SHOCK & FLUID

THERAPY
Muhammad Yusuf Muharam,
Emergency Physician
Emergency & Trauma Department,

Hospital Queen Elizabeth
Kota Kinabalu, Sabah
24th September 2014

OUTLINE

Introduction

Definition of shock

Classification of shock

Management of shock

Summary

INTRODUCTION

In reality, there are a few concepts that are actually
bad.
1. We don‟t understand shock at all

2. Our timeframe is bad
- what happens in the early hours that makes a
difference?
3. Our tools we use to measure shock are bad
– lactate?

4. The patients are bad – comorbids
5. The environment is bad. – time & pressure

DEFINITION OF SHOCK

• Inadequate oxygen delivery to meet
metabolic demands
• Results in global tissue hypoperfusion and
metabolic acidosis

UNDERSTANDING SHOCK
• Cellular responses to decreased systemic
oxygen delivery
• ATP depletion → ion pump dysfunction
• Cellular edema
• Hydrolysis of cellular membranes and
cellular death
• Leads to systemic metabolic lactic acidosis
that overcomes the body‟s compensatory
mechanisms

GLOBAL TISSUE HYPOXIA • Endothelial inflammation and disruption • Inability of O2 delivery to meet demand • Result: • Lactic acidosis • CV insufficiency • Increased metabolic demands .

CLASSIFICATION OF SHOCK • Distributive • Anaphylactic • Neurogenic • Septic • Obstructive • Hypovolemic • Cardiogenic .

Anaphylactic shock . and a sensation of her “throat closing off”. diaphoretic. She is currently hypotensive.WHAT TYPE OF SHOCK IS THIS? • A 34 yo F presents to the ED after dining at a restaurant where shortly after eating the first few bites of her meal. began wheezing. nausea. tachycardic and ill appearing. became anxious. noted diffuse pruritic rash.

do not require a sensitizing exposure • Not IgE mediated .ANAPHYLACTIC SHOCK • Anaphylaxis – a severe systemic hypersensitivity reaction characterized by multisystem involvement • IgE mediated • Anaphylactoid reaction – clinically indistinguishable from anaphylaxis.

anxiety. respiratory and circulatory collapse – SHOCK!!! distress . shortness of breath and lightheadedness •Finally. flushing.ANAPHYLACTIC SHOCK • What are some symptoms of anaphylaxis? • First.Throat fullness. chest tightness.Pruritus.Altered mental status. urticaria appear •Next.

ANAPHYLACTIC SHOCK • Risk factors for fatal anaphylaxis • Poorly controlled asthma • Previous anaphylaxis • Reoccurrence rates • 40-60% for insect stings • 20-40% for radiocontrast agents • 10-20% for penicillin • Most common causes • Antibiotics • Insects • Food .

localized urticaria can progress to full anaphylaxis • Symptoms usually begin within 60 minutes of exposure • Faster the onset of symptoms = more severe reaction • Biphasic phenomenon occurs in up to 20% of patients • Symptoms return 3-4 hours after initial reaction has cleared • A “lump in my throat” and “hoarseness” heralds lifethreatening laryngeal edema .ANAPHYLACTIC SHOCK • Mild.

bradycardic. with warm extremities Neurogenic .WHAT TYPE OF SHOCK IS THIS? • A 41 yo M presents to the ER after an MVA complaining of decreased sensation below his waist and is now hypotensive.

NEUROGENIC SHOCK • Occurs after acute spinal cord injury • Sympathetic outflow is disrupted leaving unopposed vagal tone • Results in hypotension and bradycardia • Spinal shock. the terms are not interchangeable) .temporary loss of spinal reflex activity below a total or near total spinal cord injury (not the same as neurogenic shock.

NEUROGENIC SHOCK • Loss of sympathetic tone results in warm and dry skin • Shock usually lasts from 1 to 3 weeks • Any injury above T1 can disrupt the entire sympathetic system • Higher injuries = worse paralysis .

with warm extremities Septic shock . tachycardic.4. She is febrile to 39. hypotensive with a widened pulse pressure.WHAT TYPE OF SHOCK IS THIS? • An 81 yo F resident of a nursing home presents to the ED with altered mental status.

000 or < 4.SEPSIS • Two or more of SIRS criteria • • • • Temp > 38 or < 36 C HR > 90 RR > 20 WBC > 12.000 • Plus the presumed existence of infection • Blood pressure can be normal! • Shock Index (SI) .

SEPTIC SHOCK • Clinical signs: • • • • • Hyperthermia or hypothermia Tachycardia Wide pulse pressure Low blood pressure (SBP<90) Mental status changes .

On PE. you note the pt to be tachycardic. hypoxic.WHAT TYPE OF SHOCK IS THIS? • A 24 yo M presents to the ED after an MVC c/o chest pain and difficulty breathing. and with decreased breath sounds on left Obstructive shock . hypotensive.

SOB. air/pressure builds up • Mediastinum shifted impeding venous return • „kinking of great vessels‟ • Chest pain. decreased breath sounds • No tests needed! .OBSTRUCTIVE SHOCK • Tension pneumothorax • Air trapped in pleural space with 1 way valve.

muffled heart sounds. echo .OBSTRUCTIVE SHOCK • Cardiac tamponade • Blood in pericardial sac prevents VR to and contraction of heart • Related to trauma. pericarditis. MI • Beck’s triad: hypotension. JVD • Diagnosis: large heart CXR.

tachycardia. venostasis • Signs: Tachypnea.OBSTRUCTIVE SHOCK • Pulmonary embolism • Virchow‟s triad: hypercoaguable. venous injury. hypoxia • Low risk: D-dimer • Higher risk: CTPA chest or VQ scan .

OBSTRUCTIVE SHOCK • Aortic stenosis • Resistance to systolic ejection causes decreased cardiac function • Chest pain with syncope • Systolic ejection murmur • Diagnosed with echo • Vasodilators (NTG) will drop pressure! .

afebrile. with cool but dry skin Hypovolemic Shock . The pt is hypotensive. tachycardic.WHAT TYPE OF SHOCK IS THIS? • 68 yo M with hx of HTN and DM presents to the ER with abrupt onset of diffuse abdominal pain with radiation to his low back.

pancreatitis Burns Neglect. environmental (dehydration) • Hemorrhagic • • • • • GI bleed Trauma Massive hemoptysis AAA rupture Ectopic pregnancy.HYPOVOLAEMIC SHOCK • Non-hemorrhagic • • • • • Vomiting Diarrhea Bowel obstruction. post-partum bleeding .

CLASSIFICATION OF SHOCK IN BLOOD LOSS .

tachycardia and cool.WHAT TYPE OF SHOCK IS THIS? • A 55 yo M with hx of HTN. DM presents with “crushing” substernal chest pain. clammy extremities Cardiogenic shock . hypotension. diaphoresis.

CARDIOGENIC SHOCK • Defined as: • SBP < 90 mmHg • CI < 2.2 L/m/m2 • PCWP > 18 mmHg • Signs: • • • • • • Cool. mottled skin Tachypnea Hypotension Altered mental status Narrowed pulse pressure Basal lung crepts. murmur .

MANAGEMENT OF SHOCK  Approach to the Patient in Shock in ED:      Focused History Physical examination Focused investigation Focused treatment Referral & Disposition .

sores CV – JVD. RR.APPROACH TO THE PATIENT IN SHOCK • History • • • • • • • • Recent illness Fever Chest pain. rashes. guarding. rigidity. oxygen sat. rebound Renal – urine output Infectious source . ABG GI – abd pain. heart sounds Resp – lung sounds. temp. SOB Abdominal pain Comorbidities Medications Toxins/Ingestions Recent hospitalization or surgery • Baseline mental status • Physical examination • • • • • • • • • Appearance Vital Signs CNS – mental status Skin – color.

IS THIS PATIENT IN SHOCK? • Patient looks ill • Altered mental status • Skin cool and mottled or hot and flushed • Weak or absent Yes! peripheral pulses These are all signs and • SBP <110 symptoms of shock • Tachycardia .

AIRWAY • Determine need for intubation but remember: intubation can worsen hypotension • Sedatives can lower blood pressure • Positive pressure ventilation decreases preload • May need volume resuscitation prior to intubation to avoid hemodynamic collapse .

CONTROL WORK OF BREATHING • Respiratory muscles consume a significant amount of oxygen • Tachypnea can contribute to lactic acidosis • Mechanical ventilation and sedation decrease WOB and improves survival • DON‟T FORGET supplemental O2 .

MAINTAINING OXYGEN DELIVERY • Decrease oxygen demands • Provide analgesia and anxiolytics to relax muscles and avoid shivering • Maintain arterial oxygen saturation/content • Give supplemental oxygen • Maintain Hemoglobin > 10 g/dL • Serial lactate levels or central venous oxygen saturations to assess tissue oxygen extraction .

5 ml/kg/hr (30 ml/hr) • Improving heart rate • No outcome benefit from colloids .OPTIMIZING CIRCULATION • 2 large bore cannula & send blood Ix • Isotonic crystalloids (NS/RL) • 1:3 for hypovolaemic shock • Titrate: • CVP 8-12 mm Hg • Urine output 0.

you know SBP is at least this number 60 70 80 90 .SHOCK • Do you remember how to quickly estimate blood pressure by pulse? • If you palpate a pulse.

.

INFUSION RATES .

MTLS .

MTLS .

Crystalloids MTLS .

Hesteril .Haemeccel.• Colloid .Starch .Gelatins . Gelafundin .blood products replace 1:1 TLS .

.

D-dimer .FURTHER EVALUATION • • • • • • • CT of head Lumbar puncture Wound cultures Acute abdominal series Abdominal/pelvic USG or CT Cortisol/CRP/Calcitonin level Fibrinogen. FDPs.

HYPOVOLEMIC SHOCK • ABCs • Control any bleeding • Crystalloids • Normal Saline or Lactate Ringers • Up to 1-2 liters • PRBCs • O negative or cross matched • Arrange definitive treatment .

TREATMENT OF CARDIOGENIC SHOCK • AMI • „MONA‟ • PCI or thrombolytics • RV infarct • Fluids and Dobutamine (no NTG) • Disposition .

as soon as possible • EGDT protocol 2012 .TREATMENT OF SEPTIC SHOCK • ABCs • Empiric antibiotics. • based on suspected source.

dopamine) and titrate to effect • Goal: MAP > 65 mmHg • Consider adrenal insufficiency • IV hydrocortisone 100 mg . • vasopressor (norepinephrine.PERSISTENT HYPOTENSION • If no response after 1-2 L.

3 mg IM of 1:1000 (epi-pen) • Repeat every 5-10 min as needed • For CV collapse.ANAPHYLACTIC SHOCK.000 • If refractory. 1 mg IV of 1:10. start IV infusion • Supportive • H2 blocker.TREATMENT • Adrenaline • 0. Antihistamine etc .

B.TREATMENT • A.NEUROGENIC SHOCK.Cs • Remember c-spine precautions • Fluid resuscitation • Search for other causes of hypotension • For bradycardia • Atropine / dopamine infusion • Pacemaker .

consider thrombolytics .OBSTRUCTIVE SHOCK  Tension pneumothorax  Needle decompression & chest tube  Cardiac tamponade  Pericardiocentesis  Pulmonary embolism  Heparin.

PERSISTENT HYPOTENSION • Inadequate volume resuscitation • Pneumothorax • Cardiac tamponade • Hidden bleeding • Adrenal insufficiency .

END POINTS OF RESUSCITATION • Maximize survival and minimize morbidity • Goal directed approach • • • • Urine output > 0.5 mL/kg/hr CVP 8-12 mmHg MAP 65 to 90 mmHg Central venous oxygen concentration > 70% .

(Ongoing resus) Clinical assessment: formulate the question 2. Re-scan / monitor progress / further investigations .Form a working diagnosis 4.SUMMARY 1. Continue resuscitation 5. Rapid shock screen 3.

.THANK YOU …..