Low BP / fast pulse

No BP / no pulse
Professor Michael Irwin
Head
Department of Anaesthesiology
University of Hong Kong
Objectives
• Understand the concept of oxygen delivery
and its determinants

• Understand the classification of the causes of

shock and their management

• Understand the principles of basic life

support
Determinants of oxygen delivery
• Oxygen content of blood
• CaO2

• Ability to deliver oxygenated blood around

the body
• Cardiac output (CO)
Shock
• Inadequate oxygen delivery to meet cellular
metabolic demands

• May be caused by a failure of one or more factors

Impaired oxygen delivery
Impaired oxygen delivery

Hypoxia
Impaired oxygen delivery

Hypoxia

Anaerobic metabolism
Impaired oxygen delivery

Hypoxia

Anaerobic metabolism

Acidosis
Impaired oxygen delivery

Hypoxia

Anaerobic metabolism

Acidosis

Cell death
Oxygen delivery (DO2)

DO2 = CO x CaO2

Cardiac output (HR x SV) Oxygen content

 Oxygen content (CaO2)

(Hb x SaO2 x 1.34) + (pO2 x 0.027)

100

1.34 ml of O2 can be carried by 1 gram of fully saturated

haemoglobin

0.027 ml of O2 will be dissolved in plasma for each kPa of O2

partial pressure
 Classification of Shock
• Hypovolaemic
• e.g. following haemorrhage, burns, dehydration

• Cardiogenic (“pump failure”)

• e.g. following myocardial infarction

• Distributive
• vasodilatation and myocardial depression

• Others
• e.g. obstructive, adrenocortical insufficiency, neurogenic (spinal cord injury)
 Hypovolaemic Shock

• Result of intravascular blood volume depletion

• haemorrhage, vomiting, diarrhoea, dehydration, evaporation
during major operations

• ↓ preload causes ↓ in stroke volume.

• ↓ CO, BP & LV filling pressures

• ↑ SVR (from vasoconstriction) & HR

• sympathetic compensatory response to ↓ BP
 Cardiogenic Shock
• ↓ blood flow due to an intrinsic defect in cardiac function
(muscle or valves)

• ↓ contractility causes ↓ stroke volume

• ↑ LV filling pressures (backward failure)

• +/- pulmonary oedema

• ↑ SVR & HR (sympathetic compensatory response to the low BP)

Distributive Shock
• Peripheral vascular dilatation causes ↓ SVR
• Sepsis, anaphylaxis, adrenal insufficiency, neurogenic

• ↑ CO but the perfusion of many vital organs is

compromised because of ↓ BP
• body loses it’s ability to distribute blood properly

• Low to normal LV filling pressures

• Warm peripheries, bounding pulses

Obstructive Shock
• Mechanical obstruction to cardiac filling

• Consider cardiac tamponade

• JVP/CVP is high, BP low, pulsus paradoxus

• Other causes
• tension pneumothorax
• massive pulmonary embolus
Treatment of shock

• Identify the cause

• Treat it appropriately

• Restore oxygen delivery

• Basic Life Support

Treatment of shock
• Hypovolaemic
• give intravenous fluids and/or blood
• Vasopressors – short term effect

• Cardiogenic (“pump failure”)

• vasodilators and/or inotropes

• Sepsis
• as above + eradication of infective focus & give antibiotics
 Basic
Life Support
Introduction
• Initial assessment
• Shout for help
• Get AED if possible
• Open the airway
• Chest compressions
• BLS: 2 rescue breaths – 30 compressions
• +airway/facemask = BLS with airway adjunct
Objectives
• Maintain adequate ventilation & circulation until
means can be obtained to reverse the underlying
cause of the arrest

• “holding operation”

• May itself reverse the cause

• Rapid deployment is essential

• irreversible cerebral damage in 3 - 4 minutes
Recognition of Cardiac Arrest
•The diagnosis is clinical
• Loss of consciousness

• Absent major pulse

• Healthcare providers have difficulty detecting a pulse or may take too
long
• Assume that cardiac arrest is present if an adult suddenly collapses or an
unresponsive victim is not breathing normally
• Take no more than 10 seconds to check for a pulse and, if you do not
definitely feel a pulse within that time period, start chest compressions
Opening the Airway

•Head tilt

•Chin lift

•Jaw thrust

Caution
Suspected cervical spine injury
Is Patient Breathing?

YES

•Use Recovery Position

•Call for help

Is Patient Breathing?
NO

•Start chest compressions:

•Kneel by the side of the victim

•Identify correct site of compressions
•Apply vertical pressure with arms straight
•Press down on the sternum 5- 6 cm, and release fully
•Rate 100-120/min
•Compression and release should take an equal
amount of time
Expired Air Ventilation

• Occlude casualty’s nose, maintain chin lift

• Take normal full deep breath

• Ensure good mouth to mouth seal

 Expired Air Ventilation
• Blow steadily (1 sec) into casualty’s mouth until visible chest rise and watch
chest rise
• Maintain chin lift, allow chest to fall
• Repeat
• Laerdal mask
• Laryngeal mask
• Self-inflating bag
 CPR
• Single Rescuer
• 30 Compressions: 2 Ventilations

• Two Rescuers
• 30 Compressions: 2 Ventilations

• With advanced airway in situ, no need for coordination: Breaths

should be given once every 8 seconds simultaneously with
compressions

• 8-10 breaths and at least 100-120 compressions / minute

Compression only CPR
• If untrained or unwilling to give rescue breaths, give chest compressions only

• Chest compressions should be given continuously at a rate of 100-120/min

• STOP ONLY if the victim show signs of regaining consciousness AND starts to
breathe normally

• Continue until qualified help arrives and takes over or you become
exhausted
 Summary

Assessment and open the airway / activate

emergency response
• C Chest compressions

• A Airway

• B Breathing
It’s easy!!!
Post-cardiac arrest care
1. Optimise cardiopulmonary function and vital organ
perfusion after ROSC

2. Transport/transfer to an appropriate hospital/ICU/CCU

3. Identify and treat ACS and other reversible causes

4. Control temperature to optimise neurologic recovery

5. Anticipate, treat and prevent multiple organ dysfunction

 Scenario 1
25 years old male motorcyclist
collision with a lamppost
Initial findings
• Unconscious (GCS 7/15)

• Weak, rapid pulse

• Signs of airway obstruction (stridor)

What should we do?
• A = airway
• neck stabilisation & intubate

• B = breathing
• ventilate (Ambu bag, high conc. O2)

• C = circulation
• 14G iv cannula x 2 (L arm, L saphenous vein)
• 10 ml blood for X-M
Reassess
BP 60/40
Pulse 150/min
GCS 7/15
# R femur
?# pelvis
R chest injury
Why is this patient hypotensive
& tachycardic?
• Cardiogenic problem?
• is his heart unable to pump blood

• Preload problem?
• does his heart not have anything to pump
Hypovolaemia
Treatment
• IV colloid solution

• 1000 ml (fluid warmer) stat

• Assess & repeat

Initial improvement then
deterioration
↓ SaO2

↑ airway pressure

↓ air entry R side

Differential diagnosis
• Further bleeding

• Tension pneumothorax

• Cardiac tamponade
Outcome
• Pneumothorax found on R side

• Drained

• Improvement
 Scenario 2

69 years old male 48 hours after surgery for aortic

aneurysectomy

Epidural local anaesthetic infusion - good

analgesia
Preoperative co-morbidities
• Stable angina

• Hypertension - well controlled

• Non insulin dependent diabetes

• Smoker - mild COPD

Found to be……….
• Pale
• Sweaty
• Conscious but slightly confused
• P 130 irregular
• BP 90/50
Management
• A = airway
• clear

• B = breathing
• slightly tachypnoeic, O2 therapy given (nasal)

• C = circulation
• iv cannula inserted

• Resuscitation trolley sent for

 Differential diagnosis
• Arrhythmia
• ECG monitor shows atrial fibrillation
• ?secondary to MI (peak time for post op incidence) or ischaemia

• Hypotension
• could be 2y to arrhythmia or excessive sympathetic block from
epidural (usually not tachycardic) or surgical bleeding

• LA toxicity
• usually causes bradyarrhythmia
Cardiogenic
shock
Pump failure
Pathophysiology
• Loss of atrial contraction (a.f.)

• Fast heart rate in presence of ischaemic heart

disease
• myocardial supply demand imbalance
• exacerbation of ischaemia
• decreased myocardial contractility
Treatment
• Unstable haemodynamics
• cardioversion
• Stable
• antiarrhythmic drugs
• May require inotropic support
• Excessive iv fluids will exacerbate this
patients condition