Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation Ziad Sifri, MD Surgical Fundamentals and Algorithmic App

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Learning Objectives. Definition, diagnosis and types of shockHemorrhagic 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 patientsInitial assessment of patients in non-Hemorrhagic s
Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation ...

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1. Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation Ziad Sifri, MD Surgical Fundamentals and Algorithmic Approach to Patient Care Session#7: 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

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 > -2 Chem-7: ?Bicarb Lactate: >2 Metabolic acidosis 2nd to Inadequate tissue perfusion Shift to anaerobic metabolism Production of lactic acid

9. Pitfalls

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

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?

21. Goal #2 ?Support the patient?

23. A - Establish good IV access

24. B - Fluid Resuscitation

26. B - Fluid Resuscitation

27. The effect of the 3:1 Rule

28. Assess patient?s response to fluid resuscitation Clinical parameters: MS: return of CVS: HR, MAP Urinary output Laboratory parameters: BD, Acid/base balance Lactate

29. Assess patient?s 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%. What?s next?

32. Portable CXR

33. Case #1 What?s next? Chest tube puts out 1 liter of blood. What?s next?

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. ???

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

46. Before What?s next??

47. Pelvic: Angiogram

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

51. ?Hypovolemic Shock?

52. ?Hypovolemic Shock?

53. ?Septic Shock?

54. ?Septic Shock?

55. ?Cardiogenic Shock?

56. ?Cardiogenic Shock?

57. ?Obstructive Cardiogenic Shock?

58. ?Neurogenic Shock?

59. ?Neurogenic Shock?

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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