There are five main goals in the management of Shock Treatment of Patient: (1) rapid recognition of the shock state. (2) correction of the initiating insult (e.g., pericardiocentesis, defibnllation, hemostasis, antibiotics), (3) correction of the secondary consequences of the shock state (e.g., acidosis, hypoxemia, disseminated intravascular coagulation), (4) maintenance of the function of vital organs (e.g., cardiac output, arterial pressure, urinary output), and (5) identification and correction of aggravating factors. All five goals are approached simultaneously.
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The prognosis of a patient in shock is determined by the etiology of the shock state (e.g., hypovolemic traumatic shock in a young, healthy adult carries a mortality of less than 20 per cent in many centers, while cardiogenic shock due to massive anterior infarct carries a mortality of more than 70 per cent even in the most aggressive medical center), by the duration of shock and consequent secondary organ dysfunction, and by the speed of recognition and appropriateness of medical intervention.
A key element in the patient in shock is hemodynamic mnnitorinp
Management of the patient in shock requires accurate and serial measurements of heart rate and rhythm, respiratory rate and adequacy of gas exchange, systemic blood pressure and cardiac filling pressures, cardiac output and tissue perfusion indices, and end-organ function (mental status, unne output, liver function, etc.).
1. The electrocardiogram permits serial assessment of cardiac rate and rhythm and promptly detects serious arrhythmias such as premature ventricular beats, ventricular tachycardia or fibrillation, high degree heart block, serious sinus bradycardia, and atrial arrhythmias. In addition, senal 12-lead ECG’s may
2. Arterial blood gases and pH.
These should also be monitored routinely. Correction of acidosis and hypoxia are essential elements in the management of the early phases of shock.
3. Central venous and Swan-Ganz catheters.
The monitoring of central venous pressure provides an index of the status of absolute and relative blood volume and of the need for fluid replacement. The catheter should be inserted through the antecubital or external jugular vein; only if the physician is experienced should it be introduced through the subclavian or the internal jugular vein. Central venous pressure obtained with the catheter advanced to the superior vena cava is normally between 5 and 8 mm Hg, but it should be elevated to 10 mm Hg if one is to expect an adequate cardiac output in patients in shock. Central venous pressure reflects the filling pressure of the right ventricle and hence is an adequate indicator of cardiac filling pressure only in patients who have no underlying cardiac or pulmonary disease and are not on a mechanical ventilator.
The central venous pressure is probably adequate only for the initial management of young adults suffering from traumatic hypovolemic shock. In the patient with known or suspected cardiac or pulmonary disease, or in whom management includes the use of positive-pressure ventilation, state of the art management requires the use of a Swan-Ganz catheter to measure pulmonary capillary wedge pressure as an indicator of left ventricular filling pressure. In addition, the Swan-Ganz catheter allows serial assessment of cardiac output and provides a route for serial oximetric studies.
The filling pressure of the left ventricle can be estimated from measurement of the “pulmonary capillary wedge” pressure with a Swan-Ganz balloon-tip catheter. A triple lumen thermodilution catheter is introduced intravenously with or without fluoroscopy but with electrocardiographic monitoring. Its tip is advanced to the pulmonary artery; the balloon is inflated with air, and it can be floated to a wedge position in one of the pulmonary arteries. The recorded pressure downstream from the inflated balloon is the “pulmonary capillary wedge” pressure, and the appearance of the left atrial pressure wave form on the oscilloscope confirms the position of the catheter tip. The wedge pressure reflects left ventncular end-diastolic pressure, but a discrepancy between the two may occur if there is severe mitral stenosis or left atrial tumors. If for some reason one is unable to get the wedge pressure, the pulmonary artery diastolic pressure may be a useful index of the wedge pressure.
The double lumen Swan-Ganz catheter has been modified to include an extra lumen that allows measurement of right ventricular end-diastolic pressure simultaneously with the wedge pressure. Another modification includes a temperature Another modification includes a temperature sensor device at the tip that allows the detection of changes in temperature following injection of cold dextrose in the right atrium, and the temperature dilution curve obtained with the temperature sensor provides an estimate of cardiac output.
4. Urinary catheter.
This allows the routine hourly measurement of urinary output. A decline in urinary output to less than 20 ml per hour is an indication of the inadequacy of arterial pressure and renal perfusion. It is a sensitive index of the progress of the shock syndrome and reflects the effectiveness of management. The most frequent cause of oliguna in shock is hypovolemia. Fluid deficits are often underestimated, particularly in the presence of sepsis. If oliguria persists despite adequate administration of fluid and elevated wedge pressure, diuretic therapy may be necessary to avoid acute renal tubular necrosis which complicates prolonged hypotension.
5. Arterial catheterization for arterial pressure monitoring.
Patients with severe or persistent hypotension and shock in whom it is difficult to measure blood pressure with the sphygmomanometer are candidates for intra-arterial pressure monitoring. There is often a discrepancy between the intra-arterial pressure measurements and the cuff pressure. There may be a low or even no recordable arterial pressure by the cuff technique when intra-artenal pressure by cannulation is normal or even at times slightly elevated. This discrepancy may result from severe peripheral vasoconstriction and low output and pulse pressure. Since the sphygmomanometric measurement of artenal pressure in shock may be erroneously low, it is advisable to palpate the femoral artery in the groin to get a better index of the strength of the pulse pressure in this more proximal large artery and to introduce an arterial cannula for monitoring arterial pressure before administering vasopressors or resorting to counterpulsation.
An arterial cannula also allows the frequent determination of blood gases and pH. The radial, brachial, or femoral arteries may be cannulated. We prefer to cannulate the radial artery, if possible, as this site has the lowest complication rate. Brachial or femoral arterial cannulation is preferred in patients who are severely hypotensive, who are on large doses of vasoactive drugs, who are markedly vasoconstncted, and in whom the radial artery is difficult to palpate.
Measurement of cardiac output by thermal or dye dilution techniques is used for management of selected patients or for the evaluation of new therapeutic regimens. The mixed venous blood oxygen content may be used as an index of total body perfusion. Within certain limitations, one can estimate the effectiveness of total body perfusion and delivery of oxygen to the tissues by monitoring the oxygen content of mixed venous or pulmonary artenal blood. The assumptions are that the total body oxygen consumption is constant or does not change drastically and that the artenal oxygen content is high and does not vary significantly. An arteriovenous oxygen difference of 6 ml per deciliter or more indicates poor tissue perfusion.