All Things Shock with Dr. Matt Siuba

Simran: Question 1- Before we talk about evaluating shock, I think it is important to define what we mean by shock. What is the definition you use Matt?

Matt:

Simran: Question 2: Lets start off with a case. A 70yo female is admitted to the RNF for AMS with a PMHx notable for HFrEF (EF 30%), DVT on rivaroxaban, ESRD on IHD via TDC. Admission labs show a leukocytosis of 13,000. You get called to transfer this patient to the ICU for an elevated lactate of 3.5. Off the bat, what are you thinking and what additional information would you like?

Matt:

Simran: So a little bit more information, Vitals: 100/45 (MAP ~65), HR 105, SpO2 94% on 3L NC, RR 26. Cool to touch, capillary refill time is 6-7 seconds. A&Ox1 from a baseline of A&Ox3, moaning. The superstar resident sent a VBG from the TDC and it had a central venous oxygen saturation of 72. How does this change what you are thinking?

Matt:

Simran: Limitations of central venous O2 and compare to mixed venous O2

Matt:

Simran: Do you think she needs to come to the ICU even though she is normotensive?

Matt:

Arjun: So to put together a schema for undifferentiated shock for learners, could you walk us through how you would approach a patient in shock?

Matt:

Simran: How would you tie in a POCUS in this case?

Matt:

Arjun: is there any good data to back up the use of POCUS in shock?

Matt:

Simran:

Coming back to our case. I will briefly summarize again. We have a 70year old female admitted for AMS with a PMHx of HFrEF, ESRD via TDC, and a DVT who is in shock. Our exam shows us cool extremities, with CRT 6-7seconds, ScvO2 72.

On further assessment: the CVP transduced from the TDC is 3; on POCUS the IVC is small and collapsible, LVOT VTI 20, no pericardial effusion, moderately reduced LV function, normal RV function, there are no pathological B lines on lung ultrasound.

So taking your systematic approach as outline above:

The tone of our patient is mixed given cool to touch and low diastolic, our filling is low as evidence by a CVP of 2 transduced off the TDC, our flow appears to be elevated given normal ScvO2 and LVOT VTI. From all of this it appears that the predominant etiology of the shock is vasoplegic, likely septic, however there are some mixed signs with the tone. What do you think of this?

Matt:

Simran: If she were to become hypotensive, do you think epinephrine would be a better choice than norepinephrine?

Matt:

Simran: Key takeaways for learners?

Matt: