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Shock

Types of shock:

Hypovolemic

  • Caused by decrease in intravascular volume secondary to loss of blood , fluids, or electrolytes.
  • >15% loss of intravascular volume can cause hypotension and progressive tissue hypoxia

Cardiogenic

  • Cardiac failure where the heart is unable to maintain adequate tissue perfusion.
  • Most often caused by MI but can be due to cardiomyopathy, myocardial contusion, valvular incompetence or stenosis, or arrhythmias.

Obstructive

  • Caused by acute decrease if cardiac output due to cardiac tamponade, tension pneumo, or PE

Distributive

  • Caused by sepsis, anaphylaxis, systemic inflammation, burns,

Setpic

  • Caused by overload of gram negative bacteremia

Neurogenic shock

  • Caused by spinal cord injury or spinal anesthetic

Treatments

  • Dobutamine – is the first line agent for cardiogenic shock. Initial dose should be .5-1mcg/kg/min as continuous intravenous infusion, then titrated every few minutes. Amrinone or milrinone can be substituted for dobutamine
  • Norepinephrine – usually used for vasodilatory shock. Initial dose is 1-2 mcg/min. Patients with refractory shock may need dosages of 10-30 mcg/min.
  • Epinephrine – may be used in severe shock and during acute resuscitation. Initial dose is 1 mcg/min as a continuous IV.
  • Dopamine –low dose (2-5 mcg/kg/min) stimulate dopaminergic and b-agonist receptors, producing increased glomerular filtration, heart rate, and contractility. Max dose is 50 mcg/kg/min.
  • Phenylephrine – can be used as first line agent for hyperdynamic septic shock when there is low systemic venous resistance and dysrhythmias or tachycardias that prevent the use of agents with b-adrenergic activity.
  • Vasopressin – used as adjunctive therapy in the tx of disbrutive or vasodilatory shock.
  • Low dose corticosteroids in septic shock with acute adrenal insufficiency. Hydrocortisone 50 mg q 6 hours and 50 mcg of 9-alpha-fludroconrtisone once daily for 7 days.
  • Volume replacement – is critical in initial management of shock
    • Hemorrhagic shock – rapid infusion of type O negative packed RBC or whole blood will give volume and clotting factors
    • Hypovolemic shock secondary to dehydration – give rapid boluses of isotonic crystalloid
    • Cardiogenic shock in absence of fluid overload requires smaller fluid challenges usually increments of 250 ml
    • Septic shock – requires large volumes of fluid for resuscitation

Citation:

Papadakis, Maxine; McPhee, Stephen. Current Medical Diagnosis and treatment 2013.

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