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RESUSCITATION
Hugh M. Foy, MD
Harborview Medical Center
University of Washington
Objectives:
SHOCK: Definition
Commonly misused
psychogenic
Webster: 12 different definitions
Types of Shock
Classic
Blalock 1937
Hematogenic
Neurogenic
Vasogenic
Cardiogenic
Classification of Shock
Carrico:ACSEarlyCareoftheInjuredPatient4thEd.
Heart (pump)
Blood Vessels
Blood
Circulation and
Electricity
Circulation
Electricity
Ohms law: V= IR
(Voltage = Current x
Resistance)
BP = CO x SVR
Circulation Schematic
The Pump (heart)
2 sided
Anatomically looks
parallel, BUT:
Physiologically and
in Actuality
Supplies 2
systems
connected in
series
The Heart:
2-Sided Pump
Right Side
Compliant, flexible
Low pressure,
variable volume
Left Side
Stiff, strong
High pressure,
fixed volume
Like the colon?
Prioritized supply
Circulatory Control
Mechanisms
Closest, fastest
Mid-level
Kidneys- Juxtaglomerular
Apparatus
Down-line
Adrenal Cortex
SHOCK
HR BP
Postural
Cap Ref
I
0-15%
nl nl
maybe
nl
II 15-30% + maybe
yes
nl
III 30-40% +++
decr
moot incr
IV
>40% ++++ <60Sys
incr
Results
Na+ leaked into cells
K+ leaked out of
cells
Albumin leaked into
interstitial space
Water followed Na+
Translocated fluid 3
times the shed blood
Measured
composition of
transloc. fluid
Conclusions
Translocated Fluid composition is LR
Inadequate O2 delivery shuts down Na+/K+
pumps, making cells leaky
Repeated the Experiment:
Treatment of Shock
Recognize Type of
Shock
Treatment of Shock
Goal: Restore
perfusion
Method: Depends on
type of Shock
Basically 2 kinds:
Hypovolemic
(hemorrhagic, septic,
neurogen.)
Cardiogenic
(Impedence or primary
Cardiac Failure)
Treatment:
Cardiogenic Shock
Oxygen by nasal cannula
IV access
Pain medication
Nitrates prn-
Treat arrythmias
CPR as needed
Treatment of Shock
Prioritized approach
Must address and treat sequentially:
PRELOAD
AFTERLOAD
PUMP
QUESTIONs:
Resuscitation Fluids
Blood
Lactated Ringers
Normal Saline
Colloids
Hypertonic Saline
Blood Substitutes
Treatment: Hemorrhagic
Shock
Large bore access
Bolus therapy
20 cc/kg
Adults- 2 liters
Monitor Effect
Repeat if necessary
After 2nd bolus: need
blood txn
10cc/kg
Evolution in Treatment
Strategies
Auto transfusion (Cell Saver)
Hyperdynamic Supranormal
Resuscitation (Shoemaker)
Less is More - Mattox
Trauma Vaccine - Vedder, et al.
Hypertonic Saline
Glue Grant-
Alternatives to Transfusion:
Autotransfusion
Hyperdynamic
Supranormal Resuscitation
Swan Ganz Catheter
Measure ratio of O2 delivery
and consumption
Push fluid resuscitation until
no longer flow dependent
Massive Edema can be lethal
(DaNang Lung, ARDS, MSOF, SIRS,
Abdominal Comp. Syn.
Multiplesynergisticfactors:someinfluencedbyventilatorstrategy
Mattox in Houston
Q: Is less fluid better?
Randomized pts. QOD
Well see
Harborview Study
Double blind, randomized study
N = 209
Endpoint: ARDS free survival
Findings:
Shock-Treatment Algorithm
Cohn SM, Nathens AB, Moore FA, Rhee P, Puyana JC, Moore EE, Beilman GJ.
Blood Transfusion
Blood Banks safer
Some risk
unavoidable
New viruses are
inevitable
False negative
screening tests
Independent risk
factor for MSOD
Time for cross-match
delays Rx
The Search for
Alternatives continues
Alternatives to Transfusion:
Blood Substitutes:
50 gm in 500 ml
No adverse effects up to 6 units
Slight increase in Bilirubin
Studies small, more needed
SUMMARY