Resuscitation and Shock

1. Resuscitation and Shock LSU Medical Student Clerkship, New Orleans, LA

2. Goals • Provide an introduction to the ABC’s of resuscitation in the ED • Review available oxygen delivery devices and airway adjuncts • Describe the pathophysiology of shock and its major subtypes • Provide an introduction to the basics of treatment of shock in the ED

3. Shock • Shock is defined as circulatory insufficiency that creates an imbalance between tissue oxygen supply and oxygen demand. The result of shock is global tissue hypoperfusion and is associated with a decreased venous oxygen content and metabolic acidosis (lactic acidosis).

4. Pathophysiology of Shock • Imbalance between tissue supply and demand Anaerobic Metabolism Lactic Acid Production

5. Emergency Medicine Always Starts with the ABC’s • Compressions • A – Airway • B - Breathing • C - Circulation

6. Airway • Remove any obstructions • Head tilt, chin lift • Jaw Thrust • Oropharyngeal and nasopharyngeal airways • Orotracheal and nasotracheal intubation • Cricothyroidotomy and Tracheotomy

7. Jaw Thrust

8. Head Tilt

9. Nasopharygeal airway

10. Orotracheal airway

11. Supraglottic devices

12. Orotracheal

13. Neck airways

14. challenges…

15. Rapid Sequence Intubation • Assume every ED patient has a full stomach • Combination of sedation and paralysis to facilitate procedure • Evidence based to increase chance of success and decrease incidence of aspiration • Not without its dangers: paralyzing a patient who cannot be ventilated

16. Rapid Sequence Intubation • Assume every ED patient has a full stomach • Combination of sedation and paralysis to facilitate procedure • Evidence based to increase chance of success and decrease incidence of aspiration • Not without its dangers: paralyzing a patient who cannot be ventilated

17. RSI Indications • Airway Protection • Respiratory Failure • Expected Clinical Course

18. Breathing • Hypoxic Respiratory Failure • Hypercapnic Respiratory Failure • Mechanical Respiratory Failure

19. Oxygen Delivery Devices • Nasal Cannula - up to 40% FiO2 • Venturi mask - fixed 25% to 50% FiO2 • Nonrebreather mask - theoretical 100% FiO2 • Bag Valve Mask – 100%FiO2 • Noninvasive Positive Pressure Ventilation (BiPAP or CPAP) FiO2 up to 100% based on setting

20. Nasal cannula/ Venturi mask

22. Positive pressure ventilation

23. Circulation • Restoration of a pulse is the first goal • ACLS • However having a pulse is not the end of the story • Adequate circulation requires correction of original mismatch

24. Types of Shock • Hypovolemic • Cardiogenic • Distributive • Obstructive

25. Hypovolemic Shock • Caused by inadequate circulating volume (decreased preload) • Hemorrhage (trauma, ruptured AAA, GI bleeding) • Fluid loss (diarrhea, vomiting, poor intake, burns, third spacing)

26. Cardiogenic Shock • Caused by pump failure (decreased cardiac output) • Myopathic – systolic dysfunction, diastolic dysfunction • Dysrrythmic – disorganized cardiac activity

27. Distributive Shock • Caused by maldistribution of bloodflow from peripheral vasodilatation and decrease in SVR (decreased afterload) • Sepsis • Neurogenic • Anaphylaxis • Toxic shock syndrome

28. Obstructive shock • Caused by extracardiac obstruction to blood flow • Cardiac tamponade, tension pneumothorax, pulmonary embolus

29. Clinical Presentation of Shock • Clinical presentation varies with type of shock • History and physical are key for determining underlying cause • Hypotension is very common • Altered mental status may be most sensitive sign of illness • Lethargy, cool clammy skin, tachypnea, tachycardia, and cyanosis are common as well DIAGNOSE THE UNDERLYING CAUSE!!!!

30. Treating Shock • Early intervention is vital to reducing morbidity and mortality • All efforts are aimed at balancing maximizing tissue oxygen supply decreasing tissue oxygen demand

31. Systemic inflammatory response syndrome • Early phase • 1) temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F); • (2) heart rate faster than 90 beats/min; • (3) respiratory rate faster than 20 breaths/min; • (4) white blood cell count greater than 12.0 less than 4.0 , or with greater than 10 percent bands

32. Multi organ disease • myocardial depression • adult respiratory distress syndrome, • disseminated intravascular coagulation, • hepatic failure • renal failure.

33. Early Goal Directed Shock Therapy

34. Treating Shock - Breathing • Maximize oxygenation (Keep Sa02 > 93%) • Control the work of breathing. Respiratory muscles are highly metabolic and can greatly increase oxygen demand.

35. Treating Shock – Fluid Resuscitation • Most patients in shock have either an absolute or relative volume deficit, except the patient in cardiogenic shock with pulmonary edema • Central venous catheterization can guide help guide via central venous pressure monitoring and SVCO2 monitoring • A good bolus is a bold bolus!! • Massive trauma transfusion- more blood products/ crystalloids

36. Treating Shock – Vasopressors • Vasopressor agents are used when there has been an inadequate response to volume resuscitation or when a patient has contraindications to volume infusion • Vasopressors are most effective after fluid resuscitation but may be necessary to avoid prolonged hypotension • Goal is generally a MAP of 65

37. Treating Shock – Vasopressors

38. Treating Shock – Endpoints • No therapeutic end point is universally effective, and only a few have been tested in prospective trials, with mixed results.

39. Treating Shock – Endpoints

40. Take Home Points • The goal of resuscitation is to maximize survival and minimize morbidity using objective hemodynamic and physiologic values to guide therapy. • The first few hours are vital. • Diagnose and treat the underlying cause!!! • Stay ahead of shock!!!!!!!