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Case A
Failure of compensation
Very severe disease
Shock
Hypoperfusion
Conscious state
Temperature of
limbs
Skin mottling
Urine output
pH
Lactate
Case A
MAP CO TPR
Global haemodynamic
relationships
Peripheral
perfusion
MAP CO TPR
Global haemodynamic
relationships
Peripheral
perfusion
MAP CO TPR
HR SV
Global haemodynamic
relationships
Peripheral
perfusion
MAP CO TPR
HR SV
JVP,CVP,
PAOP
Preload Afterload Contractility
Case A
Cardiac or or Cold
Hypovolaemic Cold
Distributive -N Warm
Obstructive* Cold
Differential diagnosis
Cardiogenic shock
Obstructive shock due to pulmonary
embolus
What next?
Immediate resuscitation of
the shocked patient
Immediately life threatening hypotension
Epinephrine 0.1 mg boluses
Vasopressor infusion
Usually fluid
BUT how much?
Cause
Treatment goals
Treatment goals
cardiac output
blood pressure
Blood flow
Perfusion pressure
Treatment goals
cardiac output
blood pressure
Blood flow
Perfusion pressure
Case A
Starling relationship
Cardiac output
Volume loading
Cardiogenic shock
End diastolic pressure
Pulmonary
oedema
Inotrope
Vasopressor
Positive chronotrope
Concentration-dependent effects
Dobutamine
Inotrope
Vasodilator
Positive chronotrope
Norepinephrine
Vasopressor
Increases cardiac output in
hypotensive patients
Increases coronary perfusion and
hence cardiac function
Cardiogenic
Aims:
Adequate diastolic pressure without
tachycardia
Increase cardiac output
Normotensive patient with poor
peripheral perfusion
Dobutamine infusion
Hypotensive patient
Norepinephrine infusion
How much?
Altered dose-
response curve in
critically ill,
particularly sepsis
Response
Dose
Dosage
Altered dose-
response curve in
critically ill,
particularly sepsis
Response
Titrate against
effect
Short half-life
Frequent
assessment 0 5 10 15 20
Mins
Titrate
Initial
dose
Early referral
Revascularization
Intra-aortic balloon pump
Treat cause
Hypovolaemic
Hypovolaemic
Vasopressors
Life threatening hypotension
Distributive shock phase
Treat underlying cause
Septic
Pathophysiology
Vasodilatation
Capillary leak
Septic
Norepinephrine or dopamine
Dobutamine
Tissue hypoperfusion despite
normotension
Source control
Antibiotics
Obstructive
More complicated
Initial treatment depends on
pathophysiology of underlying
cause
Tension pneumothorax
Emergency thoracostomy
Massive pulmonary embolus
Fluid bolus 100-250 ml
Obstructive
Resuscitation
Restore tissue perfusion
Conscious state
Temperature of limbs
Skin perfusion
Urine output
pH
Lactate
Summary
Resuscitation
Fluid
Vasopressor to restore BP
Inotrope to increase cardiac output
Titrate against patient response
Summary