Shock and Critical Care
Vasopressors !
Dr. Mahmoud W. Qandeel
Outlines
• Shock
• Physiology of shock
• Types of shock
• Vasopressors
– Receptors and physiology
– Specific types
Dr. Mahmoud W. Qandeel
Shock:
“A momentary pause in the act of
death.”
-John Collins Warren, 1800s
Dr. Mahmoud W. Qandeel
Definition
• Shock is the clinical syndrome resulting from inadequate tissue
perfusion to maintain normal cellular metabolism.
• Inadequate oxygen delivery to meet oxygen demand.
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Vicious Cycle of Shock
Dr. Mahmoud W. Qandeel
Hypovolemic shock
• Most common type of shock
• Hemorrhage is the most common reason
• Loss of plasma volume (e.g., major burns, third spacing, or GI
losses) can also result in hypovolemia.
• Decreased preload decreases CO and oxygen delivery to cells.
• Loss of red cell volume reduces Hgb levels.
Dr. Mahmoud W. Qandeel
Hemorrhagic Shock
Parameter I II III IV
Blood loss (ml) <750 750–1500 1500–2000 >2000
Blood loss (%) <15% 15–30% 30–40% >40%
Pulse rate
(beats/min) <100 >100 >120 >140
Blood pressure Normal Decreased Decreased Decreased
Respiratory rate
(bpm) 14–20 20–30 30–40 >35
Urine output
(ml/hour) >30 20–30 5–15 Negligible
CNS symptoms Normal Anxious Confused Lethargic
Dr. Mahmoud W. Qandeel
Hypovolemic shock
Treatment:
Remember
ABCs Dr. Mahmoud W. Qandeel
Treatment (preload restoration): blood and plasma volume
a. Aggressive volume administration is needed, through two large-bore IV
catheters.
b. Stop ongoing blood loss and transfuse blood as needed.
c. Consider central venous access for monitoring and high-flow fluid
administration.
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Cardiogenic Shock
Circulatory pump failure diminished forward flow and subsequent tissue
hypoxia
Hemodynamic criteria:
• Sustained hypotension
• Reduced cardiac index
• Elevated pulmonary artery wedge pressure
50-80% mortality
Myocardial Infarction – most common cause
Dr. Mahmoud W. Qandeel
Cardiogenic Shock
Acute MI Other causes
✓End-stage cardiomyopathy
✓Pump failure
✓Myocarditis
✓Mechanical complications
✓Severe myocardial contusion
• Acute mitral regurgitation from
✓Prolonged cardiopulmonary bypass
papillary muscle rupture
✓Septic shock with severe
• Ventricular septal defect
myocardial depression
• Free-wall rupture
✓Left ventricular outflow
• Pericardial tamponade obstruction
• Right ventricular infarction ✓Acute mitral regurgitation
✓Acute aortic insufficiency
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Cardiogenic Shock
Treatment:
• Maintenance of adequate oxygen
• Fluid administration
• Correct electrolyte imbalance
• Pain management
• Anti-arrhythmic drugs, pacing or cardioversion
• Inotropic Support
Improve cardiac contractility & cardiac output
• Intra-Aortic Balloon Pump
Increases cardiac output & improves coronary blood flow
• Percutaneous Transluminal Coronary Angiography
Treatment of choice (cardiogenic shock from AMI)
Dr. Mahmoud W. Qandeel
Vasodilatory Shock
✓ Systemic response to infection
• Septic
✓ Noninfectious systemic inflammation
• Anaphylaxis
✓ Neurogenic
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Septic Shock
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Vasoactive medications
Dr. Mahmoud W. Qandeel
Adrenergic
Receptors
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Vasopressors
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dopamine
• Effects depend on concentration used.
• Low dose (1–3 ug/kg/min): primarily affects dopamine receptors in
the kidneys and intestine, leading to increased blood flow
• Intermediate dose (3–10 ug/kg/min): primarily a beta receptor
agonist, increasing cardiac contractility with resulting increase in CO
• High dose ( 10 ug/kg/min): Primarily an alpha agonist and
vasoconstrictor. Its limiting effect is tachycardia but is useful in shock
where both contractility and a heart rate (HR) increase are needed.
Dr. Mahmoud W. Qandeel
Dobutamine
• Primarily affects both the beta-1 and beta-2 receptors,
increasing CO and vasodilatation, which can be beneficial in
cardiogenic shock, where increased CO and decreased SVR are
sought
Dr. Mahmoud W. Qandeel
Norepinephrine
• Strong alpha agonist that primarily causes vasoconstriction
with mild beta agonist activity that increases heart
contractility.
• Started at 1–2 ug/kg/min, the dose is increased in 1–
2ug/kg/min increments until the desired effect is reached.
• Tachycardia is its major limiting effect (but good for septic
shock); otherwise, there is really no upper limit.
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Epinephrine
• Primarily an alpha agonist with some beta agonist effect.
• It is useful for vasoconstriction and increasing CO; it is dosed
similar to norepinephrine but causes more tachycardia.
Dr. Mahmoud W. Qandeel
Phenylephrine
• Alpha agonist that causes pure arterial vasoconstriction.
• Drops are usually begun at 50 ug/min and increased in
increments of 50 ug/min until a total dose of 300 ug/min is
reached.
• Best for neurogenic shock.
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Which of the following is an appropriate definition of shock ?
(7/2016)
a) Low blood pressure.
b) Low cardiac output.
c) Low circulating volumes.
d) Inadequate tissue perfusion.
e) Abnormal vascular resistance.
Dr. Mahmoud W. Qandeel
Which of the following is an appropriate definition of shock ?
(7/2016)
a) Low blood pressure.
b) Low cardiac output.
c) Low circulating volumes.
d) Inadequate tissue perfusion.
e) Abnormal vascular resistance.
Dr. Mahmoud W. Qandeel
All of the following sentences are true about pathophysiology of
shock except ? (7/2017)
a)Shock means inadequate oxygen delivery to meet metabolic
demands .
b) Shock may occur without loss in the circulating volume .
c) Severe infection may lead to decreased cardiac preload .
d) Serum lactate decreases in shock .
e) The function of phagocytes is decreased in shock
Dr. Mahmoud W. Qandeel
All of the following sentences are true about pathophysiology of
shock except ? (7/2017)
a)Shock means inadequate oxygen delivery to meet metabolic
demands .
b) Shock may occur without loss in the circulating volume .
c) Severe infection may lead to decreased cardiac preload .
d) Serum lactate decreases in shock .
e) The function of phagocytes is decreased in shock
Dr. Mahmoud W. Qandeel
A 65 years old male patient presented to the clinic with Abdominal
Aortic Aneurysm 6 cm diameter. He underwent open surgical repair
and Just after the end of surgery Patient started to complain of
sudden severe pain in the abdomen. His vital signs as the following
Bp 80/40 mmhg RR 25 HR 42 beat per minute, CVP 8 cm H2o,
Temperature 36,5 . The most likely diagnosis : (6/2019)
a) Pulmonary Embolism
b )Cardiac Tamponade
c) Cardiogenic Shock
d) Neurogenic Shock
e) Hemorrhagic Shock Dr. Mahmoud W. Qandeel
A 65 years old male patient presented to the clinic with Abdominal
Aortic Aneurysm 6 cm diameter. He underwent open surgical repair
and Just after the end of surgery Patient started to complain of
sudden severe pain in the abdomen. His vital signs as the following
Bp 80/40 mmhg RR 25 HR 42 beat per minute, CVP 8 cm H2o,
Temperature 36,5 . The most likely diagnosis : (6/2019)
a) Pulmonary Embolism
b )Cardiac Tamponade
c) Cardiogenic Shock
d) Neurogenic Shock
e) Hemorrhagic Shock Dr. Mahmoud W. Qandeel
A 60 year old woman with no past medical problems presented
to the E.R with jaundice , RUQ pain and fever. Her Blood
pressure was 80/40 , Heart rate 120 bpm. The most appropriate
next step: ( 4/2018)
a) Urgent cholecystectomy.
b) Urgent ERCP.
c) Urgent PTC placement.
d) Volume resuscitation and IV antibiotic.
e) Urgent laparotomy.
Dr. Mahmoud W. Qandeel
A 60 year old woman with no past medical problems presented
to the E.R with jaundice , RUQ pain and fever. Her Blood
pressure was 80/40 , Heart rate 120 bpm. The most appropriate
next step: ( 4/2018)
a) Urgent cholecystectomy.
b) Urgent ERCP.
c) Urgent PTC placement.
d) Volume resuscitation and IV antibiotic.
e) Urgent laparotomy.
Dr. Mahmoud W. Qandeel
All of the following are true about the assessment of bleeding
except ? (7/2017)
a) Taking blood samples at the time of bleeding gives an accurate
level of hemoglobin.
b) Hypovolemia increases the risk of tissue hypoxia and multi organ
failure.
c) Blood loss could be estimated from the size of blood clot and the
weight of swabs used.
d) Any thirsty patient should be considered hypovolemic.
e) Arterial blood gas is a quick method to measure hemoglobin.
Dr. Mahmoud W. Qandeel
All of the following are true about the assessment of bleeding
except ? (7/2017)
a) Taking blood samples at the time of bleeding gives an accurate
level of hemoglobin.
b) Hypovolemia increases the risk of tissue hypoxia and multi organ
failure.
c) Blood loss could be estimated from the size of blood clot and the
weight of swabs used.
d) Any thirsty patient should be considered hypovolemic.
e) Arterial blood gas is a quick method to measure hemoglobin.
Dr. Mahmoud W. Qandeel
What is the first parameter to change in early hypovolemic
shock ? (4/2017)
a) Systolic blood pressure.
b) Pulse rate.
c) Diastolic blood pressure.
d) Respiratory rate.
e) Level of consciousness.
Dr. Mahmoud W. Qandeel
What is the first parameter to change in early hypovolemic
shock ? (4/2017)
a) Systolic blood pressure.
b) Pulse rate.
c) Diastolic blood pressure.
d) Respiratory rate.
e) Level of consciousness.
Dr. Mahmoud W. Qandeel
Which of the following is not true regarding sepsis ? (4/2017)
a) Tachycardia and-or tachypnea may be a sign.
b) Sepsis is defined as systemic inflammatory response
syndrome in the presence of infection.
c) Leukocytosis or leukopenia may be a sign.
d) Sepsis and hypotension is defined as septic shock.
e) Temperature greater than 38 or less than 36 may be a sign.
Dr. Mahmoud W. Qandeel
Which of the following is not true regarding sepsis ? (4/2017)
a) Tachycardia and-or tachypnea may be a sign.
b) Sepsis is defined as systemic inflammatory response
syndrome in the presence of infection.
c) Leukocytosis or leukopenia may be a sign.
d) Sepsis and hypotension is defined as septic shock.
e) Temperature greater than 38 or less than 36 may be a sign.
Dr. Mahmoud W. Qandeel
A 20 year old man got involved in RTA sustains bilateral fractured
femurs. On assessment , he is anxious and confused , with a pulse
of 130/min and BP of 70/50 mmHg. Urine output over 1 hour is 10
ml. This patient have a hemorrhagic shock type ? (4/2017)
a) Class 1
b) Class 2
c) Class 3
d) Class 4
e) Class 5
Dr. Mahmoud W. Qandeel
A 20 year old man got involved in RTA sustains bilateral fractured
femurs. On assessment , he is anxious and confused , with a pulse
of 130/min and BP of 70/50 mmHg. Urine output over 1 hour is 10
ml. This patient have a hemorrhagic shock type ? (4/2017)
a) Class 1
b) Class 2
c) Class 3
d) Class 4
e) Class 5
Dr. Mahmoud W. Qandeel
In the management of hemorrhagic shock , the best clinical sign
of successful fluid resuscitation is : (10/2016)
a) Increase in blood pressure
b) Increase in urine output
c) Increase in arterial oxygenation
d) Decrease in thirst
e) Decrease in tachycardia
Dr. Mahmoud W. Qandeel
In the management of hemorrhagic shock , the best clinical sign
of successful fluid resuscitation is : (10/2016)
a) Increase in blood pressure
b) Increase in urine output
c) Increase in arterial oxygenation
d) Decrease in thirst
e) Decrease in tachycardia
Dr. Mahmoud W. Qandeel
A 70-year-old woman has low cardiac output with increased
PCWP and increased systemic vascular resistance. What should
be the drug of choice?
(A) Dopamine
(B) Norepinephrine
(C) Dobutamine
(D) Epinephrine
(E) Phenylephrine
Dr. Mahmoud W. Qandeel
A 70-year-old woman has low cardiac output with increased
PCWP and increased systemic vascular resistance. What should
be the drug of choice?
(A) Dopamine
(B) Norepinephrine
(C) Dobutamine
(D) Epinephrine
(E) Phenylephrine
Dr. Mahmoud W. Qandeel
