Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,SHK,#,Diagnosis and Management of Shock,SHK,1,Objectives,Identify the major types of shock and principles of management,Review fluid resuscitation and use of vasopressor and inotropic agents,Understand concepts of O,2,supply and demand,Discuss the differential diagnosis of oliguria,SHK,2,Shock,Always a symptom of primary cause,Inadequate blood flow to meet tissue oxygen demand,May be associated with hypotension,Associated with signs of hypoperfusion:mental status change,oliguria,acidosis,SHK,3,Shock Categories,SHK,4,Cardiogenic,Hypovolemic,Distributive,Obstructive,Cardiogenic Shock,Decreased contractility,Increased filling pressures,decreased LV stroke work,decreased cardiac output,Increased systemic vascular resistance compensatory,Hypovolemic Shock,Decreased cardiac output,Decreased filling pressures,Compensatory increase in systemic vascular resistance,SHK,6,Distributive Shock,Normal or increased cardiac output,Low systemic vascular resistance,Low to normal filling pressures,Sepsis,anaphylaxis,neurogenic,and acute adrenal insufficiency,SHK,7,Obstructive Shock,Decreased cardiac output,Increased systemic vascular resistance,Variable filling pressures dependent on etiology,Cardiac tamponade,tension pneumothorax,massive pulmonary embolus,Cardiogenic Shock Management,Treat arrhythmias,Diastolic dysfunction may require increased filling pressures,Vasodilators if not hypotensive,Inotrope administration,Cardiogenic Shock Management,Vasopressor agent needed if hypotension present to raise aortic diastolic pressure,Consultation for mechanical assist device,Preload and afterload reduction to improve hypoxemia if blood pressure adequate,Hypovolemic Shock Management,Volume resuscitation crystalloid,colloid,Initial crystalloid choices,Lactated Ringers solution,Normal saline(high chloride may produce hyperchloremic acidosis),Match fluid given to fluid lost,Blood,crystalloid,colloid,SHK,11,Distributive Shock Therapy,Restore intravascular volume,Hypotension despite volume therapy,Inotropes and/or vasopressors,Vasopressors for MAP 10,g/kg/min),vasoconstriction,Chronotropic effect,SHK,16,Inotropic Agents,Dobutamine,5-20,g/kg/min,Inotropic and variable chronotropic effects,Decrease in systemic vascular resistance,SHK,17,Inotropic/Vasopressor Agents,Norepinephrine,0.05,g/kg/min and titrate to effect,Inotropic and vasopressor effects,Potent vasopressor at high doses,SHK,18,Inotropic/Vasopressor Agents,Epinephrine,Both,and,actions for inotropic and vasopressor effects,0.1,g/kg/min and titrate,Increases myocardial O,2,consumption,SHK,19,Therapeutic Goals in Shock,Increase O,2,delivery,Optimize O,2,content of blood,Improve cardiac output and blood pressure,Match systemic O,2,needs with O,2,delivery,Reverse/prevent organ hypoperfusion,Oliguria,Marker of hypoperfusion,Urine output in adults 2 hrs,Etiologies,Prerenal,Renal,Postrenal,SHK,21,Evaluation of Oliguria,History and physical examination,Laboratory evaluation,Urine sodium,Urine osmolality or specific gravity,BUN,creatinine,SHK,22,Evaluation of Oliguria,Laboratory TestPrerenal ATN,Blood Urea Nitrogen/201020 Creatinine Ratio,Urine Specific Gravity1.020500350,Urinary Sodium(mEq/L)40,Fractional Excretion of Sodium(%)2,Therapy in Acute Renal Insufficiency,Correct underlying cause,Monitor urine output,Assure euvolemia,Diuretics not therapeutic,Low-dose dopamine may,urine flow,Adjust dosages of other drugs,Monitor electrolytes,BUN,creatinine,Consider dialysis or hemofiltration,SHK,24,Pediatric Considerations,BP not good indication of hypoperfusion,Capillary refill,extremity temperature bettersigns of poor systemic perfusion,Epinephrine preferable to norepinephrine due to more chronotropic benefit,Fluid boluses of 20 mL/kg titrated to BP or total 60 mL/kg,before inotropes or vasopressors,SHK,25,Pediatric Considerations,Neonates consider congenitalobstructive left heart syndrome as cause of obstructive shock,Oliguria,2 yrs old,urine volume 2 mL/kg/hr,Older children,urine volume 1 mL/kg/hr,SHK,26,Key Points,樹立質(zhì)量法制觀念、提高全員質(zhì)量意識(shí)。,11月-24,11月-24,Friday,November 8,2024,人生得意須盡歡，莫使金樽空對(duì)月。,14:20:46,14:20:46,14:20,11/8/2024 2:20:46 PM,安全象只弓，不拉它就松，要想保安全，常把弓弦繃。,11月-24,14:20:46,14:20,Nov-24,08-Nov-24,加強(qiáng)交通建設(shè)管理，確保工程建設(shè)質(zhì)量。,14:20:46,14:20:46,14:20,Friday,November 8,2024,安全在于心細(xì)，事故出在麻痹。,11月-24,11月-24,14:20:46,14:20:46,November 8,2024,踏實(shí)肯干，努力奮斗。,2024年11月8日,2:20 下午,11月-24,11月-24,追求至善憑技術(shù)開拓市場(chǎng)，憑管理增創(chuàng)效益，憑服務(wù)樹立形象。,08 十一月 2024,2:20:46 下午,14:20:46,11月-24,嚴(yán)格把控質(zhì)量關(guān)，讓生產(chǎn)更加有保障。,十一月 24,2:20 下午,11月-24,14:20,November 8,2024,作業(yè)標(biāo)準(zhǔn)記得牢，駕輕就熟除煩惱。,2024/11/8 14:20:46,14:20:46,08 November 2024,好的事情馬上就會(huì)到來(lái)，一切都是最好的安排。,2:20:46 下午,2:20 下午,14:20:46,11月-24,專注今天，好好努力，剩下的交給時(shí)間。,11月-24,11月-24,14:20,14:20:46,14:20:46,Nov-24,牢記安全之責(zé)，善謀安全之策，力務(wù)安全之實(shí)。,2024/11/8 14:20:46,Friday,November 8,2024,相信相信得力量。,11月-24,2024/11/8 14:20:46,11月-24,謝謝大家！,樹立質(zhì)量法制觀念、提高全員質(zhì)量意識(shí)。,11月-24,11月-24,Friday,November 8,2024,人生得意須盡歡，莫使金樽空對(duì)月。,14:20:46,14:20:46,14:20,11/