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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 July 30, 2010 – 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
  • July 30, 2010

2
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

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

5
Types of Shock
S Septic Spinal
H Hypovolemic Hemorrhagic
O Obstructive
C Cardiogenic
K Anaphylactic
6
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

7
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

8
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

9
Other Pitfalls.
  • Urine output adequate
  • despite shock
  • Alcohol
  • Hyperglycemia
  • Home medication diuretic..
  • Therapeutic intervention Manitol
  • IV contrast CT, Angio
  • Old residual urine
  • Etc

10
General Outline
  • Definition, diagnosis and types of shock
  • Classes of Hemorrhagic shock and resuscitation

11
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

12
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
13
General Outline
  • Definition, diagnosis and types of shock
  • Classes of Hemorrhagic shock
  • Algorithm for identifying the location of
    bleeding

14
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
15
Two Goals in the management of Hemorrhagic Shock
Support the patient
Establish IV access
Fluid Resuscitation
ID and Tx the cause
Locate the source of bleeding
Control it
16
Goal 1
Identification and Treatment of the cause
1-Locate the source of bleeding
2-Control it
17
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
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
Goal 2
Support the patient
1-Establish IV access
2-Fluid Resuscitation
20
Goal 2
Support the patient
1-Establish IV access
21
Establish IV access before it is too late
22
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!)

23
Goal 2
Support the patient
2-Fluid Resuscitation
24
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

25
Electrolyte composition of crystalloid solutions
Fluid pH 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 Ringers solution NS, normal saline
solution
26
The 31 Rule
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
  • Non responders
  • Something is still bleeding!
  • Need for invasive monitoring

29
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

30
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.
  • Whats next?

31
Portable CXR
32
Case 1
  • Diagnosis?
  • Management?

33
Case 1 CT Chest
34
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.

35
Case 2
  • Dx?
  • Type of shock? Class?
  • Initial Management ?

36
Whip Stitch head laceration
37
What is missing ?
38
The Tourniquet
39
???
WHY IS THE PATIENT HYPOTENSIVE ?
AVOID GETTING THE FLOOR WET !!!!
40
Case 2
  • Still hypotensive!!!
  • He has received 2 L crystalloids 2 units PRBCs
  • CXR Normal

41
Portable Pelvic X-Ray
42
Before
After
43
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

44
Hypotension/Shock
Diagnosis
  1. Hypotension (SBPlt100)
  2. Tachycardia
  3. Tachypnea Sa O2 lt90
  4. Oliguria
  5. Change in mental status (confusion, agitation)
  6. 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. Make sure patient is on ECG monitor and Pulse Ox.
  2. Administer O2
  3. Insure adequate IV access
  4. Place foley catheter
  5. Place CVP line (when indicated)
  6. Order EKG
  7. Chest X-ray r/o Ptx

45
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)
46
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

47
Hypovolemic Shock
  • Hemodynamically
  • Low to normal PCW (due to fluid losses)
  • Normal or Decreased CO
  • High SVR (compensation)

48
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

49
Septic Shock
  • Hemodynamically
  • Low to normal PCW (vasodilatation and fluid
    losses)
  • Normal or increased CO
  • Low SVR (primary condition!)

50
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

51
Cardiogenic Shock
  • Hemodynamics
  • Elevated filling pressures
  • Diminished cardiac output due to pump failure
  • Increased SVR (compensation)

52
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

53
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

54
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

55
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)
56
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.

57
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

58
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

59
THANK YOU
  • ?
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