Shock and Vasopressors

Yilin Zhang, MD
Brandon Fainstad, MD


OBJECTIVES
  • Differentiate between different categories of shock and their hemodynamic profiles
  • Recognize commonly used vasopressors and indications for their use

Skip to practice cases.


Board Set-Up:

Part 1Types of Shock

Now that you know the differential of shock, how would you evaluate a patient with undifferented shock?  (~5 min)


Part 2Vasopressors and Inotropes

Final board: Management of Shock

TAKE HOME POINTS

PRACTICE CASES (~ 5 min each)
CASE 1

45 yo M with ischemic cardiomyopathy (EF 40%) admitted with pneumonia and hypotension. He is febrile to 39.2C, RR 26, SpO2 90% on 5L NC, BP 87/32 (MAP 50). On exam, he has warm extremities, JVP ~ 10 cm, trace BLE edema.

Labs show a Cr of 2.2 (baseline of 1), WBC 18k, lactate 3.2. ECG shows NSR without new signs of ischemia. BNP 500 (baseline range 200-600s).

What type of shock is this?  

How would you manage this patient’s shock?  


CASE 2

45 yo man with dilated cardiomyopathy (EF 20%) admitted with hypoxia and altered mental status. On exam, he is afebrile, RR 26, BP 72/45 (MAP 54), SpO2 90% on 5L NC. On exam, he is cold and clammy, JVP 12 cm, 2+ BLE edema. Initial labs (BMP, CBC) are only notable for Cr of 2.2 (baseline 1). An ECG shows sinus tachycardia without ischemic changes. Troponin is minmally elevated at 0.05. BNP > 1500 (baseline 200-500). CXR shows cephalization, Kerley B lines and bilateral pleural effusions. 

What type of shock is this? How would you further evaluate him? 

How would you manage his shock? 


Case 3

45 yo M with cirrhosis presents with 1 day of hematochezia and orthostasis. On exam, he is afebrile, RR 18, HR 140s, BP 72/45 (MAP 54), SpO2 92% on RA. On exam, he has dry mucus membranes, cold and clammy extremities, JVP is not appreciable. Initial labs (BMP, CBC) are only notable for Cr of 2.2 (baseline 1), plts 110k, hct 24% (baseline 38%), INR 2.4 (at baseline).

What type of shock is this?

How would you manage his shock? 


REFERENCES
  1. Kumar A, et al. Circulatory shock. In: Parillo JE & Dellinger P, eds. Critical Care Medicine: Principles of Diagnosis and Management in the Adult, 4th Edition. Philadelphia, PA. Elsevier Saunders. p. 299-324.e9.
  2. Overgaard CB & Dzavik V. Inotropes and Vasopressors: Review of Physology and Clinical Use in Cardiovascular Disease. Circulation. 2008; 118: 1047-1056.
  3. Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017, 43(3): 304-377.