Management of Shock: interdisciplinary approach

Management of Shock: interdisciplinary approach, be timely, recognize & treat, notify Dr.

1. fluid replacement to restore intravascular volume

2. vasoactive meds. to restore vasomotor tone & improve cardiac function

3. nutritional support to address metabolic requirements

Fluid Replacement: give it early to maximize intravascular volume

1. controversial

2. crystalloids

   a. 0.9% NaCl (isotonic)

   b. D5 lactated ringers (isotonic) – has some electrolytes, glucose, & lactate ion which changes

   to bicarb which buffers metabolic acidosis

   c. 3% NaCl (*hypernatremia can develop from hypertonic sol'n & cause fluid to move into

intravascular compartment from interstitial

3. colloids – volume expanders

a. albumin – blood product

b. hetastarch – synthetic, less expensive, can prolong clotting time

c. dextran – synthetic, less expensive, prolong platelet aggregation,

d. plasma protein fraction

Complications of Fluid Administration

1. CVP – central venous pressure – line in rt. atria measure pressure (normal is 4-12)

a. hypovolemic shock – down to -2 ("0" has to be at heart level with manometer)*

b. hypervolemic – up to 20

2. Cardiovascular overload & pulmonary edema – from too much fluid

a. UO – perfusion of kidneys & shock progession

b. mental status – confused – too much fluid get brain edema

c. skin perfusion – cold clammy

d. V/S changes BP ↓(late) pulse increased

e. lung sounds – listen for edema

Medications – Vasoactive agents

1. must be on IV pump

2. monitor every 15 minutes

3. titrate (↓or↑ ) to maintain MAP level

4. shows good perfusion, want MAP 65

Vasoactive agents

Sympathomimetics – adrenergic drugs

Amrinone (Inocor), Dobutamine (Dobutrex), Dopamine (Inotropin), Epinephrine (adrenalin), Milrinone (primacor)

1. ↑contractility, ↑stroke volume, ↑cardiac output

2. disadvantages: causes ↑oxygen demand of heart

vasopressive & vasoconstrictive affect

1. α adrenergic drugs constrict blood vessels, ↑BP
   

   a. inotropic drugs ↑stroke volume, improve cardiac contractility, ↑cardiac output

   dopamine, dobutamine, isopril (can cause rapid HR), cause↑O₂ demand of heart,

usually give a mixture. ie. dopamine & vasodilator so heart can get enough O₂

2. β₁ adrenergic drugs –↑HR & myocardial contractions

1. β₂ adrenergic drugs – vasodilation of heart & skeletal muscles & bronchioles relax

2.