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R34 Respirology
Introduction to Intensive Care Toronto Notes 2019
Causes of SHOCK
Spinal (neurogenic), Septic Hemorrhagic
Obstructive (e.g. tension pneumothorax, cardiac tamponade, PE)
Cardiogenic (e.g. arrhythmia, MI) AnaphylaKtic
Shock
• seeEmergencyMedicine,ER3
• inadequatetissueperfusionpotentiallyresultinginendorganinjury
■ categories of shock
◆ hypovolemic: hemorrhage, dehydration, vomiting, diarrhea, interstitial fluid redistribution ◆ cardiogenic: myopathic (myocardial ischemia ± infarction), mechanical, arrhythmic,
pharmacologic
◆ obstructive: massive PE (saddle embolus), pericardial tamponade, constrictive pericarditis,
Shock: Clinical Correlation
Hypovolemic: patients have cool extremities due to peripheral vasoconstriction Cardiogenic: patients usually have signs of left-sided heart failure
Obstructive: varied presentation Distributive: patients have warm extremities due to peripheral vasodilation
increased intrathoracic pressure (e.g. tension pneumothorax) ◆ distributive: sepsis, anaphylaxis, neurogenic, endocrine, toxins
Table 36. Changes Seen in Different Classes of Shock
Hypovolemic Cardiogenic Obstructive
HR  , N, or  BP    JVP   
Distributive
or


Warm
Look for obvious signs of infection or anaphylaxis
Extremities Other
Cold
Look for visible hemorrhage or signs of dehydration
Cold
Bilateral crackles on chest exam
N or Cold
Depending on cause, may see pulsus paradoxus, Kussmaul’s sign, or tracheal deviation
• treatunderlyingcause(hypovolemiaisthemostcommoncause)
• treatmentgoalistoreturncriticalorganperfusiontonormal(e.g.normalizeBP) • commontreatmentmodalitiesinclude:
Systemic Inflammatory Response Syndrome (SIRS): generalized inflammatory reaction caused by infectious and noninfectious entities, manifested by two or more of:
• Body temperature >38°C or <36°C
• Heart rate >90/min
• Respiratory rate >20/min or PaCO2 <32
mmHg
• WBC >12,000 cells/mL or <4,000 cells/
mL or >10% bands
Quick SOFA (qSOFA) Criteria
• Respiratory rate ≥22/min
• Altered mentation
• Systolic blood pressure ≤100 mmHg
■ fluid resuscitation (NOT in cardiogenic shock)
■ inotropes (e.g. dobutamine), vasopressors (e.g. norepinephrine), vasopressin
■ revascularization or thrombolytics for ischemic events
■ needle decompression or tube thoracostomy for suspected tension pneumothorax
Sepsis
• theleadingcauseofdeathinnoncoronaryICUsettingsismulti-organfailureduetosepsis
• thepredominanttheoryisthatsepsisisattributabletouncontrollableimmunesystemactivation
Definitions
• theThirdInternationalConsensusDefinitionforSepsisandSepticShock(Singeretal.JAMA2016: 315(8), 801-810) significantly revised sepsis definitions
• sepsis:lifethreateningorgandysfunctioncausedbydysregulatedhostresponsetoinfection(seeTable37) • septic shock: a subset of sepsis, where sufficient circulatory and/or cellular/metabolic abnormalities
substantially increase mortality. Clinically defined as sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥65 mmHg and having a serum lactate ≥2 mmol/L (18 mg/dL) despite adequate fluid resuscitation
Signs and Symptoms
• newguidelinesrecommendtheuseofquickSOFA(qSOFA)criteriaandSOFAscoretoreplaceSIRS criteria
• inpatientswithsuspectedinfection,bedsideapplicationofqSOFAcriteriaidentifiesindividualswithhigh likelihood of poor outcomes, including prolonged ICU stay and/or death
• apositiveqSOFA(≥2criteria)shouldpromptapplicationoftheSOFAscore,andfurtherevaluationof possible infection and organ dysfunction
• inthecontextofsuspectedinfection,aSOFAscore≥2reflectsanoverallmoralityriskof10%
• theabsenceof≥2criteriaoneitherqSOFAorSOFAscoreshouldnotdelayordeferinvestigationor
treatment of infection or any other aspect of care deemed necessary by the practitioners