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Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation Ziad Sifri, MD Surgical Fundamentals and Algorithmic Approach to Patient Care






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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. Learning Objectives. Definition, diagnosis and types of shock Hemorrhagic shock ( I-IV )
Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation Ziad Sifri, MD Surgical Fundamentals and Algorithmic Approach to Patient Care

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Slide1 l.jpgSlide 1

Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation

Ziad Sifri, MD

Surgical Fundamentals and Algorithmic Approach to Patient Care

Session#7: August 17, 2007

Learning objectives l.jpgSlide 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

Slide3 l.jpgSlide 3

The real goal however…….

is to avoid ….

Shock l.jpgSlide 4

“Shock”

  • Definition: Inadequate tissue Perfusion and Oxygenation

  • Effect: Cellular injury, Organ failure, Death

  • Causes: hemorrhagic and non-hemorrhagic

Types of shock l.jpgSlide 5

Types of Shock

?

Types of shock6 l.jpgSlide 6

Types of Shock

Shock clinical diagnosis l.jpgSlide 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)

Shock laboratory support l.jpgSlide 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

Pitfalls l.jpgSlide 9

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

Slide10 l.jpgSlide 10

Other Pitfalls….

  • Urine output adequate

  • despite shock

    • Alcohol

    • Hyperglycemia

    • Home medication: diuretics..

    • Therapeutic intervention: Mannitol

    • IV contrast: CT, Angio

    • Residual urine…

    • DI

    • Etc…

General outline l.jpgSlide 11

General Outline

  • Definition, diagnosis and types of shock

  • Hemorrhagic shock: Classes and Resuscitation

Hemorrhage trauma l.jpgSlide 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

Slide13 l.jpgSlide 13

Hemorrhagic Shock: “The Classes”

“Class I”

“Class II”

“ClassIII”

“Class IV”

EBL

EBL

EBL

EBL

<750cc

<15% of TBV

750cc – 1500cc

15 – 30% of TBV

1.5L – 2L

30 – 40% of TBV

>2L

>40% of TBV

S&S

S&S

S&S

S&S

HR: increased

Pulse Pressure: decreased

BP: no change

HR: increased

BP: decreased

MS: agitated

Urine Output: decreased

None/minimal

HR: increased

BP: decreased (<60)

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

General outline14 l.jpgSlide 14

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 l.jpgSlide 15

Two Goals in the management of “any” Shock

Two goals in the management of hemorrhagic shock l.jpgSlide 16

Two Goals in the management of Hemorrhagic Shock

Goal 1 identification and treatment of the cause l.jpgSlide 17

Goal #1 “Identification and Treatment of the cause”

Slide18 l.jpgSlide 18

Algorithm to Identify the Bleeding Source

in a Hypotensive Trauma Patient

5 Possible locations

for significant bleeding

1

2

5

3

4

Abdominal Cavity

Pelvis/Retroperitoneum

External Bleeding

Long Bones

Chest cavity

Clue:

Clue:

Clue:

Clue:

Clue:

1) Deformed extremity

2) Crush injury

3) Mangled extremity

  • Abdominal trauma

  • Distended abdomen

  • Abdominal/Pelvic trauma

  • Flank ecchymosis

  • Unstable pelvis

  • Hematuria

Blood on Floor

→ Check head/scalp

→ Check extremity

  • Chest trauma

  • Diminished breath sounds

  • Desaturation, ↑O2 requirement

Place chest tube

On affected side

EBL

Femur Fx 750cc–1L

Tib Fx 500-750cc

Chest

X-Ray

(+) Ptx-Htx

Scalp

bleed

Extremity

Bleed

First do DPL

(supra umbilical)

r/o intrabdominal

bleed

Pelvic

X-Ray

(+) Fx

FAST →

Free fluid

  • DPL → (+)

  • Gross blood

  • >105 RBCs

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 > systolic BP

Be alert for

compartment

syndrome

Angioembolization

Slide19 l.jpgSlide 19

Algorithm to Identify the Bleeding Source

in a Hypotensive Trauma Patient

5 Possible locations

for significant bleeding

1

2

5

3

4

Abdominal Cavity

Pelvis/Retroperitoneum

External Bleeding

“floor”

Long Bones

Chest cavity

Slide20 l.jpgSlide 20

Algorithm to Identify the Bleeding Source

in a Hypotensive Trauma Patient

5 Possible locations

for significant bleeding

1

2

5

3

4

Abdominal Cavity

Pelvis/Retroperitoneum

External Bleeding

“floor”

Long Bones

Chest cavity

Clue:

Clue:

Clue:

Clue:

Clue:

1) Deformed extremity

2) Crush injury

3) Mangled extremity

  • Abdominal trauma

  • Distended abdomen

  • Abdominal/Pelvic trauma

  • Flank ecchymosis

  • Unstable pelvis

  • Hematuria

Blood on Floor

→ Check head/scalp

→ Check extremity

  • Chest trauma

  • Diminished breath sounds

  • Desaturation, ↑O2 requirement

Place chest tube

On affected side

EBL

Femur Fx 750cc–1L

Tib Fx 500-750cc

Chest

X-Ray

(+) Ptx-Htx

Scalp

bleed

Extremity

Bleed

First do DPL

(supra umbilical)

r/o intrabdominal

bleed

Pelvic

X-Ray

(+) Fx

FAST →

Free fluid

  • DPL → (+)

  • Gross blood

  • >105 RBCs

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 > systolic BP

Be alert for

compartment

syndrome

Angioembolization

Goal 2 support the patient l.jpgSlide 21

Goal #2 “Support the patient”

Slide22 l.jpgSlide 22

Establish IV access before it is too late

A establish good iv access l.jpgSlide 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!)

B fluid resuscitation l.jpgSlide 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

Slide25 l.jpgSlide 25

Electrolyte composition of crystalloid solutions

LR, lactated Ringer’s solution; NS, normal saline solution

B fluid resuscitation26 l.jpgSlide 26

B - Fluid Resuscitation

  • Intravascular effect

    • 3 for 1 rule of Volume replacement: Volume lost

The effect of the 3 1 rule l.jpgSlide 27

The effect of the 3:1 Rule

Assess patient s response to fluid resuscitation l.jpgSlide 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

Assess patient s response to fluid resuscitation29 l.jpgSlide 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!

Avoid the lethal triad l.jpgSlide 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

Case 1 l.jpgSlide 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 O2Sats are 92% on an FiO2 of 100%.

What’s next?

Portable cxr l.jpgSlide 32

Portable CXR

What’s wrong with this x-ray??

Case 133 l.jpgSlide 33

Case #1

  • What’s next?

    Chest tube puts out 1 liter of blood.

  • What’s next?

Slide34 l.jpgSlide 34

Case #1: CT Chest

Slide35 l.jpgSlide 35

?

Case 2 l.jpgSlide 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?

Case 237 l.jpgSlide 37

Case #2

Management ?

  • Goal #1

    A- Locate the source of bleeding

    B- Control it

  • Goal #2

    A- Establish IV access

    B- Fluid Resuscitation

Slide38 l.jpgSlide 38

???

WHY IS THE PATIENT HYPOTENSIVE ?

Don’t Get The Floor WET !!!!

Slide39 l.jpgSlide 39

Case #2

SOURCE of BLEEDING

? ? ?

Whip stitch scalp laceration l.jpgSlide 40

Whip Stitch scalp laceration

What is missing l.jpgSlide 41

What is missing ?

Bilateral tourniquets l.jpgSlide 42

Bilateral Tourniquets

Case 243 l.jpgSlide 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

Slide44 l.jpgSlide 44

NEXT???

  • DPL? FAST?

  • Pelvic X-ray?

Portable pelvic x ray l.jpgSlide 45

Portable Pelvic X-Ray

What’s next?

Before l.jpgSlide 46

Wrapping the pelvis with a sheet

Before

After

What’s next??

Slide47 l.jpgSlide 47

Pelvic: Angiogram

Bleeding Controlled by Angio-Embolization

General outline48 l.jpgSlide 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

Slide49 l.jpgSlide 49

Hypotension/Shock

Diagnosis

  • Hypotension (SBP<100)

  • Tachycardia

  • Tachypnea; Sa O2 <90%

  • 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

  • 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

First Step in MGT

Slide50 l.jpgSlide 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

Hemorrhagic

Shock

Cardiogenic Shock

Spinal Shock

Septic Shock

Cause

1. External fluid loss

2. 3rd Spacing

Cause

Cause

Obstructive

Non-obstructive

Cause

SCI (>T4 level)

Infection

DDX

1. Trauma (*5)

2. Post-op bleeding

3. GI bleeding

Cause

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

1.Fluid resuscitation

2.Find source of

bleeding and control it

3.Correct coagulopathy

Treatment

1. Identify & drain source of infection

2. Start appropriate Abx

3. Supportive care

- Fluid resuscitation

- Vaso pressors

(Phenylephirine, Norepinephrine)

Hypovolemic shock l.jpgSlide 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

Hypovolemic shock52 l.jpgSlide 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

  • Septic shock l.jpgSlide 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

    Septic shock54 l.jpgSlide 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

  • Cardiogenic shock l.jpgSlide 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

    Cardiogenic shock56 l.jpgSlide 56

    “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 l.jpgSlide 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

    Neurogenic shock l.jpgSlide 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

    Neurogenic shock59 l.jpgSlide 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

  • Slide60 l.jpgSlide 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

    Hemorrhagic

    Shock

    Cardiogenic Shock

    Spinal Shock

    Septic Shock

    Cause

    1. External fluid loss

    2. 3rd Spacing

    Cause

    Cause

    Obstructive

    Non-obstructive

    Cause

    SCI (>T4 level)

    Infection

    DDX

    1. Trauma (*5)

    2. Post-op bleeding

    3. GI bleeding

    Cause

    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

    1.Fluid resuscitation

    2.Find source of

    bleeding and control it

    3.Correct coagulopathy

    Treatment

    1. Identify & drain source of infection

    2. Start appropriate Abx

    3. Supportive care

    - Fluid resuscitation

    - Vaso pressors

    (Phenylephirine, Norepinephrine)

    Case 3 l.jpgSlide 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

    Case 4 l.jpgSlide 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

    Conclusion l.jpgSlide 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

    Thank you l.jpgSlide 64

    THANK YOU

    ?

    Thank you good luck l.jpgSlide 65

    THANK YOU&GOOD LUCK


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