by:
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**Tx: [[Epinephrine]], [[methylene blue]], ECMO
###Warm extremities
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*[[Adrenal insufficiency]]
###Bounding pulse
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**Dx: Clinical, cortisol level, [[hyperkalemia]] + [[hyponatremia]]
###The other three components are normal (HR, volume status, contractility)
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**Tx: [[Hydrocortisone]] 100-200mg
 
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*[[Hypocalcemia]]
== Lack of Response to Normal Tx (DDX)  ==
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**Dx: ionized calcium, [[prolonged QTc]]
 
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**Tx: [[Calcium chloride]] or [[calcium gluconate]]
#Cardiogenic
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*[[Hemorrhagic shock|Occult bleeding]]
##Acute Valvular Regurg/VSD
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**Dx: Clinical (consider [[GI bleed]] and retroperitoneal hematoma)
##CHF
+
**Tx: Transfusion, treat coagulopathy, surgery/IR interventions
##Dysrhythmia
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*[[Toxicology (main)|Toxicologic]]
##Ischemia/Infarction
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**Dx: Clinical (consider [[beta blocker toxicity]], [[calcium channel blocker toxicity]], [[TCA overdose]], etc)
##Myocardial Contusion/Myocarditis
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**Tx: Depends on etiology (glucagon, hyperinsulin euglycemia therapy, sodium bicarbonate, ECMO, etc)
#Obstructive
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*2nd cause of shock
##Air embolism
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**Dx: Clinical, consider [[RUSH exam]]
##Aortic Stenosis
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**Tx: Address underlying cause
##Cardiac Tamponade
 
##Massive PE
 
##Tension Pneumo
 
#Distributive
 
##Adrenal Crisis
 
##Anaphylaxis
 
##Neurogenic
 
##Sepsis
 
##Toxicologic
 
#Hypovolemic
 
##Hemorrhage Traumatic and Non-traumatic
 
##Severe Dehydration
 
  
 
==See Also==
 
==See Also==
 
*[[Ultrasound in Shock and Hypotension]]
 
*[[Ultrasound in Shock and Hypotension]]
*[[Cardiogenic Shock]]
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*[[Pediatric shock]]
 +
 
 +
==External Links==
 +
*[http://pemplaybook.org/podcast/approach-to-shock/ Pediatric Emergency Playbook Podcast: Approach to Shock]
  
== Source ==
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==References==
2/06 DONALDSON (Adapted from Tintinalli)
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<references/>
  
Morchi 2010
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==Videos==
 +
{{#widget:YouTube|id=rOADTgtWuD4}}
 +
{{#widget:YouTube|id=uZgusFEwmmk}}
  
[[Category:Airway/Resus]]
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[[Category:Critical Care]]
[[Category:Cards]]
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[[Category:Cardiology]]

Latest revision as of 21:02, 9 March 2021

This page is for adult patients. For pediatric patients, see: undifferentiated shock.

Overview

  • Inadequate perfusion of the tissues
  • Goal to increase the flow of oxygenated blood to the tissues
  • MAP<50 in dog studies brain will become ischemic and patients might presents as an altered mental status [1]

Undifferentiated Hypotension Algorithm[2]

Check/manage the following in order:

Algorithm for the Evaluation of Hypotension(By Dr. Ravi Morchi)
  • Pulse (assess based on patient's age)
    • Too slow or too fast (to the point where CO is affected)?
      • If so, HR is likely primary etiology of hypotension
      • Pace or cardiovert
  • Volume status
  • Contractility
  • Systemic Vascular Resistance
    • Pathologic vasodilation (decreased SVR) suggested by:
      • Warm extremities
      • Bounding pulse
    • Treated based on likely etiology of distributive shock (see below)

Differential Diagnosis

Shock

Evaluation

Shock index (SI)[3]

SI = HR / SBP

  • Used when HR and SBP do not predict severity of hypovolemia in early stages
  • May be used as secondary triage tool in mass casualty incidents[4]
  • 0.5-0.7 is normal
  • >0.70-0.75 for occult shock or requirement of life-saving intervention

Consider RUSH to CVS

Management

  • Treat underlying type

Vasopressors

Pressor Initial Dose Max Dose Cardiac Effect BP Effect Arrhythmias Special Notes
Dobutamine 3-5 mcg/kg/min 5-15 mcg/kg/min (as high as 200) [5] Strong ß1 agonist +inotrope +chronotrope, Weak ß2 agonist +weak vasodilatation ) alpha effect minimal HR variable effects [6]. Also Increase SA and AV node fx indicated in decompensated systolic HF, Debut Research 1979[7] Isoproterenol has most Β2 vasodilatory and Β1 HR effects
Dopamine 2 mcg/kg/min 20-50 mcg/kg/min β1 and NorEpi release α effects if > 20mcg/kg/min Arrhythmogenic from β1 effects More adverse events when used in shock compared to Norepi[8]
Epinepherine 0.1-1 mcg/kg/min + inotropy, + chronotropy
Norepinephrine 0.2 mcg/kg/min 0.2-1.3 mcg/kg/min (5mcg/kg/min) [9] mild β1 direct effect β1 and strong α1,2 effects Less arrhythmias than Dopamine[8] First line for sepsis. Increases MAP with vasoconstriction, increases coronary perfusion pressure, little β2 effects.
Milrinone 50 mcg/kg x 10 min 0.375-75 mcg/kg/min Direct influx of Ca2+ channels Smooth muscle vasodilator PDE Inhibitor which increases Ca2+ uptake by sarcolemma. No venodilatory activity
Phenylephrine 100-180 mcg/min then 40-60 mcg/min 0.4-9 mcg/kg/min Alpha agonist Long half life
Vasopressin Fixed Dose 0.01 to 0.04 U/min unknown increases via ADH peptide should not be titrated due to ischemic effects
Methylene blue[10] IV bolus 2 mg/kg over 15 min 1-2 mg/kg/hour Possible increased inotropy, cardiac use of ATP Inhibits NO mediated peripheral vasodilation Don't use in G6PD deficiency, ARDS, pulmonary hypertension
Medication IV Dose (mcg/kg/min) Concentration
Norepinephrine (Levophed) 0.1-2 mcg/kg/min 8mg in 500mL D5W
Dopamine 2-20 mcg/kg/min 400mg in 250 D5W
Dobutamine 2-20 mcg/kg/min 250mg in 250 mg D5W
Epinephrine 0.1-1 mcg/kg/min 1mg in 250 D5W

Causes of non-response to vasopressors[11]

See Also

External Links

References

  1. Plöchl, W, D J Cook, T A Orszulak, and R C Daly. 1998. Critical cerebral perfusion pressure during tepid heart operations in dogs. The Annals of thoracic surgery, no. 1. http://www.ncbi.nlm.nih.gov/pubmed/9692450
  2. Morchi R. Diagnosis Deconstructed: Solving Hypotensionin 30 Seconds. Emergency Medicine News. 2015.
  3. Levitan, Richard M. Fundamentals of Airway Management. 3rd ed. Irving, TX: Emergency Medicine Residents' Association, 2015.
  4. Vassallo J et al. Usefulness of the Shock Index as a secondary triage tool. J R Army Med Corps. 2015 Mar;161(1):53-7.
  5. https://www.ncbi.nlm.nih.gov/pubmed/8449087
  6. Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine
  7. 8.0 8.1 De Backer Daniel et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM 363(9). 779-789
  8. https://www.ncbi.nlm.nih.gov/pubmed/15542956
  9. Pasin L et al. Methylene blue as a vasopressor: a meta-analysis of randomised trials. Crit Care Resusc. 2013 Mar;15(1):42-8.
  10. Anand Swaminathan, "Occult Causes of Non-Response to Vasopressors", REBEL EM blog, July 13, 2017. Available at: https://rebelem.com/occult-causes-of-non-response-to-vasopressors/.

Videos