LEARNING OBJECTIVES:

KNOWLEDGE: Students should be able to describe:

• the four major categories of shock, their pathophysiology, and their most common underlying etiologies
• the physical exam findings which differentiate the different causes of shock
• the basic premises underlying the use of pulmonary artery catheters in the assessment and management of patients with shock
• the hemodynamic profiles of the different types of shock
• the basics of treatment of shock

SKILLS: Students should be able to:

HISTORY AND PHYSICAL EXAM:

• Obtain a pertinent history and focused physical exam on a patient in shock and be able to formulate an appropriate differential diagnosis as to the underlying etiology.

COMMUNICATION SKILLS:

• Succinctly present data relevant to the evaluation of the patient in shock to members of the health care team.

MANAGEMENT:

• Undertake the initial resuscitation of the patient in shock.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able to:

• Appreciate the gravity of shock and the urgency at which resuscitative efforts must be undertaken to minimize complications.

Prior to orientation day, please review the following chapters of the online video regarding Swan Ganz catheters: http://www.nejm.org/doi/full/10.1056/NEJMvcm1212416 :

• Chapters 2 and 3: Indications and contraindications (1 min, 50 sec)
• Chapter 6: Procedure (4 minutes)
• Chapter 9: Interpretation (2 min, 36 sec)

REFERENCES:

Shock review:

1. N Engl J Med 2013; 369:1726-1734

PA catheters:

1. Trends in the Use of the Pulmonary Artery Catheter in the United States, 1993-2004. JAMA. 2007;298(4):423-429
2. Impact of the Pulmonary Artery Catheter in Critically Ill Patients. JAMA. 2005;294(13):1664-1670

Specific Strategies for Resuscitating Patients in Shock
EGDT or Not?

1. Rivers E, et al.  NEJM 2001;345(19):1368-77.
2. ProCESS Trial: NEJM 2014 (1); 1683-93.
3. ARSE trial: NEJM 2014; 371:1496-1506
4. PROMISE trial.  NEJM 2015; 372:1301-1311

Steroids for Severe Sepsis:

1. Annane D, et al.  The Effect of Treatment with Low Doses of Hydrocortisone and Fludrocortisone on Mortality in Patients with Septic Shock.  JAMA 2002;288(7):862-71.
2. Corticus study.  NEJM 2008; 358:111-124

Vasopressin for Severe Sepsis:

1. VASST trial.  N Engl J Med 2008; 358:877-887

Saline is as good as albumin:

1. SAFE trial.  NEJM 2004:350;2247-56.
2. ALBIOS trial.  NEJM 2014: 370(15); 1412-21.

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