Internal Medicine

0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:21

1340 Shock

➣Lactate Level >2 mEq/L

Most accurate marker of shock; consider empiric therapy if

laboratory turnaround >1 hr

■Advanced Studies:

➣A-VDO 2 >5 ml/dl

requires PA catheter; may be normal in sepsis

Mixed Venous O 2 <70%

➣requires PA catheter; may be normal in sepsis

■Urine:

➣Fractional Excretion Sodium <1%

➣(UNa×PCr)/(UCr×PNa)×^100

➣Urine Sodium <20 mEq/ml (hypovolemia)

■Other Tests:

➣ECG – signs of ischemia, MI

➣Cardiac Output – PA catheter, Echocardiography

differential diagnosis

Hypovolemic vs Cardiogenic

■Hypovolemia: Low PCWP, inadequate RA or LV filling on echocar-

diography

■Cardiogenic: ECG changes, hypodynamic LV on echo, increased tro-

ponin, CPK, adequate PCWP

Septic vs Neurogenic

■Septic: Fever, leukocytosis, bacteremia, normal mixed venous O 2 ,

AVDO 2

■Neurogenic: Acute spinal trauma

management

What to Do First:

■Secure airway: Endotracheal intubation if mentally altered

■Institute respiratory support: bag-valve or mechanical ventilat-

ion

➣Caution: Positive pressure will exacerbate hypotension

➣Continuous monitoring with arterial catheter is recommended

■Augment preload: Fluid Challenge: 20 cc/kg crystalloid, 10 cc/kg

colloid

■Raise systemic perfusion pressure: Dopamine, phenylepherine,

epinepherine, norepinepherine

■Caution: Dobutamine may exacerbate hypotension