Difference between revisions of "Undifferentiated shock"

(See Also)
(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]].''
 +
==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 <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> 
  
#SBP <90 in nl pt
+
==Undifferentiated [[Hypotension]] Algorithm<ref>Morchi R. Diagnosis Deconstructed: Solving [[Hypotension]]in 30 Seconds. Emergency Medicine News. 2015.</ref>==
#SBP<100 with h/o HTN or age >60
+
Check/manage the following in order:
#ABG = lactate > 4 or base def < -4
 
#MAP = SVR x CO
 
  
== Types ==
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[[File:Hypotension.png|thumbnail|Algorithm for the Evaluation of [[Hypotension]](By Dr. Ravi Morchi)]]
  
{| border="1"
+
*Pulse (assess based on patient's age)
|-
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**Too [[bradycardia|slow]] or too [[tachycardia|fast]] (to the point where CO is affected)?
| '''Type'''
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***If so, HR is likely primary etiology of hypotension
| '''Skin'''
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***Pace or cardiovert
| '''HR'''
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*Volume status
| '''Oth'''
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**What is the LV end-diastolic volume?
|-
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***Approximated by the [[IVC ultrasound|IVC diameter]] or CVP
| Hypovolemic
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***If low:
| cold
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****Assess for [[hemorrhage|blood]] loss versus [[hypovolemia|fluid loss]]
| inc
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*****[[FAST exam|FAST]] for intra-abdominal bleed
| <br/>
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*****US for ruptured [[Aortic ultrasound|AAA]]
|-
+
*****Guaiac for [[GI bleed]]
| Obstructive
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*****[[CXR]] for [[hemothorax]]
| cold
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****Treat with [[IVF]] and/or [[pRBCs]] depending on cause
| inc
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*Contractility
| <br/>
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**Is the myocardium severely depressed in its contractile function ([[cardiogenic shock]])?
|-
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***Assess via [[Ultrasound: In Shock and Hypotension|ultrasound]]
| Cardiogenic
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***Treat with inotrope (e.g. [[epinephrine]], [[dopamine]]
| cold
+
**Is forward flow occurring?
| inc/dec
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***Assess for valvular dysfunction ([[mitral regurgitation|MR]], [[aortic regurgitation|AR]])
| &nbsp;?dysth
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***Assess for obstruction ([[PE]], [[tamponade]])
|-
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*Systemic Vascular Resistance
| Distributive
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**Pathologic vasodilation (decreased SVR) suggested by:
| warm
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***Warm extremities
| inc
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***Bounding pulse
| <br/>
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**Treated based on likely etiology of distributive shock (see below)
|-
 
| Neurogenic
 
| warm
 
| dec
 
| <br/>
 
|}
 
  
== Undifferentiated Hypotension Algorithm ==
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==Differential Diagnosis==
 +
{{Shock DDX}}
  
Check:
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==Evaluation==
 +
{{Shock index}}
  
#HR (age appropriate)
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===Consider RUSH to CVS===
##<40 and >150-180 --> likely HR = Primary etiology
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*[[RUSH exam]]
###Tx with cardioversion/defib or pace
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*[[calcium chloride|Calcium]] bolus as inotrope
##Plasma vs. RBC loss
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*[[Vasopressin]]
###Evaluate CVP, IVC, UOP
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*[[Steroids]], stress-dose, mineralocorticoids
###Check for GI, intraperitoneal, lung, retroperitoneal loss/sequestration
 
#Contractility
 
##Bounding/thready pulse, hyperdynamic precordium
 
##Dx with ultrasound
 
###Will have high afterload
 
####May be due to STEMI, CHF
 
#Forward flow
 
##Valvular dysfunction (MR) or obstruction
 
###Evaluate via auscultation, ultrasound
 
####Consider PE, HOCM
 
#Volume Status - LVEDP (approx by CVP, IVC, etc.)
 
##History of volume loss
 
##Lung Exam
 
##Mucous membrane
 
##Ultrasound IVC (RUQ window or AAA)
 
##Hemeacuu, Guaic
 
##Cardiac Ultrasound
 
#SVR
 
##Pathologic vasodilation
 
###Warm extremities, bounding pulse
 
####Consider sympathetic dysregulation/neurogenic shock
 
##Cool extremities and "normal" BP
 
###Consider vasoconstriction and treat as hypotension from the top
 
  
== Lack of Response to Normal Tx (DDX)  ==
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==Management==
 +
*Treat underlying type
  
#Cardiogenic
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{{Vasopressor table}}
##Acute Valvular Regurg/VSD
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##CHF
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===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>===
##Dysrhythmia
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*[[Acidosis]]
##Ischemia/Infarction
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**Dx: Blood gas, BMP
##Myocardial Contusion/Myocarditis
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**Tx: treat underlying cause, consider bicarbonate gtt
#Obstructive
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*[[Hypothyroidism]]
##Air embolism
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**Dx: Clinical, TSH
##Aortic Stenosis
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**Tx: [[levothyroxine]]
##Cardiac Tamponade
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*[[Anaphylaxis]]
##Massive PE
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**Dx: History
##Tension Pneumo
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**Tx: [[Epinephrine]], [[methylene blue]], ECMO
#Distributive
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*[[Adrenal insufficiency]]
##Adrenal Crisis
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**Dx: Clinical, cortisol level, [[hyperkalemia]] + [[hyponatremia]]
##Anaphylaxis
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**Tx: [[Hydrocortisone]] 100-200mg
##Neurogenic
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*[[Hypocalcemia]]
##Sepsis
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**Dx: ionized calcium, [[prolonged QTc]]
##Toxicologic
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**Tx: [[Calcium chloride]] or [[calcium gluconate]]
#Hypovolemic
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*[[Hemorrhagic shock|Occult bleeding]]
##Hemorrhage Traumatic and Non-traumatic
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**Dx: Clinical (consider [[GI bleed]] and retroperitoneal hematoma)
##Severe Dehydration
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**Tx: Transfusion, treat coagulopathy, surgery/IR interventions
 +
*[[Toxicology (main)|Toxicologic]]
 +
**Dx: Clinical (consider [[beta blocker toxicity]], [[calcium channel blocker toxicity]], [[TCA overdose]], etc)
 +
**Tx: Depends on etiology (glucagon, hyperinsulin euglycemia therapy, sodium bicarbonate, ECMO, etc)
 +
*2nd cause of shock
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**Dx: Clinical, consider [[RUSH exam]]
 +
**Tx: Address underlying cause
  
 
==See Also==
 
==See Also==
 
*[[Ultrasound in Shock and Hypotension]]
 
*[[Ultrasound in Shock and Hypotension]]
*[[Cardiogenic Shock]]
+
*[[Pediatric shock]]
 +
 
 +
==External Links==
 +
*[http://pemplaybook.org/podcast/approach-to-shock/ Pediatric Emergency Playbook Podcast: Approach to Shock]
  
== Source ==
+
==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