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Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation Ziad Sifri, MD Surgical Fundamentals and Algorithmic Approach to Patient Care July 30, 2010 The Goals 1. Definition and diagnosis of shock 2. Classes of hemorrhagic shock and resuscitation 3. Algorithm for the identifying of the location of bleeding 4. IV access and resuscitation in a Trauma patient 5. Initial management of patients in non-hemorrhagic shock 6. Diagnosis of the various types of non-hemorrhagic shock 7. Management of non-hemorrhagic shock The real goal however……. is to avoid …. Definition • Def: Inadequate tissue Perfusion and Oxygenation • Effect: Cellular injury, Organ failure, Death • Causes: hemorrhagic and non-hemorrhagic 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 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: diuretic.. •Therapeutic intervention: Manitol •IV contrast: CT, Angio •Old residual urine… •Etc… General Outline • Definition, diagnosis and types of shock • Classes of Hemorrhagic shock 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 • Algorithm for identifying the location of bleeding 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 Two Goals in the management of Hemorrhagic Shock “ID and Tx the cause” “Support the patient” Locate the source of bleeding Establish IV access Control it Fluid Resuscitation Goal #1 “Identification and Treatment of the cause” 1-Locate the source of bleeding 2-Control it 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 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 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” 1-Establish IV access 2-Fluid Resuscitation Goal #2 “Support the patient” 1-Establish IV access Establish IV access before it is too late Resuscitation: Establish 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!) Goal #2 “Support the patient” 2-Fluid Resuscitation Fluid Resuscitation Initial fluid bolus 1-2 liters in adults 20mL/kg in children Intravascular effect 3 for 1 rule of volume replacement: volume lost 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 The 3:1 Rule 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 • Non responders: – Something is still bleeding! – Need for invasive monitoring Avoid the “Lethal Triad” • Coagulopathy – Consumption of clotting factor – Dilution of platelets and clotting factors: transfusion of PRBCs – MTP (now in place at UMDNJ!) • 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 found unresponsive. He gets intubated by EMS and is reported to have a BP of 90/60 at the scene. He has a small head laceration as well as obvious abrasions over his chest. In the ED, he is noted to have decreased BS on the left side and his O2 Sats are 92% on 100% NR. What’s next? Portable CXR Case #1 • Diagnosis? • Management? Case #1 : CT Chest Case #2 18 year old male involved in a high speed MVC found unresponsive with a BP of 80/P at the scene. He has a large head laceration that is actively bleeding, an obvious abrasions over the pelvis and bilateral lower ext deform. In the ED, he is immediately intubated, he has equal BS and his sats are 100%. He is actively bleeding from his scalp and left leg. BP 80/60 P 140. Case #2 Dx? Type of shock? Class? Initial Management ? Whip Stitch head laceration What is missing ? The Tourniquet WHY IS THE PATIENT HYPOTENSIVE ? ??? AVOID GETTING THE FLOOR WET !!!! Case #2 Still hypotensive!!! He has received: 2 L crystalloids 2 units PRBCs CXR: Normal Portable Pelvic X-Ray Before After General Outline • Definition, diagnosis and types of shock • Classes of 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 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, Open wounds… Again : 2 goals 1- ID and Tx the cause Control fluid losses: surgical, wound coverage… 2- Support the Patient Hypovolemic Shock Hemodynamically: *Low to normal PCW (due to fluid losses) Normal or Decreased CO High SVR (compensation) 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 Again 2 goals 1- ID and Tx the cause Source Control: surgical, IR + start early antibiotics 2- Support the Patient Septic Shock Hemodynamically: Low to normal PCW (vasodilatation and fluid losses) Normal or increased CO *Low SVR (primary condition!) 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 goals: 1- ID and Tx the cause: Heparin, Cardiac Cath… 2- Support the Patient Cardiogenic Shock Hemodynamics: Elevated filling pressures *Diminished cardiac output due to pump failure Increased SVR (compensation) Obstructive Cardiogenic Shock No intrinsic cardiac pathology (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 Pearl: Must rule out other causes of shock in multiple 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 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, hypotension and has decreased urine output. She is intubated and transferred to the SICU. • What is ur Dx? • What is ur initial mgt? • Hemodynamics: CVP = 5 PCW = 8 C0= 8 SVR = 300. CASE # 4 • A 35 year old with a T-2 compete SCI and Grade III splenic lac arrives to the SICU. He is awake and stable . 2 hours later the nurse reports that he is hypotension (BP 80/40) with a HR of 60. He remains hypotensive despite 2L of fluid. His BD is -5 and has decreased urine output • What is ur Dx? • What is ur mgt ? • Hemodynamics: CVP = 3 PCW = 3 C0= 5 SVR = 900 Conclusion 1. You now know how recognize and diagnose shock 2. You know the classes of hemorrhagic shock 3. You have an algorithm to find the location of bleeding 4. You have an algorithm for the initial management of patients in non-hemorrhagic shock 5. You know how to Dx the types of non-hemorrhagic shocks 6. You know the 2 key Goals in the management of any shock THANK YOU ?