Fluid Management in the Hypotensive Patient Steven Roberts Cardiac Course 6 May 2008.
An Introduction to Shock - 206.176.58.104206.176.58.104/em/Introduction to Shock.pdf · Steroids...
Transcript of An Introduction to Shock - 206.176.58.104206.176.58.104/em/Introduction to Shock.pdf · Steroids...
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An Introduction to
Shock
SAEM Undergraduate Medical Education Committee
Emergency Medicine Clerkship Lecture Series
Primary Author: Julie K. A. Kasarjian, MD, PhD
Reviewer: Joshua Wallenstein, MD
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Learning Objectives
Review the approach to different
types of shock states
Review the principles of different
shock states
Septic
Cardiogenic
Anaphylactic
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Case #1
83 year old man presents with an altered mental status from a local nursing home
PMH: HTN, prostate CA, chronic UTI’s, CAD
Medications: ASA daily, NTG prn, norvasc, HCTZ, colace
NKDA
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Case #1
Physical exam:
VS: BP 86/40mmHg HR 115 RR 24 T 98.0°F SaO2 97% RA
HEENT: Edentulous
Heart: Regular rhythm, tachycardic, 2/6 systolic murmur
Lungs: Clear, tachypneic
Abdomen: Soft, non-distended, + bowel sounds
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Case #1
Physical exam:
Extremities: diminished pulses, no
edema
Skin: warm
Neurologic: oriented to name, moves
all extremities, GCS 14
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Case #1
Describe your initial management?
What needs to be done with this patient
in the first 5 minutes?
IV, O2, Monitor, ABC’s2 large bore IV lines (14 or 16 ga)
Aggressive fluid resuscitation with
NS
Supplemental O2
Cardiac monitoring
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Case #1
Based on your clinical suspicion, what
laboratory studies are indicated?
What imaging studies?
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Sepsis - Definition
Heterogeneous clinical syndrome
caused by infection with any class of
microorganism
Gram-negative: 55-60%
Gram-positive: 35-40%
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Sepsis - Clinical Features
Hypo-/hyperthermia
Tachycardia-/Tachypnea
Altered mental status
Decreased capillary refill/mottling >2
seconds
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Sepsis - Diagnostic Features
Hyperglycemia
Leukocytosis-/leukopenia
Hyperlactemia
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Severe Sepsis
Sepsis with either hypotension or
systemic manifestations of
hypoperfusion
Lactic acidosis
Oliguria
Altered mental status
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Septic Shock
Sepsis associated with hypotension
and or findings of end organ
hypoperfusion
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Characteristics of Septic Shock
Systemic vasodilation and hypotension
Tachycardia; depressed contractility
Vascular leakage and edema leading to relative hypovolemia
Compromised blood flow to vital organs
Disseminated intravascular coagulation
Metabolic acidosis
Respiratory insufficiency and multiple organ failure
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Systemic Inflammatory Response
Syndrome (SIRS)
Two or more of the following conditions
Temperature >38°C or <36°C
Heart rate > 90 beats/min
Respiratory rate >20 breaths/min
PaCO2, <32 mmHg
WBC >12,000 mm3 or <4000, or >10% immature (band) cells
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Multiple Organ Dysfunction
Syndrome (MODS)
Progressive organ failure following
severe infectious or noninfectious
insults (severe burns, multiple trauma)
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Sepsis - Treatment
Insure Adequate oxygenation and ventilation to limit work of breathing
Aggressive IV fluid resuscitation (crystalloid)
Antibiotic therapy
Empiric (after cultures)
Based on source/patient status (community,healthcare associated, immunocompromised)
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Sepsis - Treatment
***Early goal directed therapy
Vasopressor support - if hypotensive
despite IVF
Based on initial response to fluid resuscitation
Blood product transfusion
Tight glucose control (controversial)
Steroids (controversial)
If hypotensive despite IVF/pressors
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Case #2
A 62 year old female presents with progressive substernal chest pain, now with worsening shortness of breath
PMH: Hypertension, CAD
Meds: Clonidine, Lopressor, ASA
Social: Smoker
NKDA
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Case #2
Physical exam
VS: BP 86/50 HR 86 RR 24 T 37.0°F SaO2 96%
General: restless
Heart: regular rate, harsh SEM, tachycardic
Lungs: rales, tachypneic
Abdomen: obese, NT/ND
Extremities: LE edema
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ECG
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Chest Radiograph
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Cardiogenic Shock - Definition
Insufficient cardiac output to meet
metabolic demands of tissues
Usually from acute myocardial infarction
(AMI) >40% of LV myocardium
Sustained hypotension with inadequate
tissue perfusion in spite of adequate left
ventricular filling pressure
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Cardiogenic Shock
Manifested by organ dysfunction such as
oliguria, confusion, cool extremities and
lactic acidosis
Strict definitions:
Systolic BP of <90 mmHg for greater than 30
minutes
Cardiac index of <2.2L/min/m2 in the presence
of a pulmonary capillary wedge pressure of
>15 mmHg
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Cardiogenic Shock - Clinical
Features Hypoperfusion
Hypotension
SBP <90 mmHg, or
MAP decrease by 30 mmHg
Pulse pressure <20 mmHg
Organ dysfunction including:
Oliguria, confusion, cool extremities and lactic acidosis
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Cardiogenic Shock - Causes
Pump failure
Acute myocardial infarction (including RV)
Mechanical complications
Acute valvular insufficiency
Acute mitral regurgitation
Rupture of the interventricular septum
Free wall rupture
Tamponade
Other
End stage cardiomyopathy
Myocarditis
Prolonged cardiopulmonary bypass
LV outflow obstructionAortic stenosis
Obstruction to LV fillingMitral stenosis
Acute aortic insufficiency
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Initial Evaluation
ABC’s (primary survey)
Careful history/physical exam
Safety netIV access, oxygen, cardiac monitoring
12-lead ECG
CXR
Labs:CBC, CMP, coags, cardiac markers, BNP, etc.
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Cardiogenic Shock -
ManagementWill depend on suspected etiology
Early cardiology involvement
Bedside echocardiogram
Invasive monitoring
Diagnostic/therapeutic cardiac catheterization
IABP
Emergent CABG
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Echocardiogram
Can guide treatment by identifying any wall motion abnormalities
Rapid diagnosis of mechanical causes of cardiogenic shock
Papillary muscle rupture
Acute mitral regurgitation
Acute VSD
Free wall rupture
Tamponade
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Case #3
24 year old male, unrestrained driver,
high speed MVA
Complains of severe abdominal pain
at the scene
SBP 90 mmHg HR 118 RR 26
GCS 14, responds to verbal stimuli
Abdominal tenderness with guarding
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CT Scan Abdomen
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Hemorrhagic Shock
Class I II III IV
Blood
Loss (ml)<750 750-1,500
1,500-
2,000>2,000
Blood
Loss (%)<15% 15-30% 30-40% >40%
HR <100/min >100 >120 >140
BP Normal Pulse
Pressure SBP SBP
Need for
TransfusionNo No Most All
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Hypovolemic Shock
Ensure adequate ventilation/oxygenation
Control hemorrhage
Aggressive IV fluids
Consider pRBC transfusion
Treat severe acidosis
Correct underlying cause early
Surgical hemorrhage control
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Hypovolemic Shock
FAST scan
To OR directly versus CT scan/other
imaging
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Case #4
32 year old male presenting with
acute onset shortness of
breath/wheezing, pruritic rash,
vomiting after eating shellfish
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Anaphylactic Shock
Widespread hypersensitivity
Vasodilatation leads to:
Hypovolemia, altered cellular metabolism
Histamine release leads to:
Increased permeability and massive
vasodilatation
Respiratory distress with bronchospasm
and laryngospasm
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Anaphylactic Shock
Up to 2/3 of cases offending agent not
identified
Food most common identified cause
Venom, medications, exercise, and
latex are other causes
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Anaphylaxis/Allergic Reactions
Sensitization to:
Drugs (penicillin, sulfa)
Foods (shellfish, nuts, eggs,
preservatives, tetrazine dyes)
Stings (hymenoptera)
No sensitizing exposure:
Dextran, codeine, radiocontrast material
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Anaphylactic Shock - Treatment
Control airway and ventilation
Crystalloid 10-20 mL/kg
Epinephrine
Diphenhydramine
Steroids - 5-10 mg/kg hydrocortisone
or 1-2 mg/kg methylprednisilone
H2 blockers
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Approach to Patient in Shock
General approach to a patient in the
initial stages of shock follows similar
principles regardless of the inciting
factors or etiology
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Shock - Description
Inadequate blood/oxygen supply to
tissues
Build up of toxic metabolites
Physiologic responses cannot meet
tissue demands
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Physical Exam
Hypotension and tachycardia
Peripheral hypoperfusion
Peripheral vasoconstriction (common)
Altered mental status
Oliguria or anuria
Metabolic acidosis (common)
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Criteria for Diagnosis - Shock
Ill appearance or altered mental status
HR >100 bpm
RR >22 bpm or PaCO2 <32 mm Hg
Arterial base deficit <-5 mEq/L or lactate >
4
Urine output < 0.5mL/kg/hr
Arterial hypotension > 20 minutes
** four criteria should be met, regardless of cause
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Cardiovascular
Systemic vasodilation and hypotension (SBP <90 mmHg)
Tachycardia (100 bpm)
Increased cardiac output (hyperdynamic -early, hypodynamic - late
Ventricular dilation;decreased ejection fraction
Loss of sympathetic responsiveness
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Pulmonary and Renal
Hyperventilation with respiratory alkalosis
Pulmonary hypertension and edema
Hypoxemia arterial Pa02<50 mmHg
Reduced pulmonary compliance; increased work of breathing
Respiratory muscle failure
Renal hypoperfusion; oliguria
Acute tubular necrosis and renal failure
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Autonomic Response
Arteriolar vasoconstriction - redistribute blood from skin, skeletal muscle, kidneys, splanchnic viscera
Increase heart rate and contractility
Release of vasoactive hormones
epinephrine, norepinephrine, dopamine, cortisol
Release of ADH and activation of renin-angiotension-aldosterone system
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Shock - Labs
DIC
Leukopenia, thrombocytopenia,
polycythemia
Metabolic acidosis
Increased lactate
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Stages of Shock
Early reversible/compensatory shock
Mean arterial pressure drops 10 -15 mm
Hg
Decrease in circulating blood volume
(25-35%) 1000ml
Sympathetic nervous system stimulated;
release of catecholamines
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Intermediate
Further drop in MAP (20%)
Increase in fluid loss (1,500-2,500 ml)
Peripheral vasoconstriction
Body switches to anaerobic
metabolism forming lactic acid as a
waste product
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Intermediate
Body increases heart rate and vasoconstriction
Heart and brain become hypoxic
More severe effects on other tissues which become: ischemic and anoxic
State of acidosis/hyperkalemia develops
Needs rapid treatment
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Refractory
Refractory or irreversible shock
Tissues are anoxic, cellular death widespread
Restoration of blood pressure and fluid volume may not restore homeostasis of tissues
Cellular death leads to tissue death; vital organs fail and death occurs
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Shock
Components of Blood Flow
Cardiac Output (CO)
Blood volume/central venous
pressure (CVP)
Systemic vascular resistance (SVR)
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Shock
Pulmonary-
Capillary
Wedge
Pressure
Cardiac
Output
SVR
Hypovolemic ↓ ↓ ↑
Obstructive ↑ or ↓ ↓ ↑
Cardiogenic ↑ ↓ ↑
Distributive ↓ ↑ ↓
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Hypovolemic shock
Cool, clammy, mottled extremities
Tachycardia, tachypnea
Poor capillary refill
Decreased pulses
Flat neck veins
Anxiety/obtundation
Hypotension
Oliguria
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Obstructive shock
Narrowed pulse pressure
Diaphoresis
Jugular vein distention
Cool, clammy extremities
Rales
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Vasogenic
Flushing
Wide pulse pressure
Sepsis
Anaphylactic shock
Neurogenic
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Treatment
Initial
• Goal of treatment is to optimize perfusion and
oxygenation of vital organs
ABC’s
• Intubate if indicated
• Large bore IV lines
• Consider invasive monitoring in select
circumstances to guide fluid resuscitation
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Treatment
Hypovolemic Shock
• Identify source of blood / fluid loss
• Aggressive fluid resuscitation (SBP>100)
• Use crystalloid first
• Transfuse as needed
• Operative management for hemorrhagic shock
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Treatment
Cardiogenic Shock
• Caution with fluid
• Treat underlying cause- MI, tamponade,
dysrhythmias
• Inotropic support – dopamine,
dobutamine, phenylephrine
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Treatment
Vasogenic Shock/Sepsis
• Aggressive crystalloids
• Ideal urine output >30cc/hr
• Early antibiotics
• Identify infectious etiology
• Inotropes as needed
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Treatment
Anaphylactic Shock
• Intubate for airway support
• Histamine blockers
• Corticosteroids
• Nebulized albuterol
• Epi 1:1000 SQ/IM
• Epi 1:10000 IV if severe or refractory
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Key Points
Patients can be in shock with a normal blood
pressure
Shock reflects a degree of tissue hypoperfusion
Pay close attention to and understand the
relationship:
MAP = CO x SVR
CO = HR x SV
Sinus tachycardia is almost always a compensatory
response
Identify and treat the underlying cause not the HR
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Thanks
• Darren Manthey, MD
• EM Clerkship Director
• Sanford School of Medicine
• Sanford Health - Trauma 5
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