LEARNING OBJECTIVES:

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.

COMMUNICATION SKILLS:

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

MANAGEMENT:

• http://www.stritch.luc.edu/lumen/MedEd/MEDICINE/subint/index.htm Undertake the initial resuscitation of the patient in shock.

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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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REFERENCES:

1. Connors AF, Speroff T, Dawson NV, 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
   
   
2. 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.  Management based on catheter-derived data was at the discretion of the attending physician rather than by protocol.  In the control arm, 78% of patients underwent echocardiography.  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

1. Rivers E, et al. Early Goal Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. NEJM 2001;345(19):1368-77.
2. 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.
3. Keh D, et al. Immunologic and Hemodynamic Effects of “Low-Dose” Hydrocortisone in Septic Shock. AJRCCM 2003;167:512-520.
4. Landry DW and Oliver JA. Mechanisms of Disease: The Pathogenesis of Vasodilatory Shock [Review Article]. NEJM 2001(8);345:588-95.

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