Critical Care Medicine-Part 2 | Shock | QuadBloggers

• Definition-Clinical condition of organ dysfunction resulting from an imbalance between cellular oxygen supply
• And furthermore demand or presence of multisystem end-organ hypoperfusion.
• These conditions are commonly seen in Intensive care units (ICU).
• Subsequently, adequate oxygen supply can reverse the organ dysfunction in early shock.
• When its untreated the reversible process can turn into an irreversible phase leading to death from multisystem organ dysfunction.
• A thorough assessment simultaneously is required by the clinician for early intervention and to provide initial therapy to avoid irreversible organ multisystem dysfunction and death.

Initial evaluation( Critical care medicine-part 2):

• Clinical indicators include :
  • a) Mean arterial pressure
  • b) Tachycardia
  • c) Tachypnea
  • d) Cool skin,extremities
  • e) Altered mental status
  • f) Oliguria
• Initial evaluation of a hypotensive patient should also involve a thorough bed-side assessment of cardiac output.

Signs of decreased cardiac output in critical care medicine-part 2:

• 1) Narrow pulse pressure
• 2) Cold extremities with delay in the refill of capillary vessels.

Signs of increased cardiac output:

• 1) Widened pulse pressure
• 2) Warm extremities
• 3) Rapid capillary refill
• If a patient with “Hypotension shows signs of increased cardiac output”,then the reduced blood pressure is due to decreased systemic vascular resistance.
  • The main cause of high cardiac output hypotension are as follows:
  • a) Sepsis
  • b) Liver failure
  • c) Pancreatitis
  • d) Burns
  • e) Trauma
  • f) Anaphylaxis
  • g) Thyrotoxicosis
  • h) Peripheral artriovenous shunts
• If a patient with “Hypotension shows signs of decreased cardiac output”,intravascular volume should be assessed based on the history that suggests hemorrhage or volume loss due to vomiting,diarrhea and polyuria.
  • A) Reduced intravascular volume :
  • (1) Any changes in the right atrial pressure with spontaneous respiration can predict the fluid responsiveness.

• (2)Patients with fluid responsive shock (hypovolemic) manifest with change in pulse pressure during mechanical ventilation.

• B) Increased intravascular volume and cardiac dysfunction(critical care medicine-part 2):
  • On examination,shows S3 OR S4 gallop on ECG.
  • Increased JVP
  • Additionally, Edema
  • Moreover, Crackles on lung auscultation.
• Chest x-ray shows cardiomegaly,widening of vascular pedicle,kerley B lines and pulmonary edema.
• Hence the most common types of shock are as follows:
  • A) Hypovolemic shock
  • B) Septic shock
  • C)High output hypotension.
• On the whole,initial assessment of shock is vital for proper diagnosis with aggressive resuscitation being the intervention for survival from hypovolemic and cardiogenic shock.
• Ultrasound of thorax and abdomen is also done by intensivists for physical examination to assess volumes,adequacy of cardiac performances.
• In conclusion, The main goal is to reestablish tissue perfusion and to prevent end-organ damage with proper resuscitation.

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Please refer this book simultaneously for detailed description of diseases: Harrisons book of internal medicine