Transcript No Slide Title

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 IV”
“Class III”
EBL
EBL
EBL
EBL
<750cc
<15% of TBV
750cc – 1500cc
15 – 30% of TBV
1.5L – 2L
30 – 40% of TBV
>2L
>40% of TBV
S&S
S&S
HR: increased
Pulse Pressure: decreased
BP: no change
HR: increased
BP: decreased
MS: agitated
Urine Output: decreased
Tx
Tx
S&S
None/minimal
Tx
Crystalloids
Crystalloids
1. Crystalloid (1 – 2L)
2. Transfusion (1 – 2units)
3. Identify source of Bleed(*5)
S&S
HR: increased
BP: decreased (<60)
MS: decreased
Tx
1.
2.
3.
4.
Crystalloid (2L)
Transfusion (2 – 4 units)
Identify source of Bleed(*5)
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
bleeding
Establish IV access
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
Abdominal Cavity
Chest cavity
-Chest trauma
- Diminished breath sounds
- Desaturation, ↑O2 requirement
Chest
X-Ray
(+) Ptx-Htx
FAST →
Free fluid
External Bleeding
Clue:
DPL → (+)
-Gross blood
- >105 RBCs
Chest tube
≥ 1L of Blood
Clue:
-Abdominal/Pelvic trauma
-Flank ecchymosis
-Unstable pelvis
-Hematuria
- Abdominal trauma
- Distended abdomen
DPL (+)
First do DPL
(supra umbilical)
r/o intrabdominal
bleed
Pelvic
X-Ray
(+) Fx
DPL (-)
1) Wrap sheet around pelvis
2) Pelvic angiography
OR →Thoracotomy
5
4
Pelvis/Retroperitoneum
Clue:
Clue:
Place chest tube
On affected side
3
Blood on Floor
→ Check head/scalp
→ Check extremity
Scalp
bleed
Whip-stitch
with
nylon suture
Extremity
Bleed
Pressure
and
Elevation
Bleeding not
controlled
Long Bones
Clue:
1) Deformed extremity
2) Crush injury
3) Mangled extremity
EBL
Femur Fx 750cc–1L
Tib Fx 500-750cc
Consult Ortho
Immobilization and
minimal manipulation
of injured extremity
using splint (3Ps)
OR → Exploratory laparotomy
(+) Blush/Extravasation
Angioembolization
Tourniquet proximal
to injury
- set > systolic BP
Be alert for
compartment
syndrome
Algorithm to Identify the Bleeding Source
in a Hypotensive Trauma Patient
5 Possible locations
for significant bleeding
1
Chest cavity
2
Abdominal Cavity
3
Pelvis/Retroperitoneum
4
External Bleeding
“floor”
5
Long Bones
Algorithm to Identify the Bleeding Source
in a Hypotensive Trauma Patient
5 Possible locations
for significant bleeding
1
2
Abdominal Cavity
Chest cavity
-Chest trauma
- Diminished breath sounds
- Desaturation, ↑O2 requirement
Chest
X-Ray
(+) Ptx-Htx
FAST →
Free fluid
External Bleeding
“floor”
Clue:
DPL → (+)
-Gross blood
- >105 RBCs
Chest tube
≥ 1L of Blood
Clue:
-Abdominal/Pelvic trauma
-Flank ecchymosis
-Unstable pelvis
-Hematuria
- Abdominal trauma
- Distended abdomen
DPL (+)
First do DPL
(supra umbilical)
r/o intrabdominal
bleed
Pelvic
X-Ray
(+) Fx
DPL (-)
1) Wrap sheet around pelvis
2) Pelvic angiography
OR →Thoracotomy
5
4
Pelvis/Retroperitoneum
Clue:
Clue:
Place chest tube
On affected side
3
Blood on Floor
→ Check head/scalp
→ Check extremity
Scalp
bleed
Whip-stitch
with
nylon suture
Extremity
Bleed
Pressure
and
Elevation
Bleeding not
controlled
OR → Exploratory laparotomy
(+) Blush/Extravasation
Angioembolization
Tourniquet proximal
to injury
- set > systolic BP
Long Bones
Clue:
1) Deformed extremity
2) Crush injury
3) Mangled extremity
EBL
Femur Fx 750cc–1L
Tib Fx 500-750cc
Consult Ortho
Immobilization and
minimal manipulation
of injured extremity
using splint (3Ps)
Be alert for
compartment
syndrome
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
Fluid
Na
Cl
Lactate
(mEq/L) (mEq/L) (mEq/l)
Ca
(mEq/L)
K
(mEq/L)
Osm
(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
After
Before
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.
2.
3.
4.
5.
6.
Hypotension (SBP<100)
Tachycardia
Tachypnea; Sa O2 <90%
Oliguria
Change in mental status (confusion, agitation)
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
First Step in MGT
1.
2.
3.
4.
5.
6.
7.
Make sure patient is on ECG monitor and Pulse Ox.
Administer O2
Insure adequate IV access
Place foley catheter
Place CVP line (when indicated)
Order EKG
Chest X-ray r/o Ptx
Shock
1
2
Hemodynamic findings
Hemodynamic findings
CVP, PCW: decreased
CO: decreased
SVR: increased
Hypovolemic
Shock
3
Hemodynamic findings
CVP, PCW: decreased
CO: increased then decreased
SVR: decreased
CVP, PCW: increased
CO: decreased
SVR: increased
Hemorrhagic
Shock
Cardiogenic Shock
Spinal Shock
Septic Shock
Cause
1. External fluid loss
2. 3rd Spacing
Treatment
Cause
Cause
1. Trauma (*5)
2. Post-op bleeding
3. GI bleeding
1. Fluid resuscitation
2. Control/replace
fluid losses
Cause
SCI (>T4 level)
Infection
Treatment
Supportive Care
→Fluid “to fill the tank”
→ Vaso pressors
(Phenylephirine, Norepinephrine)
Treatment
1. Fluid resuscitation
2. Find source of
bleeding and control it
3. Correct coagulopathy
Treatment
1.
2.
3.
-
Identify & drain source of infection
Start appropriate Abx
Supportive care
Fluid resuscitation
Vaso pressors
(Phenylephirine, Norepinephrine)
Non-obstructive
Obstructive
DDX
Cause
1. Tension PX
2. Cardiac tamponade
3. PE
1. AMI
2. CHF
Treatment
1. CT placement
2. Pericardiocentesis
3. IV Heparin
Treatment
1. Diuresis
- Lasix
2. Afterload reduction
- Nitroprusside, Nitroglycerine
- ACE inhibitor
3. Inotropic support
- Dobutamine, Milrinone
“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
Hemodynamic findings
Hemodynamic findings
CVP, PCW: decreased
CO: decreased
SVR: increased
Hypovolemic
Shock
3
Hemodynamic findings
CVP, PCW: decreased
CO: increased then decreased
SVR: decreased
CVP, PCW: increased
CO: decreased
SVR: increased
Hemorrhagic
Shock
Cardiogenic Shock
Spinal Shock
Septic Shock
Cause
1. External fluid loss
2. 3rd Spacing
Treatment
Cause
Cause
1. Trauma (*5)
2. Post-op bleeding
3. GI bleeding
1. Fluid resuscitation
2. Control/replace
fluid losses
Cause
SCI (>T4 level)
Infection
Treatment
Supportive Care
→Fluid “to fill the tank”
→ Vaso pressors
(Phenylephirine, Norepinephrine)
Treatment
1. Fluid resuscitation
2. Find source of
bleeding and control it
3. Correct coagulopathy
Treatment
1.
2.
3.
-
Identify & drain source of infection
Start appropriate Abx
Supportive care
Fluid resuscitation
Vaso pressors
(Phenylephirine, Norepinephrine)
Non-obstructive
Obstructive
DDX
Cause
1. Tension PX
2. Cardiac tamponade
3. PE
1. AMI
2. CHF
Treatment
1. CT placement
2. Pericardiocentesis
3. IV Heparin
Treatment
1. Diuresis
- Lasix
2. Afterload reduction
- Nitroprusside, Nitroglycerine
- ACE inhibitor
3. Inotropic support
- Dobutamine, Milrinone
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
?
THANK YOU
&
GOOD LUCK