Shock is the next-door neighbor of death. Shock can present in a myriad of different forms, making early recognition challenging. However, early diagnosis is essential. Shock can be caused by a broad differential of serious illnesses. Unlike most differential diagnosis lists, every item on this differential is life-threatening. Fortunately, many causes of shock are reversible if identified early. Therefore, as soon as shock is identified the cause must be sorted out and treated as rapidly as possible.
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The IBCC chapter is located here.
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Josh Farkas
Josh is the creator of PulmCrit.org. He is an assistant professor of Pulmonary and Critical Care Medicine at the University of Vermont (Burlington Vermont, USA).
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As always great post, filled with multiple pearls to care for shocky patients. I wrote a cardiogenic shock protocol for the hospital I work at now, we still trying to implement one. However I’ll be more than happy to share it with you. Thanks again for all of the hard work.
I would think the central venous saturation is occasionally helpful. E.g. I see little point in giving fluid to a patient with an ScvO2 of 90 %, even if they are volume responsive. Little point in raising cardiac output in that case.
svcO2 is theoretically useful but I don’t think it adds anything to the ghestalt evaluation of a competent physician (esp with echo). don’t forget that no matter how helpful something is, it can also provide incorrect information. more info isn’t necessarily better info.
https://emcrit.org/pulmcrit/central-venous-saturation/
The patient with an ScvO2 of 90% (severe cellular dysoxia) may still need fluids (or perhaps some other intervention to increase cardiac output in case they have occult hypoperfusion. Worth to look at venoarterial pCO2 gap in these cases.
What POCUS view is best for acute mitral or aortic valve regurgitation? Any view you can get (subxiphoid, parasternal long)? Or do you have a preference for these particular pathologies?
Parasternal long is generally a good view to screen for severe regurgitation in the aortic and mitral valves because it’s an easy view to get in most patients and you can quickly scan through both valves in a few seconds.
Apical views (e.g. apical 4- or 5-chamber) are excellent for valves but can be harder to get in all critically ill patients esp obese patients on ventilation.
Subcostal 4- or 5- chamber can be fine for aortic and mitral valves, maybe a bit harder to get the angles right but it could get the job done. In patients who *only* have good subcostal views you could also use a subcostal short axis to pan through the mitral and aortic valves in short axis and see if there is anything terrible going on.
Essentially use whatever views you can get 🙂
Very helpful, Thanks!
Great write up in shock. It was interesting to see about changing views of lactate. It is true that many times at the bedside we see shock, metabolic acidosis but almost normal lactates. Any thoughts on why would metabolic acidosis be present in septic shock with normal lactates