Dr Sifri InternSHOCKLecture

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Dr Sifri InternSHOCKLecture Powered By Docstoc
					    Hypotension, Shock, Hemorrhage
      and IV Fluid Resuscitation




                     Ziad Sifri, MD

Surgical Fundamentals and Algorithmic Approach to Patient Care
                 Session#7: August 17, 2007
                       Learning Objectives
1.       Definition, diagnosis and types of shock
2.       Hemorrhagic shock ( I-IV )
3.       Initial management of patients in Hemorrhagic shock
     –      Algorithm for the identifying of the location of bleeding
     –      IV access and resuscitation of Trauma patients
4.       Initial assessment of patients in non-Hemorrhagic shock
5.       Diagnosis of the various types of non-Hemorrhagic shock
6.       Management of non-Hemorrhagic shock
7.       Case Scenarios
The real goal however…….
                is to avoid ….
                      “Shock”

• Definition: Inadequate tissue Perfusion and
  Oxygenation


• Effect: Cellular injury, Organ failure, Death


• Causes: hemorrhagic and non-hemorrhagic
Types of Shock




    ?
    Types of Shock
S   Septic & Spinal

H   Hypovolemic & Hemorrhagic

O   Obstructive

C   Cardiogenic

K   Anaphylactic
          Shock: “Clinical Diagnosis’

•   CNS: Altered MS – 2 extremes (Dr M. presentation)
•   CVS1: Tachycardia, ↑ diastolic BP, ↓ pulse pressure
•   CVS2:↓ MAP, ↓ cardiac output
•   Resp: Tachypnea and ↑O2 requirement (Dr M. presentation)
•   GU: Decrease U/O
•   GI: Ileus?
•   Skin: Progressive vasoconstriction-cool extremities

• History (for clues)
        Shock: “Laboratory Support”

• Metabolic acidosis
   – ABG: Acidosis, BD > -2
   – Chem-7: ↓Bicarb
   – Lactate: >2


• Metabolic acidosis 2nd to
   – Inadequate tissue perfusion
   – Shift to anaerobic metabolism
   – Production of lactic acid
                          Pitfalls
•Extremes of age
   •Infant>160; preschool 140; school age 120; adult 100

•Athletes

•Pregnancy

•Medications
  •Beta blockers, pacemaker

•Hgb/Hct concentration
  •Unreliable for acute blood loss
              Other Pitfalls….
Urine output adequate
despite shock

   •Alcohol
   •Hyperglycemia
   •Home medication: diuretics..
   •Therapeutic intervention: Mannitol
   •IV contrast: CT, Angio
   •Residual urine…
   •DI
   •Etc…
                  General Outline

• Definition, diagnosis and types of shock


• Hemorrhagic shock: Classes and Resuscitation
              Hemorrhage & Trauma
• Normal blood volume
  – Adults: 7% of ideal weight
     • 70 kg man had blood volume of 5 liters
  – Child: 9% of ideal weight

• Hemorrhage
  – Loss of circulating blood volume
  – How much volume loss to cause shock?
  – Classes of hemorrhage I-IV
                      Hemorrhagic Shock: “The Classes”


        “Class I”                 “Class II”                     “Class III”                         “Class IV”


 EBL                      EBL                         EBL                                EBL

 <750cc                   750cc – 1500cc              1.5L – 2L                          >2L
 <15% of TBV              15 – 30% of TBV             30 – 40% of TBV                    >40% of TBV



S&S                       S&S                         S&S
                                                                                         S&S
                                                      HR: increased
                          HR: increased                                                  HR: increased
                                                      BP: decreased
       None/minimal       Pulse Pressure: decreased                                      BP: decreased (<60)
                                                      MS: agitated
                          BP: no change                                                  MS: decreased
                                                      Urine Output: decreased

Tx                        Tx                          Tx                                Tx

                                                      1. Crystalloid (1 – 2L)            1.   Crystalloid (2L)
       Crystalloids               Crystalloids        2. Transfusion (1 – 2units)        2.   Transfusion (2 – 4 units)
                                                      3. Identify source of Bleed(*5)    3.   Identify source of Bleed(*5)
                                                                                         4.   OR
                  General Outline

• Definition, diagnosis and types of shock
• Classes of Hemorrhagic shock


• Initial management of patients in Hemorrhagic shock
   Two Goals in the management of
           “any” Shock



     GOAL #1                 GOAL #2

“ID and Tx the cause”   “Support the patient”
      Two Goals in the management of
           Hemorrhagic Shock
1 - “ID and Tx the cause”   2 - “Support the patient”


   Locate the source of        Establish IV access
        bleeding

        Control it             Fluid Resuscitation
                  Goal #1
“Identification and Treatment of the cause”




       A-Locate the source of bleeding



                B-Control it
                                                  Algorithm to Identify the Bleeding Source
                                                      in a Hypotensive Trauma Patient

                                                                         5 Possible locations
                                                                        for significant bleeding

        1                                            2                                 3                                  4                                5


   Chest cavity                               Abdominal Cavity                  Pelvis/Retroperitoneum              External Bleeding                    Long Bones


                                          Clue:                                Clue:                              Clue:                            Clue:
Clue:
                                                                               -Abdominal/Pelvic trauma             Blood on Floor                1) Deformed extremity
 -Chest trauma                              - Abdominal trauma                                                                                    2) Crush injury
 - Diminished breath sounds                                                    -Flank ecchymosis                    → Check head/scalp
                                            - Distended abdomen                                                                                   3) Mangled extremity
                                                                               -Unstable pelvis                     → Check extremity
 - Desaturation, ↑O2 requirement
                                                                               -Hematuria


 Place chest tube         Chest                                                                                                    Extremity               EBL
                                                          DPL → (+)                First do DPL          Pelvic       Scalp
 On affected side        X-Ray                                                                                                      Bleed          Femur Fx 750cc–1L
                       (+) Ptx-Htx      FAST →           -Gross blood           (supra umbilical)        X-Ray        bleed
                                                                                                                                                    Tib Fx 500-750cc
                                        Free fluid                              r/o intrabdominal        (+) Fx
                                                         - >105 RBCs
                                                                                       bleed
   Chest tube                                                                                                       Whip-stitch       Pressure         Consult Ortho
  ≥ 1L of Blood                                                     DPL (+)            DPL (-)
                                                                                                                        with
                                                                                                                                        and
                                                                                                                    nylon suture
                                                                                                                                      Elevation      Immobilization and
                                                                                                                                                    minimal manipulation
                                                                                1) Wrap sheet around pelvis                        Bleeding not     of injured extremity
OR →Thoracotomy                                                                 2) Pelvic angiography                               controlled        using splint (3Ps)
                                     OR → Exploratory laparotomy

                                                                                    (+) Blush/Extravasation               Tourniquet proximal
                                                                                                                                 to injury                Be alert for
                                                                                                                                                         compartment
                                                                                                                           - set > systolic BP
                                                                                                                                                           syndrome
                                                                                    Angioembolization
                  Algorithm to Identify the Bleeding Source
                      in a Hypotensive Trauma Patient

                                   5 Possible locations
                                  for significant bleeding

     1              2                            3                      4                5


                                                                   External Bleeding
Chest cavity   Abdominal Cavity           Pelvis/Retroperitoneum                       Long Bones
                                                                        “floor”
                                                  Algorithm to Identify the Bleeding Source
                                                      in a Hypotensive Trauma Patient

                                                                         5 Possible locations
                                                                        for significant bleeding

        1                                            2                                 3                                  4                                5


                                                                                                                    External Bleeding
   Chest cavity                               Abdominal Cavity                  Pelvis/Retroperitoneum                                                   Long Bones
                                                                                                                         “floor”


                                          Clue:                                Clue:                              Clue:                            Clue:
Clue:
                                                                               -Abdominal/Pelvic trauma             Blood on Floor                1) Deformed extremity
 -Chest trauma                              - Abdominal trauma                                                                                    2) Crush injury
 - Diminished breath sounds                                                    -Flank ecchymosis                    → Check head/scalp
                                            - Distended abdomen                                                                                   3) Mangled extremity
                                                                               -Unstable pelvis                     → Check extremity
 - Desaturation, ↑O2 requirement
                                                                               -Hematuria


 Place chest tube         Chest                                                                                                    Extremity               EBL
                                                          DPL → (+)                First do DPL          Pelvic       Scalp
 On affected side        X-Ray                                                                                                      Bleed          Femur Fx 750cc–1L
                       (+) Ptx-Htx      FAST →           -Gross blood           (supra umbilical)        X-Ray        bleed
                                                                                                                                                    Tib Fx 500-750cc
                                        Free fluid                              r/o intrabdominal        (+) Fx
                                                         - >105 RBCs
                                                                                       bleed
   Chest tube                                                                                                       Whip-stitch       Pressure         Consult Ortho
  ≥ 1L of Blood                                                     DPL (+)            DPL (-)
                                                                                                                        with
                                                                                                                                        and
                                                                                                                    nylon suture
                                                                                                                                      Elevation      Immobilization and
                                                                                                                                                    minimal manipulation
                                                                                1) Wrap sheet around pelvis                        Bleeding not     of injured extremity
OR →Thoracotomy                                                                 2) Pelvic angiography                               controlled        using splint (3Ps)
                                     OR → Exploratory laparotomy

                                                                                    (+) Blush/Extravasation               Tourniquet proximal
                                                                                                                                 to injury                Be alert for
                                                                                                                                                         compartment
                                                                                                                           - set > systolic BP
                                                                                                                                                           syndrome
                                                                                    Angioembolization
        Goal #2

“Support the patient”


  A-Establish IV access


  B-Fluid Resuscitation
Establish IV access before it is too late
               A - Establish good IV access

Must insure good vascular access:
   •2 large caliber: 14-16-gauge IV
      -Rate of flow is proportional to r4 and is inversely proportional to the length
      -Short large caliber peripheral IVs are the best for resuscitation

   •Central Access: Central line or Cordis
      -Cannot obtain peripheral access
                -IVDA, severe hypovolemia, extremity injury
      -Massive bleeding
      -Preferred Site: Femoral *
                                   (*Unless pelvic or abdominal vascular injury suspected!)
                B - Fluid Resuscitation

Initial fluid bolus
    1-2 liters in adults
    20mL/kg in children


Type of fluid for resuscitation
      -Isotonic electrolyte solution
            Lactated ringers vs. normal saline
        Electrolyte composition of crystalloid solutions

           pH        Na      Cl      Lactate         Ca          K         Osm
Fluid                (mEq/L) (mEq/L) (mEq/l)         (mEq/L)     (mEq/L)   (mOsm/L)


   LR        6.7        130       109         28             3      4        279


   NS        6.0        154       154         0              0      0        308




LR, lactated Ringer’s solution; NS, normal saline solution
               B - Fluid Resuscitation

 Intravascular effect
   3 for 1 rule of Volume replacement: Volume lost
The effect of the 3:1 Rule
     Assess patient’s response to fluid
               resuscitation
• Clinical parameters:
  – MS: return of
  – CVS: HR, MAP
  – Urinary output

• Laboratory parameters:
  – BD, Acid/base balance
  – Lactate
       Assess patient’s response to fluid
                 resuscitation
Three possible responses:

1. Responders
   •    Bleeding has stopped

2. Transient responders
   •    Something is still slowly bleeding!

3. Non responders:
   •    Ongoing significant bleeding!
   •    Immediate need for intervention!
             Avoid the “Lethal Triad”

• Coagulopathy
  –   Consumption of clotting factor
  –   Dilution of platelets and clotting factors: transfusion of PRBCs
  –   MTP (now in place at UMDNJ!)
  –   Factor VIIa

• Hypothermia
  – Perpetuates coagulopathy
  – Most forgotten vital sign in resuscitation (check foley!)

• Acidosis
  – Inadequate resuscitation and tissue perfusion
  – Anaerobic metabolism and of lactic acid production
                            Case #1
38 year old male ped-struck is found unresponsive. He gets intubated
   by EMS. On arrival to the ED his BP is 90/60, HR 130.

Is the patient in Shock? Type of Shock? Class?


He is noted to have decreased BS on the left side and his O2 Sats are
  92% on an FiO2 of 100%.

What’s next?
         Portable CXR




What’s wrong with this x-ray??
                 Case #1

• What’s next?

Chest tube puts out 1 liter of blood.

• What’s next?
Case #1 : CT Chest
                            Case #2
18 year old male involved in a high speed MVC found unresponsive
   with a BP of 60/P at the scene. He has a large head laceration that
   is actively bleeding, an obvious abrasions over the pelvis and
   bilateral mangled lower extremities.

In the ED, he is immediately intubated, he has equal BS, his sats are
   100%. He is actively bleeding from his scalp and legs. His pelvis is
   unstable. BP 70/40 P 150.

Is the patient in Shock?
Type of Shock?
Class?
                       Case #2
Management ?

  – Goal #1
    A- Locate the source of bleeding
    B- Control it

  – Goal #2
    A- Establish IV access
    B- Fluid Resuscitation
WHY IS THE PATIENT HYPOTENSIVE ?




                  ???
        Don’t Get The Floor WET !!!!
  Case #2


SOURCE of
BLEEDING
  ???
Whip Stitch scalp laceration
What is missing ?
Bilateral Tourniquets
                    Case #2
• Still hypotensive despite bilateral tourniquets
  and despite whipstiching the scalp laceration
• He has received: 2 L crystalloids 2 units PRBCs
• CXR: Normal
                  NEXT???

• DPL? FAST?

• Pelvic X-ray?
Portable Pelvic X-Ray




     What’s next?
 Wrapping the pelvis with a sheet

Before                        After




         What’s next??
           Pelvic: Angiogram




Bleeding Controlled by Angio-Embolization
                        General Outline

• Definition, diagnosis and types of shock
• Classes of Hemorrhagic shock
• Initial management of patients in hemorrhagic shock
   – Algorithm for identifying the location of bleeding
   – IV Access and Resuscitation in a Trauma patient

• Initial Management of patients in non-hemorrhagic shock
• Management of non-hemorrhagic shock
• Case Scenarios
                             Hypotension/Shock


        Diagnosis
                              1.    Hypotension (SBP<100)
                              2.    Tachycardia
                              3.    Tachypnea; Sa O2 <90%
                              4.    Oliguria
                              5.    Change in mental status (confusion, agitation)
                              6.    Labs: Acidosis, Basic Deficit, Anion Gap, Lactate



                                                  Yes (patient is in shock)



Quick evaluation of A,B,C   *Notify senior resident on call and place the patient on ECG Monitor and pulse oximeter

                            A. Assess airway:
                                if inadequate
                                     - BVM; call anesthesia to intubate if needed
                            B. Assess breathing:
                               if ↓ breath sounds
                                     - CXR (stable pt)
                                     - Place chest tube (unstable pt)
                            C. Assess circulation:
                               - No pulse → CPR
                               - Check rate rhythm →unstable arrhythmia → ACLS Protocol



                            1.     Make sure patient is on ECG monitor and Pulse Ox.
    First Step in MGT
                            2.     Administer O2
                            3.     Insure adequate IV access
                            4.     Place foley catheter
                            5.     Place CVP line (when indicated)
                            6.     Order EKG
                            7.     Chest X-ray r/o Ptx
                                                                      Shock
                    1                                                          2                                                       3

      Hemodynamic findings                                 Hemodynamic findings                                                Hemodynamic findings
        CVP, PCW: decreased                                      CVP, PCW: decreased                                           CVP, PCW: increased
        CO: decreased                                            CO: increased then decreased                                  CO: decreased
        SVR: increased                                           SVR: decreased                                                SVR: increased


 Hypovolemic                    Hemorrhagic                                                                                      Cardiogenic Shock
    Shock                         Shock
                                                               Spinal Shock                   Septic Shock

Cause
 1. External fluid loss                                   Cause                           Cause                        Obstructive                      Non-obstructive
 2. 3rd Spacing              Cause
                                                               SCI (>T4 level)                    Infection
                                                                                                               DDX
                             1. Trauma (*5)                                                                                                         Cause
                             2. Post-op bleeding                                                               1. Tension PX
                                                                                                                                                         1. AMI
                             3. GI bleeding                                                                    2. Cardiac tamponade
Treatment                                              Treatment                                                                                         2. CHF
                                                                                                               3. PE
 1. Fluid resuscitation                                 Supportive Care
 2. Control/replace                                     →Fluid “to fill the tank”
    fluid losses                                        → Vaso pressors                                       Treatment
                                                           (Phenylephirine, Norepinephrine)                                                Treatment
                                                                                                               1. CT placement
                                                                                                               2. Pericardiocentesis       1. Diuresis
                          Treatment
                                                                                                               3. IV Heparin                  - Lasix
                          1. Fluid resuscitation        Treatment                                                                          2. Afterload reduction
                          2. Find source of                                                                                                  - Nitroprusside, Nitroglycerine
                                                          1.   Identify & drain source of infection
                             bleeding and control it                                                                                         - ACE inhibitor
                                                          2.   Start appropriate Abx
                          3. Correct coagulopathy                                                                                          3. Inotropic support
                                                          3.   Supportive care
                                                           -   Fluid resuscitation                                                            - Dobutamine, Milrinone
                                                           -   Vaso pressors
                                                               (Phenylephirine, Norepinephrine)
                       “Hypovolemic Shock”
Most common cause of shock in surgical patients
Excessive fluid losses (internal or external)
   Internal: Pancreatitis, bowel ischemia, bowel edema, ascites..
   External: Burns, E-C Fistula, Large open wounds…


2 main goals
   1- ID and Tx the cause
        Tx: Control fluid losses: surgical, wound coverage…
   2- Support the Patient
                “Hypovolemic Shock”
 Hemodynamics:
         *Low to normal PCW (due to fluid losses)
         Normal or Decreased CO
         High SVR (compensation)
 Management:
         Fluids
        No pressors
                                             *primary process
                             “Septic Shock”
Second most common cause of shock in surgical patients
“Vasoregulatory substances” released produce a decrease in systemic
vascular resistance, manifested by warm pink skin with peripheral
vasodilatation

Two main goals
   1 - ID and Tx the cause
       Tx: Source Control (surgical, IR) + start antibiotics early
   2 - Support the Patient
                   “Septic Shock”
Hemodynamics:
       Low to normal PCW (vasodilatation and fluid losses)
       Normal or increased CO (late; decrease CO)
       *Low SVR
Management:
        Fluids
       Pressors
                                             *primary process
                     “Cardiogenic Shock”
• Forward blood flow is inadequate secondary to pump failure
• Most common cause is acute myocardial infarction (AMI)
• Other causes include:
   •Myocardial contusion, Aortic insufficiency, End-stage cardiomyopathy


Two main goals:
       1- ID and Tx the cause: Cardiac Cath…
             Tx: Heparin..
       2 - Support the Patient
                  “Cardiogenic Shock”
Hemodynamics:
      Elevated filling pressures
     *Diminished cardiac output due to pump failure
      Increased SVR (compensation)
 Management
     Diuresis
     Afterload reduction
     Inotropes
                                               *primary process
     “Obstructive Cardiogenic Shock”
 No intrinsic cardiac pathology (Non - MI)
 Pump failure due to inflow or outflow obstruction
 Cause :
    Tension Pneumothorax
    PE
    Cardiac Temponade
    Air embolus (rare)
Dx and Management specific to each process
                          “Neurogenic Shock”
Spinal cord injuries produce hypotension due to a loss of
sympathetic tone
Seen in one third of patients with SCI, usually seen in patients with
an injury above T4 level
Hypotension without tachycardia or cutaneous vasoconstriction


Two main goals:
     1- ID cause, no specific Tx
     2 - Support the Patient

 Pearl: Must rule out other causes of shock in trauma patients with a spinal cord injury
            “Neurogenic Shock”
Hemodynamics:
      Normal to low PCW – due to peripheral venous pooling
      Normal to low CO- cannot compensate
      *Decreased SVR – due to loss of vasomotor tone
Management:
      R/o Bleeding
      Fluid and pressors
                                               *primary process
                                                                      Shock
                    1                                                          2                                                       3

      Hemodynamic findings                                 Hemodynamic findings                                                Hemodynamic findings
        CVP, PCW: decreased                                      CVP, PCW: decreased                                           CVP, PCW: increased
        CO: decreased                                            CO: increased then decreased                                  CO: decreased
        SVR: increased                                           SVR: decreased                                                SVR: increased


 Hypovolemic                    Hemorrhagic                                                                                      Cardiogenic Shock
    Shock                         Shock
                                                               Spinal Shock                   Septic Shock

Cause
 1. External fluid loss                                   Cause                           Cause                        Obstructive                      Non-obstructive
 2. 3rd Spacing              Cause
                                                               SCI (>T4 level)                    Infection
                                                                                                               DDX
                             1. Trauma (*5)                                                                                                         Cause
                             2. Post-op bleeding                                                               1. Tension PX
                                                                                                                                                         1. AMI
                             3. GI bleeding                                                                    2. Cardiac tamponade
Treatment                                              Treatment                                                                                         2. CHF
                                                                                                               3. PE
 1. Fluid resuscitation                                 Supportive Care
 2. Control/replace                                     →Fluid “to fill the tank”
    fluid losses                                        → Vaso pressors                                       Treatment
                                                           (Phenylephirine, Norepinephrine)                                                Treatment
                                                                                                               1. CT placement
                                                                                                               2. Pericardiocentesis       1. Diuresis
                          Treatment
                                                                                                               3. IV Heparin                  - Lasix
                          1. Fluid resuscitation        Treatment                                                                          2. Afterload reduction
                          2. Find source of                                                                                                  - Nitroprusside, Nitroglycerine
                                                          1.   Identify & drain source of infection
                             bleeding and control it                                                                                         - ACE inhibitor
                                                          2.   Start appropriate Abx
                          3. Correct coagulopathy                                                                                          3. Inotropic support
                                                          3.   Supportive care
                                                           -   Fluid resuscitation                                                            - Dobutamine, Milrinone
                                                           -   Vaso pressors
                                                               (Phenylephirine, Norepinephrine)
                          CASE # 3
• A 50 year old woman with unresectable pancreatic CA
  with a T-Bili of 20 returns from IR after upsizing of her
  PTC drains. She is confused, febrile, hypotension and
  has decreased urine output. She is intubated and
  transferred to the SICU.

• What is your Dx? Shock? Type?
• What is your management?
   1. Goal #1 – Source control, antibiotics
   2. Goal #2 – Hemodynamic Support
      Swan #: CVP = 5 PCW = 8 C0= 10 SVR = 300
                            CASE # 4
• A 88 y/o F s/p AAA repair, post-op day 1 in the ICU, she is
  intubated. The nurse reports that she is hypotensive, BP 80/40,
  pulse 120 and her urine output is equal to less than 10 cc/H for the
  past 2 hours. She remains hypotensive despite 2 liters of fluid,
  labs; hemoglobin is 10, Hgb 10, Cr 1.0 and lactate 4, BD -5. CVP
  is 15.

• What is your Dx? Shock? Type?
• What is your management?
   1. Goal #1 – r/o MI & start appropriate treatment for MI
   2. Goal #2 – Hemodynamic Support
       Swan #: CVP = 15 PCW = 18 C0= 3 SVR = 1300
                                 Conclusion:

1.       How to recognize and diagnose shock
2.       Types of shock (SHOCK): hemorrhagic & non-hemorrhagic
3.       Hemorrhagic Shock:
     •     Classes of hemorrhagic shock
     •     Algorithm to find the location of bleeding and control it
4.       Non-hemorrhagic shocks
     •     the 2 key Goals in the management of any shock
     •     Hemodynamic findings and support
THANK YOU



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THANK YOU

   &

GOOD LUCK

				
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