shock marker

Suad Al-Sulimani R2

Definition of shock in term of cellular function

Path physiology amp clinical finding of different types of shock

Biochemical shock markers Evidence based clinical values

bull Profound hemodynamic and metabolic disturbance characterized by failure of the circulatory system to maintain adequate perfusion of vital organs

Aerobic Metabolism

6 O2

GLUCOSE

METABOLISM

6 CO2

6 H2O

36 ATP

HEAT (417 kcal)

Anaerobic Metabolism

GLUCOSE METABOLISM

2 LACTIC ACID

2 ATP

HEAT (32 kcal)

InadequateInadequateCellularCellular

OxygenationOxygenation



AnaerobicAnaerobicMetabolismMetabolism


MetabolicMetabolicFailureFailure

MetabolicMetabolicFailureFailure MetabolicMetabolic

AcidosisAcidosis

MetabolicMetabolicAcidosisAcidosis

InadequateInadequateEnergyEnergy

ProductionProduction


ProductionProduction Lactic AcidLactic AcidProductionProduction

Lactic AcidLactic AcidProductionProduction

Cell DeathCell DeathCell DeathCell Death

Peripheral vasoconstrictionhellip

peripheral vascular peripheral vascular resistancehellipresistancehellip


afterloadhellipafterloadhellip afterloadhellipafterloadhellip

blood pressureblood pressure blood pressureblood pressure

Peripheral vasodilationhellip





fluid volumehellip

preloadhellippreloadhellip preloadhellippreloadhellip

contractility contractility (Starlingrsquos Law)hellip(Starlingrsquos Law)hellip


cardiac outputcardiac output cardiac outputcardiac output blood pressureblood pressure blood pressureblood pressure

fluid volumehellip





1048711 The human body responds to acutehemorrhage by activating 4 majorphysiologic systems the hematologicsystem the cardiovascular system therenal system and the neuroendocrinesystem

1048711 Platelets are activated which form an immatureclot on the bleeding source

1048711 The damaged vessel exposes collagen whichsubsequently causes fibrin deposition andstabilization of the clot

Hypovolemic Shock Cardiovascular System

1048711 Increases the heart rate increasing myocardialcontractility and constricting peripheral bloodvessels1048711 This response occurs secondary to an increase inrelease of norepinephrine and a decrease inbaseline vagal tone (regulated by thebaroreceptors in the carotid arch aortic arch leftatrium and pulmonary vessels)

1048711 The cardiovascular system also responds by redistributing blood to the brain heart and kidneys and away from skin muscle and GI tract

Hypovolemic Shock Renal System

1048711 The kidneys respond to hemorrhagicshock by stimulating an increase in renninsecretion from the juxtaglomerularapparatus

PlasmaPlasmavolumevolume


[Na+][Na+] [Na+][Na+]

KidneyKidney(juxtaglomerular(juxtaglomerular

apparatus)apparatus)


apparatus)apparatus)Detected by

Releases

ReninReninReninRenin

AngiotensinogenAngiotensin IhellipAngiotensin IhellipAngiotensin IhellipAngiotensin Ihellip

Converts

ampOr

Via ACE(AngiotensinConvertingEnzyme)

Angiotensin IIhellipAngiotensin IIhellipAngiotensin IIhellipAngiotensin IIhellip

Angiotensin IIhellipAngiotensin IIhellipAngiotensin IIhellipAngiotensin IIhellip vasoconstrictionvasoconstriction vasoconstrictionvasoconstriction PVRPVR PVRPVR

BPBP BPBP

thirstthirst thirstthirst

FluidFluidvolumevolume


ADHADH(anti-diuretic(anti-diuretic

hormone)hormone)


hormone)hormone)

AdrenalAdrenalcortexcortex


Releases

AldosteroneAldosteroneAldosteroneAldosteroneNa+Na+

reabsorptionreabsorption

Na+Na+reabsorptionreabsorption

COCO COCORASRASActivationActivation

RASRASActivationActivation

DyspneaDyspnea DyspneaDyspnea

OO22

supplysupply

OO22

supplysupply

VolumeVolumePreloadPreload


SVRSVR SVRSVR

PeripheralPeripheralamp pulmonaryamp pulmonary

edemaedema


edemaedemaImpairedImpairedmyocardial functionmyocardial function

ImpairedImpairedmyocardial functionmyocardial function

MyocardialMyocardialOO22 demand demand


CatecholamineCatecholamineReleaseRelease


Sympathetic ToneSympathetic ToneOrOr

Parasympathetic ToneParasympathetic Tone



Vascular ToneVascular ToneVascular ToneVascular Tone

Massive VasodilationMassive VasodilationMassive VasodilationMassive Vasodilation

SVR amp PreloadSVR amp Preload SVR amp PreloadSVR amp Preload Cardiac OutputCardiac Output Cardiac OutputCardiac Output

TissueTissueperfusionperfusion


Systemic Inflammatory Response Syndrome (SIRS) Systemic inflammatory response to a variety of severe clinical insults manifested by ge 2 of the following conditions Temperature gt38ordmC or lt36ordmC Heart rate gt90 beatsmin Respiratory rate gt20 breathsmin orPaCO2 lt32 torr (lt43 kPa) White blood cell count gt12000cellsmm3 lt4000 cellsmm3 or gt10immature (band) cells

Sepsis The presence of SIRS associated with a confirmed infectious process

Severe Sepsis Sepsis with either hypotension or systemic manifestations of hypoperfusionndash Lactic acidosis oliguria altered mental status

Septic Shock Sepsis with hypotension despite adequatefluid resuscitation associated with hypoperfusion abnormalities

bullHemodynamic AlterationsbullHyperdynamic State (ldquoWarm Shockrdquo)bullTachycardiabullElevated or normal cardiac outputbullDecreased systemic vascular resistance

bullHypodynamic State (ldquoCold Shockrdquo)bullLow cardiac output

Protein cactivation

bullCytokine production leads to massive production of endogenous vasodilators

bullStructural changes in the endothelium result in extravasation of intravascular fluid into interstitium and subsequent tissue edema

bullPlugging of select microvascular beds with neutrophils fibrin aggregates and microthrombi impair microvascular perfusion

bullOrgan-specific vasoconstriction

bullLoss of Sympathetic ResponsivenessbullDown-regulation of adrenergic receptor number and sensitivity possible altered signal transduction

bullVasodilatory Inflammatory MediatorsbullEndotoxin has direct vasodilatory

effectsbull Increased Nitric Oxide Production

Infection

InflammatoryMediators

Endothelial Dysfunction

Vasodilation

Hypotension Vasoconstriction Edema

Maldistribution of Microvascular Blood Flow

Organ Dysfunction

Microvascular Plugging

Ischemia

Cell Death

bullNormal compensation includesProgressive vasoconstriction Increased blood flow to major organs

Increased cardiac output Increased respiratory rate and volume

Decreased urine output

32

bull In shock the hydrostatic pressure decreases and the oncotic pressure is constant as a resultndash The fluid exchange from the capillary to the

extracellular space decreasesndash The fluid return from the extracellular space to

the capillary increasesThat will increase the blood volume which will

increase BP and will help to compensate shock situations

This system is known as the ldquoFluid shift systemrdquo

Cellular Response to Shock



NaNa++ Pump PumpFunctionFunction


ATPATPsynthesissynthesis


AnaerobicAnaerobicmetabolismmetabolism


Cellular edemaCellular edema Vascular volumeVascular volume


Impaired cellularImpaired cellularmetabolismmetabolism


OO22

useuse

OO22

useuse

Intracellular NaIntracellular Na++

amp wateramp water


amp wateramp water

Impaired Impaired glucose glucose usageusage


Stimulation of Stimulation of clotting cascade amp clotting cascade amp

inflammatoryinflammatoryresponseresponse



pyruvate + NADH + H+ = lactate + NAD+

=Accelerated aerobic glycolysis =Carbohydrate metabolism gt mitochondrial oxidative capacity Hypoxia blocks oxidative phosphoeration =Increase the lactate pyruvate ratio =Normal ratio around 101

bull Reduced lactate clerance bull Puruvate dehydrogenase

Dysfunction bull PDH shifts Pyruvate to Krebs cycle

not lactate Subnormal level in muscle in sepsis

bull Protien catabolism bull Aas converted to Puruvate then

lactate bull in hibition of mitochondrial

respiration sepsis drugs

bullGluconeogenesis 20 - Cori cycle in liver

bullOxidation 80

Lactate

Serum Lactate as a Predictor of Mortality in Emergency Department Patients With Infection Annals of Emergency Medicine 200545524-528

=An initial serum lactate may be useful in risk stratification in patients presenting to the emergency department with infections

= There appears to be an increasing trend of mortality with elevated initial lactate levels 224 patients with an initial lactate level gt 40 mmolL died within 3 days

Lactate levels greater than 25 mmolL are associated with an increase in mortalityLevels greater than 4 mmolL in patients with suspected infection have been shown to increase mortality odds 5-fold

Ann Emerg Med May 200545(5)524-8

Intensive Care Med 20012774-83 Abstract

Elevated serum lactate levels are predictive of an increased mortality in ED patients with sepsis or septic shock Current evidence indicates that monitoring serial values and determining the time to clearance is a strong predictor of patient outcome

=decline in lactate levels of at least 10 during the first 6 hours of therapy correlated with a mortality rate of lt 20

= normalization of serum lactate levels within 12-24 hours is associated with the best chance of patient survival

= Patients whose lactate levels do not return to normal within 48 hours have significantly higher rates of organ dysfunction and death

Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C

Baseline protein C levels were an independent predictor of sepsis outcome Day 1 changes in protein C regardless of baseline levels were also predictive of outcome The association of DrotAA treatment increased protein C levels and improved survival may partially explain the mechanism of action

Critical Care 2006 10R92doi101186cc4946

Procalcitonin

]Procalcitonin (PCT) has been proposed as a more specific [and better prognostic marker than CRP although its value has also been challenged It remains difficult to differentiate sepsis from other non-infectious causes of systemic inflammatory response syndrome and there is a continuous search for better biomarkers of sepsis

J Crit Care 2004 19152-157

Lancet Infect Dis 2007

base deficit has shown poor correlation with serum lactate and is affected by numerous conditions including crystalloid resuscitation As a result base deficit should not be considered a reliable surrogate for serum lactate

J Trauma 200457898-912

Base Defecit

BNPHigh concentrations of natriuretic peptides were observed in severe sepsis septic shock and in multiple organ failure probably due to increased secretion by mediators of the inflammatory processThe highest concentrations of ANP and BNP were found in lethal conditions

Therefore the assessment of natriuretic peptide may be used in scoring a patients clinical status for precise diagnosis in doubtful situations and for determining appropriate treatment

=D dimmers are grossly elevated in sepsis = Protein C are lowered = Procalcitonin also considered as bimarker for sepsis The potential role of biomarkers for diagnosis of infection in patients presenting with severe sepsis remains undefined have failed to accurately differentiate sepsis from similar critical illnesses

Am J Med 2003 115529-535

Take home massege

= Cellular response to shock is reflected as clinical manifestation =Lactate is the most important biochemical markers of shock supported by evedience = other markers has aconflicted evdiences that need to be validated

OBJECTIVES To determine and compare the respective concentrations of tumor necrosis factor (TNF)-alpha interleukin (IL)-6 soluble TNF receptors nitritenitrate (NO2-NO3-) and procalcitonin in the plasma of patients with septic shock

CONCLUSIONS These observations showed that increase of proinflammatory cytokines was a consequence of inflammation not of shock In this study comparing various shock and infectious states measurements of NO2-NO3- concentration and procalcitonin concentration represented the most suitable tests for defining patients with septic shock

63

Symptoms of shock

3 Cold and clammy skin As a result of vasoconstrictionbull Shock decreases the skin surface temperature as a result of

vasodilatation which will increase the internal body temperature Because the skin plays a major role in controlling body temperature as it will help in exchanging heat with the external environment

bull There are two mechanisms to get red of the excess heat1 Hyperventilation ( Minimal effect in humans)2 Vasodilatation of the vessels Flush ( Increase blood flow to the skin)

BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock

Changes in afterload amp preload

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Renin ndash Angiotensin-Aldosterone


Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24

Clinical Signs of Septic shock

Slide 26

Pathophysiology of Sepsis induced Ischemic Organ

Slide 28

Pathogenesis of vasodilation in sepsis

Slide 30

Slide 31

The compansatory system


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Hypoperfusion amp Lactate

Slide 40

Slide 41

What Happen to Lactate

Slide 43

Lactate

Slide 45

Slide 46

Slide 47

Hypoglycemia in shock

Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock

Definition of shock in term of cellular function

Path physiology amp clinical finding of different types of shock

Biochemical shock markers Evidence based clinical values


Aerobic Metabolism

6 O2

GLUCOSE

METABOLISM

6 CO2

6 H2O

36 ATP

HEAT (417 kcal)


GLUCOSE METABOLISM

2 LACTIC ACID

2 ATP

HEAT (32 kcal)









AcidosisAcidosis


















fluid volumehellip





fluid volumehellip















[Na+][Na+] [Na+][Na+]





Releases



Converts

ampOr




BPBP BPBP





hormone)hormone)


hormone)hormone)



Releases







OO22

supplysupply

OO22

supplysupply



SVRSVR SVRSVR


edemaedema























Protein cactivation








Infection



Vasodilation



Organ Dysfunction


Ischemia

Cell Death




32



















OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock


Aerobic Metabolism

6 O2

GLUCOSE

METABOLISM

6 CO2

6 H2O

36 ATP

HEAT (417 kcal)


GLUCOSE METABOLISM

2 LACTIC ACID

2 ATP

HEAT (32 kcal)









AcidosisAcidosis


















fluid volumehellip





fluid volumehellip















[Na+][Na+] [Na+][Na+]





Releases



Converts

ampOr




BPBP BPBP





hormone)hormone)


hormone)hormone)



Releases







OO22

supplysupply

OO22

supplysupply



SVRSVR SVRSVR


edemaedema























Protein cactivation








Infection



Vasodilation



Organ Dysfunction


Ischemia

Cell Death




32



















OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock


GLUCOSE METABOLISM

2 LACTIC ACID

2 ATP

HEAT (32 kcal)









AcidosisAcidosis


















fluid volumehellip





fluid volumehellip















[Na+][Na+] [Na+][Na+]





Releases



Converts

ampOr




BPBP BPBP





hormone)hormone)


hormone)hormone)



Releases







OO22

supplysupply

OO22

supplysupply



SVRSVR SVRSVR


edemaedema























Protein cactivation








Infection



Vasodilation



Organ Dysfunction


Ischemia

Cell Death




32



















OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock









AcidosisAcidosis


















fluid volumehellip





fluid volumehellip















[Na+][Na+] [Na+][Na+]





Releases



Converts

ampOr




BPBP BPBP





hormone)hormone)


hormone)hormone)



Releases







OO22

supplysupply

OO22

supplysupply



SVRSVR SVRSVR


edemaedema























Protein cactivation








Infection



Vasodilation



Organ Dysfunction


Ischemia

Cell Death




32



















OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock











fluid volumehellip





fluid volumehellip















[Na+][Na+] [Na+][Na+]





Releases



Converts

ampOr




BPBP BPBP





hormone)hormone)


hormone)hormone)



Releases







OO22

supplysupply

OO22

supplysupply



SVRSVR SVRSVR


edemaedema























Protein cactivation








Infection



Vasodilation



Organ Dysfunction


Ischemia

Cell Death




32



















OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock

fluid volumehellip















[Na+][Na+] [Na+][Na+]





Releases



Converts

ampOr




BPBP BPBP





hormone)hormone)


hormone)hormone)



Releases







OO22

supplysupply

OO22

supplysupply



SVRSVR SVRSVR


edemaedema























Protein cactivation








Infection



Vasodilation



Organ Dysfunction


Ischemia

Cell Death




32



















OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock











[Na+][Na+] [Na+][Na+]





Releases



Converts

ampOr




BPBP BPBP





hormone)hormone)


hormone)hormone)



Releases







OO22

supplysupply

OO22

supplysupply



SVRSVR SVRSVR


edemaedema























Protein cactivation








Infection



Vasodilation



Organ Dysfunction


Ischemia

Cell Death




32



















OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock


BPBP BPBP





hormone)hormone)


hormone)hormone)



Releases







OO22

supplysupply

OO22

supplysupply



SVRSVR SVRSVR


edemaedema























Protein cactivation








Infection



Vasodilation



Organ Dysfunction


Ischemia

Cell Death




32



















OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock




OO22

supplysupply

OO22

supplysupply



SVRSVR SVRSVR


edemaedema























Protein cactivation








Infection



Vasodilation



Organ Dysfunction


Ischemia

Cell Death




32



















OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock
















Protein cactivation








Infection



Vasodilation



Organ Dysfunction


Ischemia

Cell Death




32



















OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock








Infection



Vasodilation



Organ Dysfunction


Ischemia

Cell Death




32



















OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock




32



















OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock














OO22

useuse

OO22

useuse


amp wateramp water


amp wateramp water
















bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock










bullOxidation 80

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock

Lactate











Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock








Emerg Med J 200623622-624

Am J Surg 2006191625-630

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock

Protein C



Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock

Procalcitonin


J Crit Care 2004 19152-157



J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock


J Trauma 200457898-912

Base Defecit




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock




Am J Med 2003 115529-535

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock

Take home massege




63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock



63

Symptoms of shock




BP Real shock

Slide 1

Outline

Definition

Aerobic Metabolism


Responses to shock


Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16



Cardiogenic shock

Neurogenic shock

SEPTIC SHOCK

Slide 22

Slide 23

Slide 24


Slide 26


Slide 28


Slide 30

Slide 31



Slide 34

Slide 35

Slide 36

Slide 37

Slide 38


Slide 40

Slide 41


Slide 43

Lactate

Slide 45

Slide 46

Slide 47


Slide 49

Slide 50

Slide 51

Protein C

Procalcitonin

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Symptoms of shock

shock marker

Education

lactate serum lactate

lactate levels greater

initial serum lactate

baseline levels

lactate pyruvate ratio

increased protein c

cardiovascular system

renal system