Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation Ziad Sifri, MD

Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation

Ziad Sifri, MD

Surgical Fundamentals and Algorithmic Approach to Patient CareJuly 30, 2010

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

The real goal however…….

is to avoid ….

Definition

• Def: Inadequate tissue Perfusion and Oxygenation

• Effect: Cellular injury, Organ failure, Death

• Causes: hemorrhagic and non-hemorrhagic

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

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: diuretic..•Therapeutic intervention: Manitol•IV contrast: CT, Angio•Old residual urine…•Etc…

General Outline

• Definition, diagnosis and types of shock

• Classes of Hemorrhagic shock 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


• Classes of Hemorrhagic shock

• Algorithm for identifying the location of bleeding

Algorithm to Identify the Bleeding Source in a Hypotensive Trauma Patient

Whip-stitch with

nylon suture

ExtremityBleed

Scalp 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-Htx

PelvicX-Ray(+) Fx

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

Goal #1

“Identification and Treatment of the cause”

1-Locate the source of bleeding

2-Control it


Long BonesAbdominal CavityChest cavity Pelvis/Retroperitoneum External Bleeding


1 2 3 4 5


Whip-stitch with

nylon suture

ExtremityBleed

Scalp 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


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-Htx

PelvicX-Ray(+) Fx

Goal #2


1-Establish IV access

2-Fluid Resuscitation

Goal #2


1-Establish IV access

Establish IV access before it is too late

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!)

Goal #2


2-Fluid Resuscitation

Fluid ResuscitationInitial 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

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

The 3:1 Rule

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

• Non responders:– Something is still bleeding!– Need for invasive monitoring

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

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.

What’s next?

Portable CXR

Case #1

• Diagnosis?

• Management?

Case #1 : CT Chest

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.

Case #2

Dx?

Type of shock? Class?

Initial Management ?

Whip Stitch head laceration

What is missing ?

The Tourniquet

???

WHY IS THE PATIENT HYPOTENSIVE ?

AVOID GETTING THE FLOOR WET !!!!

Case #2

Still hypotensive!!!

He has received: 2 L crystalloids 2 units PRBCs

CXR: Normal

Portable Pelvic X-Ray

Before After

General Outline


• 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

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

Infection

Obstructive

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, Open wounds…

Again : 2 goals1- ID and Tx the cause

Control fluid losses: surgical, wound coverage…

2- Support the Patient

Hypovolemic Shock

Hemodynamically:

*Low to normal PCW (due to fluid losses)

Normal or Decreased CO

High SVR (compensation)

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


Septic Shock

Hemodynamically:

Low to normal PCW (vasodilatation and fluid losses)

Normal or increased CO

*Low SVR (primary condition!)

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…


Cardiogenic Shock

Hemodynamics:

Elevated filling pressures

*Diminished cardiac output due to pump failure

Increased SVR (compensation)

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

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

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

Shock

HypovolemicShock

Spinal Shock

Cardiogenic Shock

1. External fluid loss2. 3rd Spacing

CVP, PCW: decreasedCO: decreasedSVR: increased

1. Fluid resuscitation2. Control/replace fluid losses

Infection

Obstructive

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, 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.

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

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

THANK YOU

?

Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation Ziad Sifri, MD

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