Clinical Management of Shock

The Science and Art of Physiological Restoration

Stanislaw P. Stawicki, Mamta Swaroop

• Publisher: IntechOpen
• Year: 2020
• ISBN:
  9781838811723
• Topic: Medicine
• Subtopic: Emergency Medicine & Critical Care

Shock is a physiological state of war! From a healthcare provider perspective, the word "shock" is associated with a mixed array of feelings, including dread, well-founded fear, and deep respect. The physiological state of shock is well recognized for the associated destructive consequences, and its successful management requires prompt identification, immediate action, and sustained effort by all members of the healthcare team. This mindset of advanced preparation and constant readiness constitutes the foundation of the modern approach toward shock – early detection and prompt treatment for optimal outcomes. Despite the heterogeneity of "shock" as a clinico-pathological entity, there are some common threads that permeate all forms and manifestations of shock, with apparent increase in observed commonalities in the more advanced (and often irreversible) stages of the systemic syndrome. When faced with shock, the body and its systems do their best to compensate for the maldistribution of oxygen and nutrients. This is known as the so-called compensated shock. Beyond that, the body loses its ability to adjust any further, thus descending into "uncompensated shock," with a refractory state characterized by vasoplegia and irreversible cardiovascular failure. As the reader journeys through the chapters of the book, he or she will read about various biomarkers and endpoints of resuscitation, explore different types of shock (e.g., septic, hemorrhagic, anaphylactic) and learn about some of the less often discussed topics such as neurogenic and spinal shock, as well as the amniotic fluid embolism. Our goals were to keep things clinically relevant and practically oriented, thus enabling the reader to apply the newly acquired knowledge in their everyday clinical routines. As the reader progresses through the book, we hope to help stimulate further discourse and innovative thinking about the topic. In this context, it is critical that basic, translational, and clinical research on shock continues to advance. Only through ongoing scientific progress can we help improve outcomes for patients with both rare and common forms of shock.

Table of contents

• Clinical Management of Shock - The Science and Art of Physiological Restoration
• Contents
• Foreword on Shock
• Preface
• Chapter1 Introductory Chapter: Shock is a Physiological State of War
• Chapter2 New Biomarkers of Sepsis with Clinical Relevance
• Chapter3 Resuscitation Endpoints inTraumatic Shock: A Focused Review with Emphasis on Point-of-Care Approaches
• Chapter4 Hemorrhagic Shock
• Chapter5 Sepsis and Septic Shock
• Chapter6 Anaphylactic Shock
• Chapter7 Neurogenic Shock
• Chapter8 Spinal Shock: Differentiation from Neurogenic Shock and Key Management Approaches
• Chapter9 Amniotic Fluid Embolism
• Chapter10 Burn Shock and Resuscitation: Many Priorities, One Goal
• Chapter11 Urosepsis: Flow is Life Shock, defined as a state of insufficient perfusion and impaired tissue oxygen delivery, is a life-threatening condition of varied etiologies that requires prompt recognition, diagnosis, and resuscitation [1, 2]. Prehospital shock is associated wit a 33–52% in-hospital mortality rate [1].While trends in frequency and mortality of undifferentiated shock in the emergency department (ED) are under-explored, in-hospital mortality rates of 23–24% have been reported in Danish [1] and US ED settings [3, 4], with 90-day mortality approaching 41% [1]. Moreover, mortality ra for some subtypes of shock may be higher (e.g., trauma patientswith hemorrhagic shock) [5]. Mortality further increaseswith any associated end-organ dysfunction or failure [6], aswell aswith increased comorbidity burden as measured by the Charlson comorbidity index [1]. Despite technical improvement in diagnostics and advances in treatment, shock remains a critical finding in acute medical care. Reducing time to recognition and targeted treatment are critical aspects of patient care. Shock’s clinical recognition i traditionally based onvital sign abnormalities (blood pressure, heart rate), and it may be defined as the presence of hypotension (systolic blood pressure ≤ 100 mmH and ≥ 1 organ failures [1]. The Shock Index (SI; systolic blood pressure/heart rate) may further be used as a measure of cardiovascular failure (≥ 1) [7]. Traditionally shock has been classified into four categories: cardiogenic, distributi hypovolemic, and obstructive. However, although the circulatory system is compl and depends on a multitude of variables, some find it helpful to simplify it to three main components: cardiac function (“the pump”), intravascularvolume (“the tank”), and systemicvascular resistance (“the pipes”) [2]. In shock, dysfunction occurswithin one or more of the three components – the pump, tank, or pipes – su that tissue perfusion and oxygen delivery are impaired [2]. Acute pump malfuncti can be caused by arrhythmias, conditions that result in a sudden decrease in cardia contractility (e.g., myocardial infarction, myocarditis, valvular insufficiency) or b extracardiac conditions that obstruct cardiac output (e.g., pericardial tamponade, pulmonary embolus). Acute tank malfunction primarily results from a decrease in intravascularvolume due to hemorrhage, volume loss, or impaired venous return a impaired leftventricular preload (e.g., tension pneumothorax). Pipe malfunction may be observed with processes that altervascular tone including anaphylaxis, neurogenic (e,g., spinal cord injury), sepsis, and processes that disrupt pipe integr (e.g., aortic dissection, abdominal aortic aneurysm). Importantly, some entities (e burns, trauma, etc.) may compromise more than one system (pump, tank, pipes). Regardless of the underlying mechanism of shock, if impaired perfusion and oxyg delivery are not recognized and reversed, organ dysfunction, tissue necrosis, and death may ensue. Significant regional disparities in evidence-based care have been reported, and in-hospital mortality remains high. This book goes beyond the basics of epidemiology, pathophysiology, and recognition, and targets the difficult, and at times confusing, management decisions that clinicians treating shock are faced wi including resuscitation fluid (or blood product) selection, mechanical ventilation, vasopressor use, and decisions on surgical intervention. A thorough understandin of these topics is crucial for acute care providers and by studying this bookyou hav taken the important first steps on this journey. Competinginterests The author has no conflicts of i terest to disclose. Funding No funding was received for thiswork Andrew C. Miller, M Department of Emergency Medic Brody School of Medic East Carolina Univers Greenville, NC, U Holler JG, Henriksen DP, Mikkelsen S, et al. Shock in the emergency departmen ; a 12 year population based cohort study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2016;24:87 Wacker DA, Winters ME. Shock. Emergency Medicine Clinics of North America. 2014;32:747-758 Jones AE, Tayal VS, Sullivan DM, et al. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Critical Care Medicine. 2004;32:1703-1708 Moore CL. Determination of left ventricular fu ction by emergency physician echocardiography of hypotensive patients. Academic Emergency Medicine. 2002;9:186-193 Heckbert SR, Vedder NB, HoffmanW, et al. Outcome after hemorrhagic shock in trauma patients. The Journal of Trauma. 1998;45:545-549 Peres Bota D, Melot C, Lopes Ferreira F, et al. The Multiple Organ Dysfunction Score (MODS) versus the Sequential Organ Failure Assessment (SOFA) score in outcome prediction. Intensive Care Medicine. 2002;28:1619-1624 Rady MY, Smithline HA, Blake H, et al. A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department. Annals of Emergency Medicine. 1994;24:685-690