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 adequatedespite 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 III” “Class IV”

<750cc<15% of TBV

None/minimal

Crystalloids

750cc – 1500cc15 – 30% of TBV

HR: increasedPulse Pressure: decreasedBP: no change

Crystalloids

1.5L – 2L30 – 40% of TBV

HR: increasedBP: decreasedMS: agitatedUrine Output: decreased

1. Crystalloid (1 – 2L)2. Transfusion (1 – 2units)3. Identify source of Bleed(*5)

>2L>40% of TBV

HR: increasedBP: decreased (<60)MS: decreased

1. Crystalloid (2L)2. Transfusion (2 – 4 units)3. Identify source of Bleed(*5)4. OR

Tx Tx Tx Tx

S&S S&SS&SS&S

EBL EBLEBL EBL

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 #2

“Support the patient”

GOAL #1

“ID and Tx the cause”

Two Goals in the management of Hemorrhagic Shock

2 - “Support the patient”

Establish IV access

Fluid Resuscitation

1 - “ID and Tx the cause”

Locate the source of bleeding

Control it

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

Whip-stitch with

nylon suture

ExtremityBleed

Scalp bleed

Blood on Floor→ Check head/scalp→ Check extremity

Long Bones

OR → Exploratory laparotomy

DPL → (+)-Gross blood- >105 RBCs

FAST → Free fluid

- Abdominal trauma- Distended abdomen

Abdominal Cavity

OR →Thoracotomy

Chest tube

≥ 1L of Blood

Place chest tube On affected side

-Chest trauma- Diminished breath sounds- Desaturation, ↑O2 requirement

Chest cavity Pelvis/Retroperitoneum External Bleeding

-Abdominal/Pelvic trauma-Flank ecchymosis-Unstable pelvis-Hematuria

First do DPL(supra umbilical)r/o intrabdominal

bleed

1) Wrap sheet around pelvis2) Pelvic angiography

(+) Blush/Extravasation

1) Deformed extremity2) Crush injury3) Mangled extremity

EBLFemur Fx 750cc–1L

Tib Fx 500-750cc

Immobilization andminimal manipulationof injured extremity using splint (3Ps)

Tourniquet proximal to injury

- set > systolic BP

Pressure

and Elevation

5 Possible locations for significant bleeding

Clue:Clue: Clue: Clue: Clue:

DPL (-)DPL (+)

Angioembolization

Bleeding not controlled

Be alert for compartment

syndrome

Consult Ortho

1 2 3 4 5

ChestX-Ray

(+) Ptx-Htx

PelvicX-Ray(+) Fx

Algorithm to Identify the Bleeding Source in a Hypotensive Trauma Patient

Long BonesAbdominal CavityChest cavity Pelvis/RetroperitoneumExternal Bleeding

“floor”

5 Possible locations for significant bleeding

1 2 3 4 5

Algorithm to Identify the Bleeding Source in a Hypotensive Trauma Patient

Whip-stitch with

nylon suture

ExtremityBleed

Scalp bleed

Blood on Floor→ Check head/scalp→ Check extremity

Long Bones

OR → Exploratory laparotomy

DPL → (+)-Gross blood- >105 RBCs

FAST → Free fluid

- Abdominal trauma- Distended abdomen

Abdominal Cavity

OR →Thoracotomy

Chest tube

≥ 1L of Blood

Place chest tube On affected side

-Chest trauma- Diminished breath sounds- Desaturation, ↑O2 requirement

Chest cavity Pelvis/RetroperitoneumExternal Bleeding

“floor”

-Abdominal/Pelvic trauma-Flank ecchymosis-Unstable pelvis-Hematuria

First do DPL(supra umbilical)r/o intrabdominal

bleed

1) Wrap sheet around pelvis2) Pelvic angiography

(+) Blush/Extravasation

1) Deformed extremity2) Crush injury3) Mangled extremity

EBLFemur Fx 750cc–1L

Tib Fx 500-750cc

Immobilization andminimal manipulationof injured extremity using splint (3Ps)

Tourniquet proximal to injury

- set > systolic BP

Pressure

and Elevation

5 Possible locations for significant bleeding

Clue:Clue: Clue: Clue: Clue:

DPL (-)DPL (+)

Angioembolization

Bleeding not controlled

Be alert for compartment

syndrome

Consult Ortho

1 2 3 4 5

ChestX-Ray

(+) Ptx-Htx

PelvicX-Ray(+) Fx

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

FluidpH Na

(mEq/L)Cl (mEq/L)

Lactate (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 #138 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 #1A- Locate the source of bleedingB- Control it

– Goal #2A- Establish IV accessB- Fluid Resuscitation

???

WHY IS THE PATIENT HYPOTENSIVE ?

Don’t Get The Floor WET !!!!

SOURCE of BLEEDING

? ? ?

Case #2

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?

Before

What’s next??

After

Wrapping the pelvis with a sheet

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. Hypotension (SBP<100)2. Tachycardia3. Tachypnea; Sa O2 <90%4. Oliguria5. Change in mental status (confusion, agitation)6. Labs: Acidosis, Basic Deficit, Anion Gap, Lactate

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 neededB. 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 MGT1. Make sure patient is on ECG monitor and Pulse Ox.2. Administer O2

3. Insure adequate IV access4. Place foley catheter5. Place CVP line (when indicated)6. Order EKG7. Chest X-ray r/o Ptx

Yes (patient is in shock)

Shock

HypovolemicShock

Spinal Shock

Cardiogenic Shock

1. External fluid loss2. 3rd Spacing

CVP, PCW: decreasedCO: decreasedSVR: increased

1. Fluid resuscitation2. Control/replace fluid losses

Infection

Obstructive

CVP, PCW: decreasedCO: increased then decreasedSVR: decreased

1. Tension PX2. Cardiac tamponade3. PE

Non-obstructive

CVP, PCW: increasedCO: decreasedSVR: increased

1. Identify & drain source of infection2. Start appropriate Abx 3. Supportive care - Fluid resuscitation - Vaso pressors (Phenylephirine, Norepinephrine)

Cause

Cause

Hemodynamic findings Hemodynamic findingsHemodynamic findings

Treatment

Treatment

1 2 3

1. CT placement2. Pericardiocentesis3. IV Heparin

1. Diuresis - Lasix2. Afterload reduction - Nitroprusside, Nitroglycerine - ACE inhibitor3. Inotropic support - Dobutamine, Milrinone

TreatmentTreatment

DDX

1. AMI2. CHF

CauseSCI (>T4 level)

Cause

Supportive Care→Fluid “to fill the tank”→ Vaso pressors (Phenylephirine, Norepinephrine)

Treatment

HemorrhagicShock

Septic Shock

1. Trauma (*5)2. Post-op bleeding3. GI bleeding

Cause

1. Fluid resuscitation2. Find source of bleeding and control it3. Correct coagulopathy

Treatment

“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

HypovolemicShock

Spinal Shock

Cardiogenic Shock

1. External fluid loss2. 3rd Spacing

CVP, PCW: decreasedCO: decreasedSVR: increased

1. Fluid resuscitation2. Control/replace fluid losses

Infection

Obstructive

CVP, PCW: decreasedCO: increased then decreasedSVR: decreased

1. Tension PX2. Cardiac tamponade3. PE

Non-obstructive

CVP, PCW: increasedCO: decreasedSVR: increased

1. Identify & drain source of infection2. Start appropriate Abx 3. Supportive care - Fluid resuscitation - Vaso pressors (Phenylephirine, Norepinephrine)

Cause

Cause

Hemodynamic findings Hemodynamic findingsHemodynamic findings

Treatment

Treatment

1 2 3

1. CT placement2. Pericardiocentesis3. IV Heparin

1. Diuresis - Lasix2. Afterload reduction - Nitroprusside, Nitroglycerine - ACE inhibitor3. Inotropic support - Dobutamine, Milrinone

TreatmentTreatment

DDX

1. AMI2. CHF

CauseSCI (>T4 level)

Cause

Supportive Care→Fluid “to fill the tank”→ Vaso pressors (Phenylephirine, Norepinephrine)

Treatment

HemorrhagicShock

Septic Shock

1. Trauma (*5)2. Post-op bleeding3. GI bleeding

Cause

1. Fluid resuscitation2. Find source of bleeding and control it3. Correct coagulopathy

Treatment

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, antibiotics2. 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 MI2. 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