Doctorese lecture babble -- SHOCK

I figure being a medical student from time to time I should put something Medical-ish on here. But I don't always know what's appropriate, or at least mildly interesting. To the medical person a lot of this is probably a profoundly DUH! matter, and to the non-medical folk it's a lot of jibberish. But, to show that I am indeed not just riding the CTA back and forth for kicks and giggles with nothing to show, here are my notes from a lecture on shock, given by Dr. Not-House at Chicago Hope Hospital. I'm keeping it as I wrote it, abbreviations and all, for those who might be interested to see exactly how Medicalese looks.

SHOCK

·      Inadequate delivery of oxygen to the tissues – lack of tissue oxygenation, leading to imbalance between oxygen delivery and consumption

DelO₂ = CO x ConcaO₂

_Where: 

-       CaO₂ = RBC + Cp = (1.34xHbxsats) + (PaO₂x0.003)

-       RBCs

-       Cp = PaO₂x0.003

-       Hb sats

CO = HR x SV

-  Preload (CVP)

- Cp (=PaO₂x0.003)

-  Afterload (SVR)

1.     Hypovolemic – MVAs and GE bleeds

a.     MCC: traumatic blood loss

b.     Organ perfusion

                                               i.     Skin

1.     Color

2.     Temperature

3.     Turgor

                                             ii.     Heart

1.     Tachycardia – ALWAYS in children

2.     BP

3.     Pulse quality

                                            iii.     Lungs -- tachypnea

                                            iv.     Brain -- AMS

                                             v.     Kidneys – decreased urine output

c.     Management

                                               i.     Volume replacement

1.     What type?

a.     Isotonic

b.     No glucose – causes osmotic diuresis

c.     No K⁺ – arrhythmia

d.     Crystalloids

                                                                                                                       i.     Normal saline

                                                                                                                     ii.     Ringer’s lactate

e.     Colloids

                                                                                                                      i.     Blood

                                                                                                                    ii.     FFP

                                                                                                                  iii.     5% albumin

                                                                                                                  iv.     Dextran

                                                                                                                    v.     Synthetic Hb

2.     How much?

a.     Kids – 20mL/kg

b.     Adults – 0.5L

c.     ***Cardiogenic shock will worsen after one bolus***

3.     How fast? – as fast as they will go

                                             ii.     Monitor sats

                                            iii.     Two large-bore peripheral IVs (shorter than central lines, less resistance)

1.     90s for PIV, if not then intraosseous

2.     Tibia – medial surface

3.     Any long bone

4.     Head of sternum in adults

5.     Anything can be given IO

6.     TPN only given IO

d.     blah

2.     Septic –Mortality 30-35%

a.     ABCs

b.     IV access

c.     O2

d.     Labs/cultures

e.     Antibiotics

f.      Vasoactive drugs

Drug	Site of Action	Heart	SVR
Epinephrine	Beta > alpha	+++	+
Norepinephrine	Alpha > beta	+	+++
Dopamine	Dose-dependent 0-5 low 5-15 mid >15 high	+++ ++	+ +++
Dobutamine	Mostly Beta2	+	Decreased
ADH/Vasopressin		+	++++
Milrinone (4-6 hour clearance)		Lusitropic effects	Decreased (relaxes smooth muscle)

g.     Steroids and shock – serum cortisol

                                               i.     If low, ACTH stimulating test – if respond, do nothing

                                             ii.     If does not respond, stress-dose steroids à relative adrenal insufficiency

h.     Glucose and shock

                                               i.     Hyperglycemia presents

                                             ii.     Tight glycemic control (80-110)

3.     Cardiogenic

a.     MI

b.     Post ops

c.     Myocarditis

d.     Compensated vs. Uncompensated

  

4.     Neurogenic – distributive

5.     Anaphylactic – Distributive, histamine

6.     Obstructive – outward flow obstruction

a.     Acute tamponade

b.     Tension pneumothorax

7.     Dissociative – CO poisoning