Shock Syndromes II

Learning Objectives

Identify critical determinants affecting oxygen

delivery and the physiologic response to hypovole-

mic and obstructive shock.

the management of hypovolemic, hemorrhagic, and

obstructive shock.

Devise a treatment strategy for pharmacotherapy

adjuncts in the management of bleeding and acute

coagulopathy when treating patients with hemor-

rhagic shock.

Develop a treatment pathway for the care of patients

receiving anticoagulants and antiplatelet agents for

a life-threatening hemorrhage or critical bleeding

that incorporates current evidence and guideline

recommendations.

Apply risk stratification to guide the effective and

safe use of thrombolytic agents in the management

of acute pulmonary embolism.

Assessment of Blood Consumption

ACC

American College of Cardiology

aPCC

Activated prothrombin complex concentrate

aPTT

Activated partial thromboplastin time

CDT

Catheter-directed thrombolysis

CO

Cardiac output

Do2

Oxygen delivery

FAST

Focused Assessment with Sonography

in Trauma

Fio2

Fraction of inspired oxygen

LV

Left ventricular

MTP

Massive transfusion protocol

PCC

Prothrombin complex concentrate

PE

Pulmonary embolism

PH

Pulmonary hypertension

PT

Prothrombin time

RV

Right ventricular

SJS

Stevens-Johnson syndrome

TEG

Thromboelastogram

TTE

Transthoracic echocardiogram

Self-Assessment Questions

Answers and explanations to these questions may be

found at the end of this chapter.

A 41-year-old man presents to the emergency

department (ED) after a motorcycle accident. While

the patient is being evaluated, it is apparent that

he has broken ribs, a broken pelvis, and bilateral

broken femurs. He is confused, and his vital signs

are as follows: blood pressure 82/48 mm Hg, heart

rate 125 beats/minute, respiratory rate 34 breaths/

minute, and temperature 95°F (35°C). On further

assessment, laboratory tests show that the patient

has lost around 35% of his total blood volume.

Which classification of hemorrhage from trauma

most accurately describes this patient’s condition?

sis and portal hypertension presents to the ED with

weakness and hematemesis. Pertinent vital signs on

admission are as follows: blood pressure 76/42 mm

Hg, heart rate 134 beats/minute with a rhythm of

sinus tachycardia, and respiratory rate 24 breaths/

minute. Frank red blood is noted on nasogastric

lavage. On physical examination, the patient is con-

fused, with cold and clammy extremities. Pertinent

laboratory values are as follows: hemoglobin (Hgb)

5.5 g/dL, blood urea nitrogen (BUN) 56 mg/dL,

serum creatinine (SCr) 1.8 mg/dL, international nor-

malized ratio (INR) 2.6, total bilirubin 7.5 mg/dL,

central venous oxygen saturation (Scvo2) 58%, and

lactate 2.7 mmol/L. In this patient, which variable

would best explain reduced oxygen delivery (Do2)

and which associated clinical or biochemical sign

would best indicate a shock syndrome?