Shock | PulmPEEPs

We’re very excited for the second episode in our Pulm PEEPs Fellows’ Case Files series! For a reminder, the purpose of this series is to highlight and amplify the incredible clinical work that is done by pulmonary and critical care fellows, share fascinating cases, and assemble a diverse network of pulmonary and critical care educators. This week, we’re visiting the Pacific Northwest and headed to the University of Washington to meet two passionate educators, and hear about an incredible teaching case.

Meet Our Guests

Robin Stiller is a third-year pulmonary and critical care fellow at the University of Washington. Robin completed internal medicine residency training at the University of Washington and her clinical and research interests include procedural education and curriculum development.

Başak Çoruh Associate Professor of Medicine at the University of Washington School of Medicine and is the Program Director for the Pulmonary and Critical Care Fellowship. She completed her fellowship and the Teaching Scholars Program at UW. Başak has received numerous teaching and mentoring awards throughout her career and has leadership roles with ATS, CHEST as well as the APCCMPD.

Patient Presentation

A 56-year-old woman with a history of alcohol use and depression presents after being found down at home by her boyfriend with an unknown downtime. She was found to be unresponsive and in the supine position. Her physical exam did not show any obvious trauma but the paramedics did note vomitus on her face. She received 1 L of crystalloids in the field and was intubated and brought to the ED for further management. A bag of pill bottles was found and brought with her. Her home medications include amlodipine, baclofen, buspirone, and hydroxyzine.

Key Learning Points

**Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at the infographic below

References and Further Reading

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This week the Pulm PEEPs, David Furfaro and Kristina Montemayor, are joined by three outstanding critical care doctors and medical educators to discuss the evaluation of patients with undifferentiated shock. We cover everything from the basics about defining shock, to advanced POCUS techniques to clarify the etiology of shock. Listen today and let us know your favorite technique for evaluating shock in the ICU.

Meet Our Guests

Molly Hayes is an Assistant Professor of Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, the Director of the MICU at BIDMC, and the Director of External Education at the Carl J Shapiro Institute for Education and Research. She is also a course director for a yearly CME course on principles of critical care medicine run by BIDMC and HMS.

Nick Mark is a Pulmonologist and Intensivist at Swedish Medical Center in Seattle, Washington. He is also the founder of ICU One Pager, which produces high yield critical care education one-page guides that have been downloaded by thousands of learners.

Matt Siuba is an Assistant Professor of Medicine and intensivist at the Cleveland Clinic, where he is the associate program director for the Critical Care Medicine fellowship. He founded and runs the website Zentensivist.com, has his own associated podcast, and is a senior editor at CriticalCareNow.com.

Key Learning Points

Key graphics

Definition of shock

– Shock is defined as inadequate oxygen delivery to meet the body’s needs. Decreased perfusion and oxygen delivery leads to cell injury and death

– If you define just as hypotension, you will miss people who have cryptic shock, and categorize some people with shock who don’t have it

– Cryptic shock = a patient with normal blood pressure (MAP > 65), but who still has shock based on inadequate O₂ delivery

– O₂ delivery is broken down in to cardiac output and arterial oxygen content

Causes of shock

Shock can be divided into three large categories:

1) A pump problem – low cardiac output. This includes cardiogenic and obstructive shock. Make sure to remember to look for tamponade and valvulopathies.

2) A pipe problem – low systemic vascular resistance. This includes distributive shock. Distributive shock is most often due to sepsis but can be due to anaphylaxis, endocrinopathies, cirrhosis, or spinal shock.

3) A tank problem – low preload. This includes hypovolemic and hemorrhagic shock. Make sure to remember about high intrathoracic pressure, which can decrease effective preload.

Examining a patient with undifferentiated shock

– See if the patient is on the “Shock BUS” by examining their brain (mental status), urine output, and skin

– Feel if their skin is warm vs cold and if it is mottled

– Feel the patient’s pulses to see if they are bounding, normal, or thready

Point of Care Ultrasound

– “Ultrasound is the new stethoscope”

– The first step is to always look at the heart and look for chamber size and function. You can then look for pericardial effusion

– Point of care ultrasound then includes looking at the lungs for signs of fluid overload, consolidation, or pneumothorax

– A complete ultrasound also involves looking at the abdomen and at the extremities for DVT

– More specific ultrasound techniques include looking at:

1) IVC exam to estimate right atrial pressure. This test is often misused. It is most helpful in states when the patient has low stroke volume and trying to figure out if they have cardiac limitation to stroke volume vs if they are hypovolemic.

2) Velocity time index as a measure of cardiac output to trend with interventions

References and links for further reading

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Tag Archives: Shock

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