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) CVS 1 : Tachycardia, diastolic BP, pulse pressure CVS 2: MAP, cardiac output Resp: Tachypnea and O 2 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 2 nd 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 <750cc <15% of TBV None/minimal Crystalloids 750cc 1500cc 15 30% of TBV HR: increased Pulse Pressure: decreased BP: no change Crystalloids 1.5L 2L 30 40% of TBV HR: increased BP: decreased MS: agitated Urine Output: decreased 1. Crystalloid (1 2L) 2. Transfusion (1 2units) 3. Identify source of Bleed(*5) >2L >40% of TBV HR: increased BP: decreased (<60) MS: decreased 1. Crystalloid (2L) 2. Transfusion (2 4 units) 3. Identify source of Bleed(*5) 4. OR Tx Tx Tx Tx S&S S&S S&S S&S EBL EBL EBL EBL 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 #2
Support the patient GOAL #1
ID and Tx the cause Two Goals in the management of Hemorrhagic Shock
2 - Support the patient Establish IV access Fluid Resuscitation 1 - ID and Tx the cause Locate the source of bleeding Control it 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 Whip-stitch with nylon suture Extremity Bleed Scalp bleed Blood on Floor Check head/scalp Check extremity Long Bones OR Exploratory laparotomy DPL (+) -Gross blood - >10 5 RBCs FAST Free fluid - Abdominal trauma - Distended abdomen Abdominal Cavity OR Thoracotomy Chest tube 1L of Blood Place chest tube On affected side -Chest trauma - Diminished breath sounds - Desaturation, O 2 requirement Chest cavity Pelvis/Retroperitoneum External Bleeding -Abdominal/Pelvic trauma -Flank ecchymosis -Unstable pelvis -Hematuria First do DPL (supra umbilical) r/o intrabdominal bleed 1) Wrap sheet around pelvis 2) Pelvic angiography (+) Blush/Extravasation 1) Deformed extremity 2) Crush injury 3) Mangled extremity
EBL Femur Fx 750cc1L Tib Fx 500-750cc Immobilization and minimal manipulation of injured extremity using splint (3Ps) Tourniquet proximal to injury - set > systolic BP Pressure and Elevation 5 Possible locations for significant bleeding Clue: Clue: Clue: Clue: Clue: DPL (-) DPL (+) Angioembolization Bleeding not controlled Be alert for compartment syndrome Consult Ortho 1 2 3 4 5 Chest X-Ray (+) Ptx-Htx Pelvic X-Ray (+) Fx Algorithm to Identify the Bleeding Source in a Hypotensive Trauma Patient Long Bones Abdominal Cavity Chest cavity Pelvis/Retroperitoneum
External Bleeding floor
5 Possible locations for significant bleeding 1 2 3 4 5 Algorithm to Identify the Bleeding Source in a Hypotensive Trauma Patient Whip-stitch with nylon suture Extremity Bleed Scalp bleed Blood on Floor Check head/scalp Check extremity Long Bones OR Exploratory laparotomy DPL (+) -Gross blood - >10 5 RBCs FAST Free fluid - Abdominal trauma - Distended abdomen Abdominal Cavity OR Thoracotomy Chest tube 1L of Blood Place chest tube On affected side -Chest trauma - Diminished breath sounds - Desaturation, O 2 requirement Chest cavity Pelvis/Retroperitoneum External Bleeding floor -Abdominal/Pelvic trauma -Flank ecchymosis -Unstable pelvis -Hematuria First do DPL (supra umbilical) r/o intrabdominal bleed 1) Wrap sheet around pelvis 2) Pelvic angiography (+) Blush/Extravasation 1) Deformed extremity 2) Crush injury 3) Mangled extremity
EBL Femur Fx 750cc1L Tib Fx 500-750cc Immobilization and minimal manipulation of injured extremity using splint (3Ps) Tourniquet proximal to injury - set > systolic BP Pressure and Elevation 5 Possible locations for significant bleeding Clue: Clue: Clue: Clue: Clue: DPL (-) DPL (+) Angioembolization Bleeding not controlled Be alert for compartment syndrome Consult Ortho 1 2 3 4 5 Chest X-Ray (+) Ptx-Htx Pelvic X-Ray (+) Fx 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 r 4 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
Fluid pH Na (mEq/L) Cl (mEq/L) Lactate (mEq/l) Ca (mEq/L) K (mEq/L) Osm (mOsm/L) LR
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 O 2
Sats are 92% on an FiO2 of 100%.
Whats next?
Portable CXR Whats wrong with this x-ray?? Case #1 Whats next?
Chest tube puts out 1 liter of blood.
Whats 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 I S THE PATI ENT HYPOTENSI VE ? Dont Get The Floor WET !!!! SOURCE of BLEEDING ? ? ? Case #2 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 Whats next? Before Whats next?? After Wrapping the pelvis with a sheet
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 O 2 <90% 4. Oliguria 5. Change in mental status (confusion, agitation) 6. Labs: Acidosis, Basic Deficit, Anion Gap, Lactate 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 First Step in MGT 1. Make sure patient is on ECG monitor and Pulse Ox. 2. Administer O 2 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 Yes (patient is in shock) Shock Hypovolemic Shock Spinal Shock Cardiogenic Shock 1. External fluid loss 2. 3 rd Spacing CVP, PCW: decreased CO: decreased SVR: increased 1. Fluid resuscitation 2. Control/replace fluid losses
Infection
Obstructive CVP, PCW: decreased CO: increased then decreased SVR: decreased 1. Tension PX 2. Cardiac tamponade 3. PE Non-obstructive CVP, PCW: increased CO: decreased SVR: increased 1. Identify & drain source of infection 2. Start appropriate Abx 3. Supportive care - Fluid resuscitation - Vaso pressors (Phenylephirine, Norepinephrine) Cause Cause Hemodynamic findings Hemodynamic findings Hemodynamic findings Treatment Treatment 1 2 3 1. CT placement 2. Pericardiocentesis 3. IV Heparin 1. Diuresis - Lasix 2. Afterload reduction - Nitroprusside, Nitroglycerine - ACE inhibitor 3. Inotropic support - Dobutamine, Milrinone Treatment Treatment DDX 1. AMI 2. CHF Cause SCI (>T4 level) Cause Supportive Care Fluid to fill the tank Vaso pressors (Phenylephirine, Norepinephrine) Treatment Hemorrhagic Shock Septic Shock 1. Trauma (*5) 2. Post-op bleeding 3. GI bleeding Cause 1. Fluid resuscitation 2. Find source of bleeding and control it 3. Correct coagulopathy
Treatment 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
Obstructive CVP, PCW: decreased CO: increased then decreased SVR: decreased 1. Tension PX 2. Cardiac tamponade 3. PE Non-obstructive CVP, PCW: increased CO: decreased SVR: increased 1. Identify & drain source of infection 2. Start appropriate Abx 3. Supportive care - Fluid resuscitation - Vaso pressors (Phenylephirine, Norepinephrine) Cause Cause Hemodynamic findings Hemodynamic findings Hemodynamic findings Treatment Treatment 1 2 3 1. CT placement 2. Pericardiocentesis 3. IV Heparin 1. Diuresis - Lasix 2. Afterload reduction - Nitroprusside, Nitroglycerine - ACE inhibitor 3. Inotropic support - Dobutamine, Milrinone Treatment Treatment DDX 1. AMI 2. CHF Cause SCI (>T4 level) Cause Supportive Care Fluid to fill the tank Vaso pressors (Phenylephirine, Norepinephrine) Treatment Hemorrhagic Shock Septic Shock 1. Trauma (*5) 2. Post-op bleeding 3. GI bleeding Cause 1. Fluid resuscitation 2. Find source of bleeding and control it 3. Correct coagulopathy
Treatment 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