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Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation

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Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation Ziad Sifri, MD Surgical Fundamentals and Algorithmic Approach to Patient Care Session#7: August 17, 2007 – PowerPoint PPT presentation

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Title: Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation


1
  • Hypotension, Shock, Hemorrhage and IV Fluid
    Resuscitation
  • Ziad Sifri, MD
  • Surgical Fundamentals and Algorithmic Approach to
    Patient Care
  • Session7 August 17, 2007

2
Learning Objectives
  • Definition, diagnosis and types of shock
  • Hemorrhagic shock ( I-IV )
  • Initial management of patients in Hemorrhagic
    shock
  • Algorithm for the identifying of the location of
    bleeding
  • IV access and resuscitation of Trauma patients
  • Initial assessment of patients in non-Hemorrhagic
    shock
  • Diagnosis of the various types of non-Hemorrhagic
    shock
  • Management of non-Hemorrhagic shock
  • Case Scenarios

3
The real goal however. is to avoid .
4
Shock
  • Definition Inadequate tissue Perfusion and
    Oxygenation
  • Effect Cellular injury, Organ failure, Death
  • Causes hemorrhagic and non-hemorrhagic

5
Types of Shock
  • ?

6
Types of Shock
7
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)

8
Shock Laboratory Support
  • Metabolic acidosis
  • ABG Acidosis, BD gt -2
  • Chem-7 ?Bicarb
  • Lactate gt2
  • Metabolic acidosis 2nd to
  • Inadequate tissue perfusion
  • Shift to anaerobic metabolism
  • Production of lactic acid

9
Pitfalls
  • Extremes of age
  • Infantgt160 preschool 140 school age 120 adult
    100
  • Athletes
  • Pregnancy
  • Medications
  • Beta blockers, pacemaker
  • Hgb/Hct concentration
  • Unreliable for acute blood loss

10
Other Pitfalls.
  • Urine output adequate
  • despite shock
  • Alcohol
  • Hyperglycemia
  • Home medication diuretics..
  • Therapeutic intervention Mannitol
  • IV contrast CT, Angio
  • Residual urine
  • DI
  • Etc

11
General Outline
  • Definition, diagnosis and types of shock
  • Hemorrhagic shock Classes and Resuscitation

12
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

13
Hemorrhagic Shock The Classes
Class I
Class II
Class III
Class IV
EBL
EBL
EBL
EBL
lt750cc lt15 of TBV
750cc 1500cc 15 30 of TBV
1.5L 2L 30 40 of TBV
gt2L gt40 of TBV
SS
SS
SS
SS
HR increased Pulse Pressure decreased BP no
change
HR increased BP decreased MS agitated Urine
Output decreased
None/minimal
HR increased BP decreased (lt60) MS
decreased
Tx
Tx
Tx
Tx
Crystalloids
Crystalloids
1. Crystalloid (1 2L) 2. Transfusion (1
2units) 3. Identify source of Bleed(5)
1. Crystalloid (2L) 2. Transfusion (2 4
units) 3. Identify source of Bleed(5) 4. OR
14
General Outline
  • Definition, diagnosis and types of shock
  • Classes of Hemorrhagic shock
  • Initial management of patients in Hemorrhagic
    shock

15
Two Goals in the management of any Shock
16
Two Goals in the management of Hemorrhagic Shock
17
Goal 1 Identification and Treatment of the
cause
18
Algorithm to Identify the Bleeding Source in a
Hypotensive Trauma Patient
5 Possible locations for significant bleeding
1
2
5
3
4
Long Bones
Abdominal Cavity
Chest cavity
Pelvis/Retroperitoneum
External Bleeding
Clue
Clue
Clue
Clue
Clue
1) Deformed extremity 2) Crush injury 3) Mangled
extremity
Blood on Floor ? Check head/scalp ? Check
extremity
  • Abdominal trauma
  • Distended abdomen
  • Abdominal/Pelvic trauma
  • Flank ecchymosis
  • Unstable pelvis
  • Hematuria
  • Chest trauma
  • Diminished breath sounds
  • Desaturation, ?O2 requirement

Place chest tube On affected side
EBL Femur Fx 750cc1L Tib Fx 500-750cc
Extremity Bleed
Scalp bleed
Chest X-Ray () Ptx-Htx
First do DPL (supra umbilical) r/o
intrabdominal bleed
Pelvic X-Ray () Fx
  • DPL ? ()
  • Gross blood
  • gt105 RBCs

FAST ? Free fluid
Chest tube 1L of Blood
Consult Ortho
Whip-stitch with nylon suture
Pressure and Elevation
DPL (-)
DPL ()
Immobilization and minimal manipulation of
injured extremity using splint (3Ps)
1) Wrap sheet around pelvis 2) Pelvic angiography
OR ?Thoracotomy
Bleeding not controlled
OR ? Exploratory laparotomy
() Blush/Extravasation
  • Tourniquet proximal
  • to injury
  • set gt systolic BP

Be alert for compartment syndrome
Angioembolization
19
Algorithm to Identify the Bleeding Source in a
Hypotensive Trauma Patient
5 Possible locations for significant bleeding
1
2
5
3
4
Long Bones
Abdominal Cavity
Chest cavity
Pelvis/Retroperitoneum
External Bleeding floor
20
Algorithm to Identify the Bleeding Source in a
Hypotensive Trauma Patient
5 Possible locations for significant bleeding
1
2
5
3
4
Long Bones
Abdominal Cavity
Chest cavity
Pelvis/Retroperitoneum
External Bleeding floor
Clue
Clue
Clue
Clue
Clue
1) Deformed extremity 2) Crush injury 3) Mangled
extremity
Blood on Floor ? Check head/scalp ? Check
extremity
  • Abdominal trauma
  • Distended abdomen
  • Abdominal/Pelvic trauma
  • Flank ecchymosis
  • Unstable pelvis
  • Hematuria
  • Chest trauma
  • Diminished breath sounds
  • Desaturation, ?O2 requirement

Place chest tube On affected side
EBL Femur Fx 750cc1L Tib Fx 500-750cc
Extremity Bleed
Scalp bleed
Chest X-Ray () Ptx-Htx
First do DPL (supra umbilical) r/o
intrabdominal bleed
Pelvic X-Ray () Fx
  • DPL ? ()
  • Gross blood
  • gt105 RBCs

FAST ? Free fluid
Chest tube 1L of Blood
Consult Ortho
Whip-stitch with nylon suture
Pressure and Elevation
DPL (-)
DPL ()
Immobilization and minimal manipulation of
injured extremity using splint (3Ps)
1) Wrap sheet around pelvis 2) Pelvic angiography
OR ?Thoracotomy
Bleeding not controlled
OR ? Exploratory laparotomy
() Blush/Extravasation
  • Tourniquet proximal
  • to injury
  • set gt systolic BP

Be alert for compartment syndrome
Angioembolization
21
Goal 2 Support the patient
22
Establish IV access before it is too late
23
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!)

24
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

25
Electrolyte composition of crystalloid solutions
LR, lactated Ringers solution NS, normal saline
solution
26
B - Fluid Resuscitation
  • Intravascular effect
  • 3 for 1 rule of Volume replacement Volume lost

27
The effect of the 31 Rule
28
Assess patients response to fluid resuscitation
  • Clinical parameters
  • MS return of
  • CVS HR, MAP
  • Urinary output
  • Laboratory parameters
  • BD, Acid/base balance
  • Lactate

29
Assess patients response to fluid resuscitation
  • Three possible responses
  • Responders
  • Bleeding has stopped
  • Transient responders
  • Something is still slowly bleeding!
  • Non responders
  • Ongoing significant bleeding!
  • Immediate need for intervention!

30
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

31
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.
  • Whats next?

32
Portable CXR
Whats wrong with this x-ray??
33
Case 1
  • Whats next?
  • Chest tube puts out 1 liter of blood.
  • Whats next?

34
Case 1 CT Chest
35
?
36
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?

37
Case 2
  • Management ?
  • Goal 1
  • A- Locate the source of bleeding
  • B- Control it
  • Goal 2
  • A- Establish IV access
  • B- Fluid Resuscitation

38
???
WHY IS THE PATIENT HYPOTENSIVE ?
Dont Get The Floor WET !!!!
39
Case 2
SOURCE of BLEEDING ? ? ?
40
Whip Stitch scalp laceration
41
What is missing ?
42
Bilateral Tourniquets
43
Case 2
  • Still hypotensive despite bilateral tourniquets
    and despite whipstiching the scalp laceration
  • He has received 2 L crystalloids 2 units PRBCs
  • CXR Normal

44
NEXT???
  • DPL? FAST?
  • Pelvic X-ray?

45
Portable Pelvic X-Ray
Whats next?
46
Before
Wrapping the pelvis with a sheet
After
  • Whats next??

47
  • Pelvic Angiogram

Bleeding Controlled by Angio-Embolization
48
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

49
Hypotension/Shock
Diagnosis
  • Hypotension (SBPlt100)
  • Tachycardia
  • Tachypnea Sa O2 lt90
  • 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
  • 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

50
Shock
1
2
3
Hemodynamic findings
Hemodynamic findings
Hemodynamic findings
CVP, PCW decreased CO decreased SVR
increased
CVP, PCW decreased CO increased then
decreased SVR decreased
CVP, PCW increased CO decreased SVR
increased
Hypovolemic Shock
Cardiogenic Shock
Hemorrhagic Shock
Spinal Shock
Septic Shock
Cause
1. External fluid loss 2. 3rd Spacing
Obstructive
Non-obstructive
Cause
Cause
Cause
Infection
SCI (gtT4 level)
DDX
Cause
1. Trauma (5) 2. Post-op bleeding 3. GI bleeding
1. Tension PX 2. Cardiac tamponade 3. PE

1. AMI 2. CHF
Treatment
Treatment
1. Fluid resuscitation 2. Control/replace
fluid losses
Supportive Care ?Fluid to fill the tank ? Vaso
pressors (Phenylephirine, Norepinephrine)

Treatment
Treatment
1. CT placement 2. Pericardiocentesis 3. IV
Heparin
1. Diuresis - Lasix 2. Afterload
reduction - Nitroprusside, Nitroglycerine
- ACE inhibitor 3. Inotropic support -
Dobutamine, Milrinone
Treatment
Treatment
1. Fluid resuscitation 2. Find source of
bleeding and control it 3. Correct coagulopathy
1. Identify drain source of infection 2.
Start appropriate Abx 3. Supportive care -
Fluid resuscitation - Vaso pressors
(Phenylephirine, Norepinephrine)
51
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

52
Hypovolemic Shock
  • Hemodynamics
  • Low to normal PCW (due to fluid losses)
  • Normal or Decreased CO
  • High SVR (compensation)
  • Management
  • Fluids
  • No pressors
  • primary process

53
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

54
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

55
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

56
Cardiogenic Shock
  • Hemodynamics
  • Elevated filling pressures
  • Diminished cardiac output due to pump failure
  • Increased SVR (compensation)
  • Management
  • Diuresis
  • Afterload reduction
  • Inotropes
  • primary process

57
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

58
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

59
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

60
Shock
1
2
3
Hemodynamic findings
Hemodynamic findings
Hemodynamic findings
CVP, PCW decreased CO decreased SVR
increased
CVP, PCW decreased CO increased then
decreased SVR decreased
CVP, PCW increased CO decreased SVR
increased
Hypovolemic Shock
Cardiogenic Shock
Hemorrhagic Shock
Spinal Shock
Septic Shock
Cause
1. External fluid loss 2. 3rd Spacing
Obstructive
Non-obstructive
Cause
Cause
Cause
Infection
SCI (gtT4 level)
DDX
Cause
1. Trauma (5) 2. Post-op bleeding 3. GI bleeding
1. Tension PX 2. Cardiac tamponade 3. PE

1. AMI 2. CHF
Treatment
Treatment
1. Fluid resuscitation 2. Control/replace
fluid losses
Supportive Care ?Fluid to fill the tank ? Vaso
pressors (Phenylephirine, Norepinephrine)

Treatment
Treatment
1. CT placement 2. Pericardiocentesis 3. IV
Heparin
1. Diuresis - Lasix 2. Afterload
reduction - Nitroprusside, Nitroglycerine
- ACE inhibitor 3. Inotropic support -
Dobutamine, Milrinone
Treatment
Treatment
1. Fluid resuscitation 2. Find source of
bleeding and control it 3. Correct coagulopathy
1. Identify drain source of infection 2.
Start appropriate Abx 3. Supportive care -
Fluid resuscitation - Vaso pressors
(Phenylephirine, Norepinephrine)
61
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?
  • Goal 1 Source control, antibiotics
  • Goal 2 Hemodynamic Support
  • Swan CVP 5 PCW 8 C0 10 SVR 300

62
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?
  • Goal 1 r/o MI start appropriate treatment
    for MI
  • Goal 2 Hemodynamic Support
  • Swan CVP 15 PCW 18 C0 3 SVR 1300

63
Conclusion
  • How to recognize and diagnose shock
  • Types of shock (SHOCK) hemorrhagic
    non-hemorrhagic
  • Hemorrhagic Shock
  • Classes of hemorrhagic shock
  • Algorithm to find the location of bleeding and
    control it
  • Non-hemorrhagic shocks
  • the 2 key Goals in the management of any shock
  • Hemodynamic findings and support

64
THANK YOU
  • ?

65
THANK YOU GOOD LUCK
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