SHOCK

Author: Nazanin Meshkat MD, FRCPC, MHSc, Assistant

Professor, University of Toronto
Date Created: September 2011

Global Health Emergency Medicine Teaching Modules by GHEM is licensed under

a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.

Objectives: Part 1
To develop an understanding of the
definition and pathophysiology of shock
To develop an understanding and overview
of the different types of shock
To develop a systematic approach to the
detection and management of shock

Objectives: Part 2
To develop a deeper understanding of
sepsis and septic shock
To discuss cost effective and high impact
interventions to decrease mortality in shock

PART 1

Definition of Shock
Inadequate perfusion and oxygenation of
cells

Definition of Shock
Inadequate perfusion and oxygenation of
cells leads to:
Cellular dysfunction and damage
Organ dysfunction and damage

Why should you care?

High mortality - 20-90%
Early on the effects of O2 deprivation on
the cell are REVERSIBLE
Early intervention reduces mortality

Pathophysiology
4 types of shock

Cardiogenic
Obstructive
Hypovolemic
Distributive

Pathophysiology: Overview
Tissue perfusion is determined by Mean Arterial Pressure (MAP)

MAP = CO x SVR

Heart rate

Stroke Volume

Cardiogenic Shock:
Pathophysiology
Heart fails to pump blood out

MAP = CO x SVR
HR

Stroke Volume

Cardiogenic Shock:
Pathophysiology

Normal
MAP = CO x SVR

Cardiogenic
MAP = CO x SVR
MAP = CO x SVR
MAP

= CO x SVR

Cardiogenic Shock: Causes

MAP =

CO (HR x Stroke Volume)

x SVR

Decreased Contractility (Myocardial Infarction, myocarditis,

cardiomypothy, Post resuscitation syndrome following cardiac arrest)
Mechanical Dysfunction (Papillary muscle rupture post-MI, Severe
Aortic Stenosis, rupture of ventricular aneurysms etc)
Arrhythmia (Heart block, ventricular tachycardia, SVT, atrial
fibrillation etc.)
Cardiotoxicity (B blocker and Calcium Channel Blocker Overdose)

Obstructive Shock:
Pathophysiology
Heart pumps well, but the output is decreased
due to an obstruction (in or out of the heart)

MAP = CO x SVR
HR x Stroke volume

Obstructive Shock:
Pathophysiology

Normal
MAP = CO x SVR

Obstructive
MAP = CO x SVR
MAP = CO x SVR
MAP

= CO x SVR

Obstructive Shock: Causes

MAP =

CO (HR x Stroke Volume)

x SVR

Heart is working but there is a block to the outflow

Massive pulmonary embolism

Aortic dissection
Cardiac tamponade
Tension pneumothorax

Obstruction of venous return to heart

Vena cava syndrome - eg. neoplasms, granulomatous disease

Sickle cell splenic sequestration

Hypovolemic Shock:
Pathophysiology
Heart pumps well, but not enough blood
volume to pump

MAP = CO x SVR
HR x Stroke volume

Hypovolemic Shock:
Pathophysiology

Normal
MAP = CO x SVR

Hypovolemic
MAP = CO x SVR
MAP = CO x SVR
MAP

= CO x SVR

Hypovolemic Shock: Causes

MAP =

CO (HR x Stroke Volume)

x SVR

Decreased Intravascular volume (Preload) leads to Decreased

Stroke Volume

Hemorrhagic - trauma, GI bleed, AAA rupture, ectopic pregnancy

Hypovolemic - burns, GI losses, dehydration, third spacing (e.g.
pancreatitis, bowel obstruction), Adesonian crisis, Diabetic
Ketoacidosis

Distributive Shock:
Pathophysiology
Heart pumps well, but there is peripheral
vasodilation due to loss of vessel tone
MAP = CO x SVR
HR x Stroke volume

Distributive Shock:
Pathophysiology

Normal
MAP = CO x SVR

Distributive
MAP = co x SVR
MAP = co x SVR
MAP

co x

SVR

Distributive Shock: Causes

MAP

= CO (HR x SV) x SVR

Loss of Vessel tone

Inflammatory cascade
Sepsis and Toxic Shock Syndrome
Anaphylaxis

Post resuscitation syndrome following cardiac arrest

Decreased sympathetic nervous system function
Neurogenic - C spine or upper thoracic cord injuries

Toxins
Due to cellular poisons -Carbon monoxide, methemoglobinemia,
cyanide
Drug overdose (a1 antagonists)

To Summarize
Type of
Shock

Insult

Physiologic
Effect

Compensation

Cardiogenic

Heart fails to pump

blood out

CO

BaroRc
SVR

Obstructive

Heart pumps well, but

CO
the outflow is obstructed

BaroRc
SVR

Hemorrhagic Heart pumps well, but

not enough blood
volume to pump

CO

BaroRc
SVR

Distributive

SVR

CO

Heart pumps well, but

there is peripheral
vasodilation

Okits really not THAT simple

MAP = CO x SVR
HR x Stroke volume
Preload Afterload Contractility

Type of
Shock

Insult

Physio Compen Compensation

logic
sation
Heart Rate
Effect

Cardiogenic

Heart fails to
pump blood
out

CO

BaroRc
SVR

Obstructive

Heart pumps
well, but the
outflow is
obstructed

CO

BaroRc
SVR

Hemorrhagic

Heart pumps CO
well, but not
enough blood
volume to
pump

BaroRc
SVR

Distributive

Heart pumps
well, but
there is
peripheral
vasodilation

CO

No Change in neurogenic
shock

No Change in neurogenic
shock

SVR

Compensation
Contractility

Additional Compensatory
Mechanisms
Renin-Angiotensin-Aldosterone Mechanism
AII components lead to vasoconstriction
Aldosterone leads to water conservation

ADH leads to water retention and thirst

Inflammatory cascade

Case 1
24 year old male
Previously healthy
Lives in a malaria endemic area (PNG)
Brought in by friends after a fight - he was kicked
in the abdomen
He is agitated, and wont lie flat on the stretcher
HR 92, BP 126/72, SaO2 95%, RR 26

Stages of Shock
Insult
Preshock
(Compensation)
Shock
(Compensation
Overwhelmed)
End organ
Damage
Death

Timeline and progression will

depend on:
-Cause
-Patient Characteristics
-Intervention

Case 1: Stages of Shock

Stage

Pathophysiology

Clinical Findings

Insult

Splenic Rupture -- Blood

Loss

Abdominal tenderness and girth

Case 1: Stages of Shock

Stage

Pathophysiology

Clinical Findings

Insult

Splenic Rupture -- Blood Loss

Abdominal tenderness and

girth

Preshock Hemostatic compensation

MAP is maintained
MAP =CO(HR xSV) xSVR HR will be increased
Decreased CO is compensated by Extremities will be cool due
increase in HR and SVR
to vasoconstriction

Case 1: Stages of Shock

Stage

Pathophysiology

Clinical Findings

Insult

Splenic Rupture -- Blood

Loss

Abdominal tenderness and

girth

Preshock

Hemostatic compensation

MAP is maintained
HR will be increased
Extremities will be cool due to
vasoconstriction

MAP =CO(HR xSV) x

SVR
Decreased CO is compensated
by increase in HR and SVR

Shock

Compensatory mechanisms
fail

MAP is reduced
Tachycardia, dyspnea,
restlessness

Case 1: Stages of Shock

Stage

Pathophysiology

Clinical Findings

Insult

Splenic Rupture -- Blood Loss Abdominal tenderness and girth

Preshock Hemostatic compensation

MAP is maintained
MAP =CO(HR xSV) x SVR HR will be increased
Decreased CO is compensated
Extremities will be cool due to
by increase in HR and SVR
vasoconstriction

Shock

Compensatory mechanisms
fail

MAP is reduced
Tachycardia, dyspnea,
restlessness

End
organ
dysfuncti
on

Cell death and organ failure

Decreased renal function

Liver failure
Disseminated Intravascular
Coagulopathy
Death

Is this Shock?
Signs and symptoms
Laboratory findings
Hemodynamic measures

Symptoms and Signs of Shock

Level of consciousness

Initially may show few symptoms

Continuum starts with

Anxiety
Agitation
Confusion and Delirium
Obtundation and Coma

In infants

Poor tone
Unfocused gaze
Weak cry
Lethargy/Coma
(Sunken or bulging fontanelle)

Symptoms and Signs of Shock

Pulse
Tachycardia HR > 100 - What are a few exceptions?
Rapid, weak, thready distal pulses

Respirations
Tachypnea
Shallow, irregular, labored

Symptoms and Signs of Shock

Blood Pressure
May be normal!
Definition of hypotension

Systolic < 90 mmHg

MAP < 65 mmHg
40 mmHg drop systolic BP from from baseline
Children

Systolic BP < 1 month = < 60 mmHg

Systolic BP 1 month - 10 years = < 70 mmHg + (2 x age in years)

In children hypotension develops late, late, late

A pre-terminal event

Symptoms and Signs of Shock

Skin
Cold, clammy (Cardiogenic, Obstructive,
Hemorrhagic)
Warm (Distributive shock)
Mottled appearance in children
Look for petechia

Dry Mucous membranes

Low urine output <0.5 ml/kg/hr

Hypovolemic Distributive Cardiogenic

Shock
Shock
Shock

Obstructive
Shock

HR

Increased

JVP

May be
increased or
decreased

Increased

Low

Increased
(Normal in
Neurogenic
shock)
Low

High

High

BP

Low

Low

Low

Low

SKIN

Cold

CAP
REFILL

Slow

Warm (Cold Cold

in severe
shock)
Slow
Slow

Cold
Slow

Empiric Criteria for Shock

4 out of 6 criteria have to be met

Ill appearance or altered mental status

Heart rate >100
Respiratory rate > 22 (or PaCO2 < 32 mmHg)
Urine output < 0.5 ml/kg/hr
Arterial hypotension > 20 minutes duration
Lactate > 4

Lactate
Lactate is increased in Shock
Predictor of Mortality
Can be used as a guide to resuscitation
However it is not necessary, or available in
many settings

Management of Shock
History
Physical exam
Labs
Other investigations
Treat the Shock - Start treatment as soon
as you suspect Pre-shock or Shock
Monitor

Historical Features

Trauma?
Pregnant?
Acute abdominal pain?
Vomiting or Diarrhea?
Hematochezia or hematemesis?
Fever? Focus of infection?
Chest pain?

Physical Exam
Vitals - HR, BP, Temperature, Respiratory
rate, Oxygen Saturation
Capillary blood sugar
Weight in children

Physical Exam
In a patient with normal level of
consciousness - Physical exam can be
directed to the history

Physical Exam
In a patient with abnormal level of consciousness
Primary survey
Cardiovascular (murmers, JVP, muffled heart sounds)
Respiratory exam (crackles, wheezes),
Abdominal exam
Rectal and vaginal exam
Skin and mucous membranes
Neurologic examination

Laboratory Tests

CBC, Electrolytes, Creatinine/BUN, glucose

+/- Lactate
+/- Capillary blood sugar
+/- Cardiac Enzymes
Blood Cultures - from two different sites
Beta HCG
+/- Cross Match

Other investigations

ECG
Urinalysis
CXR
+/- Echo
+/- FAST

Treatment
Start treatment immediately

Stages of Shock
Insult
Preshock
(Compensation)
Shock
(Compensation
Overwhelmed)
End organ
Damage
Death

Early Intervention can arrest or

reduce the damage

Treatment
ABCs 5 to 15

Airway
Breathing
Circulation
Put the patient on a monitor if available

Treat underlying cause

Treatment: Airway and Breathing

Give oxygen

Treatment: Airway and Breathing

Consider Intubation
Is the cause quickly reversible?
Generally no need for intubation

3 reasons to intubate in the setting of shock

Inability to oxygenate
Inability to maintain airway
Work of breathing

Treatment: Circulation
Treat the early signs of shock (Cold,
clammy? Decreased capillary refill?
Tachycardic? Agitated?)
DO NOT WAIT for hypotension

Treatment: Circulation
Start IV +/- Central line (or Intraosseous)
Do Blood Work +/- Blood Cultures

Treatment: Circulation
Fluids - 20 ml/kg bolus x 3
Normal saline
Ringers lactate

Back to Case 1
24 year old male
Previously healthy
Lives in a malaria endemic area (PNG)
Brought in by friends after a fight - he was kicked
in the abdomen
He is agitated, and wont lie flat on the stretcher
HR 92, BP 126/72, SaO2 95%, RR 26

Case 1
On examination

Extremely agitated
Clammy and cold
Heart exam - normal
Chest exam - good air entry
Abdomen - bruised, tender, distended
No other signs of trauma

Case 1: Management
Hemorrhagic (Hypovolemic Shock)
ABCs
Monitors
O2
Intubate?
IV lines x 2, Fluid boluses, Call for Blood - O type
Blood work including cross match
Treat Underlying Cause

Case 1: Management
Hemorrhagic (Hypovolemic Shock)
ABCs

Monitors
O2
Intubate?
IV lines x 2, Fluid boluses, Call for Blood - O type
Blood work including cross match

Treat Underlying Cause

Give Blood
Call the surgeon stat
If the patient does not respond to initial boluses and blood
products - take to the Operating Room

Blood Products
Use blood products if no improvement to fluids
PRBC 5-10 ml/kg
O- in child-bearing years and O+ in everyone else
+/- Platelets

Case 2
23 year old woman in Addis Ababa
Has been fatigued and short of breath for a
few days
She fainted and family brought her in
They tell you she has a heart problem

Case 2
HR 132, BP 76/36, SaO2 88%, RR 30, Temp 36.3
Appearance - obtunded
Cardiovascular exam - S1, S2, irregular,
holosytolic murmer, JVP is 5 cm ASA, no edema
Chest - bilateral crackles, accessory muscle use
Abdomen - unremarkable
Rest of exam is normal

Stages of Shock
Insult
Preshock
(Compensation)
Shock
(Compensation
Overwhelmed)
End organ
Damage
Death

What stage is she at?

Case 2: Management
Cardiogenic Shock
ABCs
Monitors
O2
IV and blood work
ECG - Atrial Fibrillation, rate 130s
Treat Underlying Cause

Case 2: Management
Cardiogenic Shock
ABCs
Monitors
O2
IV and blood work
Intubate?
ECG - Atrial Fibrillation, rate 130s
Treat Underlying Cause

Case 2: Why would you intubate?

Is the cause quickly reversible?

UNLIKELY

3 reasons to intubate in the setting of shock

Inability to oxygenate
Inability to maintain airway
Work of breathing

Inability to oxygenate
(Pulmonary edema,
SaO2 88%)
Accessory
Muscle Use

Case 2: Why Intubate?

Strenuous use of accessory respiratory
muscles (i.e. work of breathing) can:
Increase O2 consumption by 50-100%
Decrease cerebral blood flow by 50%

Case 2: Management
Cardiogenic Shock
ABCs
Monitors
O2
IV and blood work
Intubate?
ECG - Atrial Fibrillation, rate 130s
Treat Underlying Cause

Case 2: Management
Cardiogenic Shock
Treat Underlying Cause
Lasix
Atrial Fibrillation - Cardioversion? Rate control?
Inotropes - Dobutamine +/- Norepinephrine
(Vasopressor)
Look for precipitating causes - infectious?

Vasopressors in Cardiogenic Shock

Norepinephrine
Dopamine
Epinephrine
Phenylephrine

Case 3
36 year old woman
Pedestrian hit by a car
She is brought into the hospital 2 hrs after
accident
Short of breath
Has been complaining of chest pain

Case 3
HR 126, SBP 82, SaO2 70%, RR 36, Temp 35
Obtunded, Accessory muscle use
Trachea is deviated to Left
Heart - distant heart sounds
Chest - decreased air entry on the right, broken
ribs, subcutaneous emphysema
Abdominal exam - normal
Apart from bruises and scrapes no other signs of
trauma

Stages of Shock
Insult
Preshock
(Compensation)
Shock
(Compensation
Overwhelmed)
End organ
Damage
Death

What stage is she at?

Case 3: Management
Obstructive Shock
ABCs

Monitors
O2
IV
Intubate?
BW

Treat Underlying Cause

Case 3: Management
Obstructive Shock

ABCs

Monitors
O2
IV
Intubate?
BW

Treat Underlying Cause

Needle thoracentesis
Chest tube
CXR

Case 3: Management
Obstructive Shock

ABCs

Monitors
O2
IV
Intubate?
BW

Treat Underlying Cause

Needle thoracentesis
Chest tube
CXR

Case 3: Management
Obstructive Shock

ABCs

Monitors
O2
IV
Intubate?
BW

Treat Underlying Cause

Needle thoracentesis
Chest tube
CXR
Intubate if no response

Case 3
You perform a needle thoracentesis - hear
a hissing sound
Chest tube is inserted successfully
HR 96, BP 100/76, SaO2 96% on O2, RR
26
You resume your clinical duties, and call
the surgeon

Case 3
1 hr has gone by
You are having lunch
The nurse puts her head through the door
to tell you about another patient at triage,
and as she is leaving By the way, that
woman with the chest tube, is feeling not
so good and leaves.

Case 3

You are back at the bedside

The patient is obtunded again
Pale and Clammy
HR 130, BP 86/52, SaO2 96% on O2
Chest tube seems to be working
Trachea is midline
Heart - Normal
Chest - Good air entry
Abdomen - decreased bowel sounds, distended

Combined Shock
Different types of shock can coexist
Can you think of other examples?

Monitoring

Vitals - BP, HR, SaO2

Mental Status
Urine Output (> 1-2 ml/kg/hr)
When something changes or if you do not
observe a response to your treatment re-examine the patient

Can we measure cell hypoxia?

Lactate - we already talked about - a surrogate
Venous Oxygen Saturation - more direct measure

Venous Oxygen Saturation

Hg carries O2
A percentage of O2 is extracted by the
tissue for cellular respiration
Usually the cells extract < 30% of the O2

Venous Oxygen Saturation

Svo2 = Mixed venous oxygen saturation
Measured from pulmonary artery by Swan-Ganz catheter.
Normal

> 65%

Scvo2 = Central venous oxygen saturation

Measured through central venous cannulation of SVC or R
Atrium - i.e. Central Line
Normal

> 70%

PART 2

Case 4
40 year old male
RUQ abdominal pain, fever, fatigued for 5-6
days
No past medical history

Case 4
HR 110, BP 100/72, SaO2 96%, T 39.2, RR 26
Drowsy
Warm skin
Heart - S1, S2, no Murmers
Chest - good A/E x 2
Abdomen - decreased bowel sound, tender RUQ

Stages of Shock
Insult
Preshock
(Compensation)
Shock
(Compensation
Overwhelmed)
End organ
Damage
Death

What stage is he at?

Stages of Sepsis
SIRS
SEPSIS
SEVERE
SEPSIS
SEPTIC
SHOCK
MODS/DEATH

Definitions of Sepsis
Systemic Inflammatory Response Syndrome (SIRS) 2
or > of:
-Temp > 38 or < 36
-RR > 20
-HR > 90/min
-WBC >12,000 or <6,000 or more than 10%
immature bands

Definitions of Sepsis
Sepsis SIRS with proven or suspected
microbial source

Severe Sepsis sepsis with one or more

signs of organ dysfunction or hypoperfusion.

Definitions of Sepsis
Septic shock = Sepsis + Refractory
hypotension
-Unresponsive to initial fluids 20-40cc/kg
Vasopressor dependant
MODS multiple organ dysfunction
syndrome
-2 or more organs

Stages of Sepsis
Mortality
SIRS

7%

SEPSIS

16%

SEVERE
SEPSIS

20%

SEPTIC
SHOCK

70%

MODS/DEATH

Pathophysiology
Complex pathophysiologic mechanisms

Pathophysiology
Inflammatory Cascade:
Humoral, cellular and Neuroendocrine (TNF, IL
etc)
Endothelial reaction
Endothelial permeability = leaking vessels
Coagulation and complement systems
Microvascular flow impairment

Pathophysiology
End result = Global Cellular Hypoxia

Focus of Infection
Any focus of infection can cause sepsis

Gastrointestinal
GU
Oral
Skin

Risk Factors for Sepsis

Infants
Immunocompromised patients

Diabetes
Steroids
HIV
Chemotherapy/malignancy
Malnutrition

Sickle cell disease

Disrupted barriers
Foley, burns, central lines, procedures

Back to Case 4

HR 110, BP 100/72, SaO2 96%, T 39.2, RR 20

Drowsy
Warm skin
Heart - S1, S2, no Murmers
Chest - good A/E x 2
Abdomen - decreased bowel sound, tender RUQ

Case 4: Management
Distributive Shock (SEPSIS)
ABCs

Monitors
O2
IV fluids 20 cc/kg x 3
Intubate?
BW

Treat Underlying Cause

Resuscitation in Sepsis
Early goal directed therapy - Rivers et al NEJM 2001
Used in pts who have: an infection, 2 or more SIRS, have a
systolic < 90 after 20-30cc/ml or have a lactate > 4.
Emergency patients by emergency doctors
Resuscitation protocol started early - 6 hrs

Resuscitation in Sepsis: EGDT

The theory is to normalize
Preload - 1st
Afterload - 2nd
Contractility - 3rd

BACK TO OUR EQUATION

MAP = CO x SVR
(HR x Stroke volume)

Preload

Afterload
Contractility

BACK TO OUR EQUATION

MAP = CO x SVR
(HR x Stroke volume)

Preload

Afterload
Contractility

Preload
Dependent on intravascular volume
If depleted intravascular volume (due to increased endothelial
permeability) - PRELOAD DECREASES
Can use the CVP as measurement of preload
Normal = 8-12 mm Hg

Preload
How do you correct decreased preload (or intravascular
volume)
Give fluids
Rivers showed an average of 5 L in first 6 hours
What is the end point?

BACK TO OUR EQUATION

MAP = CO x SVR
(HR x Stroke volume)

Preload

Afterload
Contractility

Afterload
Afterload determines tissue perfusion
Using the MAP as a surrogate measure - Keep between 60-90
mm Hg
In sepsis afterload is decreased d/t loss of vessel tone

Afterload
How do you correct decreased afterload?
Use vasopressor agent
Norepinephrine
Alternative Dopamine or Phenylpehrine

BACK TO OUR EQUATION

MAP = CO x SVR
(HR x Stroke volume)

Preload

Afterload
Contractility

Contractility
Use the central venous oxygen saturation
(ScvO2) as a surrogate measure

Shown to a be a surrogate for cardiac index

Keep > 70%

Contractility
How to improve ScvO2 > 70%?
Optimize arterial O2 with non-rebreather
Ensure a hematocrit > 30 (Transfuse to reach a hematocrit of > 30)
Use Inotrope - Dobutamine 2.5ug/kg per minute and titrated (max
20ug/kg)
Respiratory Support - Intubation (Dont forget to sedate and paralyze)

Suspect infection
Document source within 2hrs

EGDT

The high risk pt: Systolic < 90 after bolus

Or
Lactate > 4mmol/l
Abx within 1 hr
+ source control
Decrease 02
Consumption

INTUBATE

<8mm hg

CVP
> 8 12 mm hg
MAP
> 65 95mm hg

<65 or >90mmhg Vasoactive

agent

Scv02
>70%
NO

Crystalloid

Goals Achieved

<70%

Packed RBC
to Hct >30%
<70%

Inotropes

>70%

Suspect infection
Document source within 2hrs

EGDT

The high risk pt: systolic < 90 after bolus

Or
Lactate > 4mmol/l

INTUBATE EARLY
IF IMPENDING
RESPIRATORY
FAILURE

Abx within 1 hr
+ source control
Decrease 02
Consumption

INTUBATE

<8mm hg

CVP
> 8 12 mm hg
MAP
> 65 95mm hg

<65 or >90mmhg

Scv02
>70%
NO

Crystalloid

Goals Achieved

<70%

Vasopressor

Packed RBC
to Hct >30%
<70%

Inotropes

>70%

Suspect infection
Document source within 2hrs

MODIFIED

The high risk pt: systolic < 90 after bolus

INTUBATE EARLY
IF IMPENDING
RESPIRATORY
FAILURE

Abx within 1 hr
And source control
< 65 mmHg

MAP (Urine
>65 mmHg Output)
<65 mmHg
MAP

Decrease 02
Consumption

INTUBATE

>65mm hg

> 10%
NO

Lactate
Clearance

Goals Achieved

< 10 %

More fluids
Vasopressors
Packed RBC
to Hct >30%

< 10%
Inotropes

> 10%

Case 4: Management
Distributive Shock (SEPSIS)
ABCs
Monitors
O2
IV fluids 20 cc/kg
Intubate
BW

Treat Underlying Cause

Acetaminophen
Antibiotics - GIVE EARLY
Source control - the 4 Ds = Drain, Debride, Device removal,
Definitive Control

Antibiotics

Early Antibiotics

Within 3-6hrs can reduce mortality - 30%

Within 1 hr for those severely sick
Dont wait for the cultures treat empirically then
change if need.

Other treatments for severe sepsis:

Glucocorticoids
Glycemic Control
Activated protein C

Couple of words about Steroids in

sepsis
New Guidelines for the management of
sepsis and septic shock = Surviving
Sepsis Campaign
Grade 2C consider steroids for septic shock
in patients with BP that responds poorly to fluid
resuscitation and vasopressors

Critical Care Med 2008 Jan 36:296

Concluding Remarks
Know how to distinguish different types of
shock and treat accordingly
Look for early signs of shock
SHOCK = hypotension

Concluding Remarks
Choose cost effective and high impact
interventions
Do not need central lines and ScvO2
measurements to make an impact!!

Concluding Remarks
ABCs 5 to 15
Cant intubate?
Give oxygen
Develop algorithms for bag valve mask ventilation
Treat fever to decrease respiratory rate

Treat early with fluids - need lots of it!!

Concluding Remarks
Monitor the patient
Do not need central venous pressure and
ScvO2
Use the HR, MAP, mental status, urine output
Lactate clearance?

Concluding Remarks
Start antibiotics within an hour!
Do not wait for cultures or blood work