Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation
Ziad Sifri, MD
Surgical Fundamentals and Algorithmic Approach to Patient CareSession#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
ExtremityBleedScalp
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-HtxPelvicX-Ray(+) Fx
Algorithm to Identify the Bleeding Source in a Hypotensive Trauma Patient
Long BonesAbdominal CavityChest cavity Pelvis/Retroperitoneum External 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
ExtremityBleedScalp
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“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-HtxPelvicX-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 #218 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??
AfterWrapping 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
InfectionObstructive
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 goals1- 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 goals1 - 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
InfectionObstructive
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
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