Approach to the patient in shock：对休克病人的方法.pptVIP

Approach to the patient in shock Epidemiology and mortality Approximately one million cases per year Septic: 40-60% mortality Cardiogenic: 36-56% mortality pathophys Shock is circulatory insufficiency that creates an imbalance between tissue oxygen supply (delivery) and oxygen demand (consumption Leads to a reduction in effective tissue perfusion with its attendant biochemical, bioenergetic, and subcellular sequelae Pathophys, cont’d When compensatory mechanisms fail to correct the imbalance between tissue supply and demand, anaerobic metabolism occurs, resulting in the formation of lactic acid. Clinical features weakness, lethargy, or altered mental status bleeding, vomiting, diarrhea, excessive urination Table 25.4 gives complete physical exam findings in shock Shock index: HR/SBP Normal is .5 - .7 diagnosis Labs and imaging Sepsis panel CXR Ultrasound IVC compressibility treatment Early Goal Directed Therapy ABCDE A goal-directed approach of urine output 0.5 mL/kg/h CVP 8 to12 mm Hg MAP 65 to 90 mm Hg ScvO2 70% during ED resuscitation of septic shock significantly decreases mortality Resources Tintinalli Ch. 25 * *  White blood cell count 12.0 x 109/L, 4.0 x 109/L, or 10% immature forms or bands Respiratory rate 20 breaths/min Heart rate 90 beats/min Temperature 38°C (100.4°F) or 36°C (96.8°F) Two or more of the following features are required to make a diagnosis of SIRS: Table 25-5 Classification of Shock Metabolic derangements that impair cellular respiration such as cyanide toxicity, sepsis. Distributive Caused by extra cardiac obstruction to blood flow Obstructive Caused by inadequate cardiac pump function Cardiogenic Caused by inadequate circulating volume Hypovolemic Comment Type