shock and resuscitation

8/12/2019 Shock and Resuscitation

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Shock and Resuscitation

Scott Nguyen, MD

Elmhurst Hospital Center
http://medipptx.blogspot.com/http://medipptx.blogspot.com/


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Definition of Shock

Condition of inadequate delivery of oxygenand nutrients necessary for normal tissueand cellular function


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Types of Shock

Hypovolemic Inflammatory Compressive Neurogenic

Cardiogenic


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41M assaulted in street, stabbed in L sideof chest.

VS 90/60, HR 130, RR 40s, O2 Sat 85% Decrease BS on Left, Left JVD, tracheal

shift toward Right


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Compressive Shock

External forces compress the chambers ofthe heart or great veins (VC) resulting indecreased cardiac filling / cardiac output.

Mechanism of Tension Pneumothorax?


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Tension Pneumothorax


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Other Method of CompressiveShock?

PericardialTamponade

Compression by fluidin pericardial sacobstructs contractionby heart

Sx: Becks Triad


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Pericardial Tamponade


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ED Thoracotomy: Survival based

on mechanism

J Trauma. 1998 Jul;45(1):87-94


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22M s/p high speed car accident, head oncollision, flipped restrained driver

VS HR 140, BP 90/60, RR 15

Unresponsive Chest / Abdomen bruising all over surface,

distended, tender diffusely


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Initial CXR negative

Despite volume resuscitation w/ 2 L NS,no improvement in hemodynamics

DPL - gross blood in abdomen


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Hypovolemic shock

Acute blood loss in trauma patient results in lossof circulatory volume SNS stimulation, Release of epinephrine and

norepinephrine Vasopressin release Activation of Renin angiotensin cascade Vasosconstriction to maintain cerebral and coronary

blood flow Shock in a trauma patient should be presumed

to be due to hemorrhage until proven otherwise


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Sources of Bleeding

External Thoracic - CXR Intraperitoneal

DPL FAST CT

Retroperitoneal Pelvic Fractures CT, angiography


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Initial Resuscitation in HypovolemicShock

Vascular Access Large bore IV access in upper extremities

(14 -16 g)

Central veins (Introducer) Femoral vs Neck

Saphenous vein cutdown


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Initial Fluid Resuscitation 1-2 L bolus Isotonic Fluid (Formula?)

Repeat x 2

Normal Saline (.9% NaCl) Isotonic Hi chloride Hyperchloremic acidosis

Lactated Ringers Lactate and acetate to buffer acidemia which occurs w/ shock

state

Need __? volume of resuscitation crystalloid tocompensate for same volume of blood loss


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Colloids

Albumin or Starch Expand intravascular volume much more than

crystalloid Theoretical advatange that would require less

volume of resuscitation No clear evidence that is better than crystalloids Much less available


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Hypertonic Saline

7.5% Saline Solution Pull intracellular water out into intravascular

space

Much better blood volume expansion Some evidence of favorable effects on

inflammatory response to injury Less cellular edema associated w/ damage May be good for situations where large volume

resuscitation is not available (ie mass casualties,combat)


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Tranfusion

Data suggests limiting transfusions incritically ill Poorer overall outcome Immunosuppresses? May be true in euvolemic ICU patient

But in SHOCK..first priority is to restoreintravascular volume


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ACS guidelines

Hb 7 g/dl is adequate in a young patient (NoCAD, bleeding controlled)

Hb 8 g/dl is adequate in a young patient who

may be at slight risk for further bleeding. Hb 9 g/dl is required if the risk of bleeding issubstantial.

Hb 10 g/dl should be the goal if overt ischemia

is present or there is a significant risk of occultischemic disease (peripheral vascular disease,CAD)


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Irreversible shock Ongoing fluid / blood

requirement despitecontrol of hemorrhage

Persistent hypotensiondespite restoration ofintravascular volume

Futile cycle ofuncorrectablehypothermia,hypoperfusion, acidosis,coagulopathy

Inevitably terminal


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74F BIBA found passed out in Hotsummer apartment, lethargic, febrile,delerious

CVA tenderness, Dirty UA, Cloudy urine Fever 102, HR 110, BP 80/50, RR 20 WBC 24


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Treatment

Antibiotics Resuscitation w/ crystalloid Operative drainage of infected collections

Inotropes


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19M diving into pool, hit head at bottom Grasping neck and head when rescued

from water BIBA limp, sensory deficits VS HR 50, BP 80/40


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Neurogenic Shock

Diminished tissue perfusion d/t loss ofvasomotor tone to peripheral arterial beds

Cspine or Hi Tspine injuries disruptsympathetic regulation of vascular tone

No sympathetic imput to heart to increaseHR and contractility, No catecholaminerelease


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Initial Treatment

Secure airway Fluid resuscitation

Vasoconstrictors to improve vascular tone


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Cardiogenic Shock

Circulatory pump failure resulting in tissuehypoxia Direct myocardial contusion

Valvular injury Pre-existing cardiac disease + trauma

Decrease cardiac output in face of adequateintravascular volume=> Heart Failure


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Diagnosis

Measure Cardiac Output by Swan GanzCatheter

Transesophageal echocardiography

Hi CVP, Wedge Pressure, Low CO


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Treatment

Maintain intravascular volume, but do notoverload (Heart failure, pulmonary edema)

Inotrophic support Dobutamine Dopamine Epinephrine

Intra-aortic balloon pump


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Hemodynamic Profiles

K lk

j

PCWP CVP CO/CI SVR/I Hypovolemic Low Low Low High

Cardiogenic High High Low High

Inflammatory Low / N Low/N High Low

Neurogenic Low Low Low Low

Shock

shock and resuscitation

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