KNOWLEDGE: Students should be able to describe:
- the three major categories of shock, their pathophysiology, and their most common underlying etiologies;
- the physical exam findings which differentiate septic shock from hypovolemic and/or cardiogenic shock;
- the basic premises underlying the use of pulmonary artery catheters in the assessment and management of patients with shock focusing on indications, complications, and limitations.
- the hemodynamic profiles of septic, hypovolemic, and cardiogenic shock;
- the basics of treatment of shock with emphasis on the unique approaches to septic shock, hypoveolumic shock, and cardiogenic shock.
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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.
- Succinctly present data relevant to the evaluation of the patient in shock to members of the health care team.
- 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 necessary tempo at which resuscitative efforts must be undertaken to minimize complications.
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- Connors AF et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 1996;276:889-897. This famous prospective cohort study found worse outcome with use of PACs in the critically ill, instantly becoming a source of enormous controversy. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8782638
- Richard C, Warszawski J, Anguel N, et al. Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2003;290:2713-20. This multicenter study of 676 patients with common indications for PA catheter placement in the MICU found neither harm nor benefit with catheter placement. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14645314&query_hl=1&itool=pubmed_docsum
Specific Strategies for Resuscitating Patients in Shock EGDT or Not
- Rivers E, et al. Early Goal Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. NEJM 2001;345(19):1368-77.
- The ProCESS Trial: NEJM 2014 (1); 1683-93.
Steroids for Severe Sepsis
- 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.
- Keh D, et al. Immunologic and Hemodynamic Effects of “Low-Dose” Hydrocortisone in Septic Shock. AJRCCM 2003;167:512-520.
Vasopressin for Severe Sepsis
- Landry DW and Oliver JA. Mechanisms of Disease: The Pathogenesis of Vasodilatory Shock [Review Article].NEJM 2001(8);345:588-95
- Landry et al. Circulation 1997;95:1122.
Saline is as good as albumin
- NEJM 2004:350;2247-56.
- NEJM 2014: 370(15); 1412-21.
- JAMA 2010
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