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Sergio Zanotti MDAssistant Professor of Medicine
Robert Wood Johnson Medical SchoolCooper University Hospital
Camden, New Jersey
How useful and sensitive are clinical findings in the diagnosis of shock?
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How useful and sensitive are clinical findings in the diagnosis of shock?
• Introduction
• Methods
• How useful?
• How sensitive?
• Conclusions
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Introduction
Shock represents the failure of the
circulatory systems to maintain adequate
delivery of oxygen and other nutrients to
tissues.
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Classification of Shock
Distributive(septic shock)
Obstructive(pulmonary embolism)
Cardiogenic(myocardial infarction)
Hypovolemic(hemorrhage)
PA
OP
CO
S
VR
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Methods
Medline: January 1966 to April 2006 Key Words: Shock, clinical findings, physical
exam, examination, diagnosis, blood pressure, capillary refill, temperature, sensitivity, hypovolemia, sepsis, cardiogenic.
Based on review of titles and abstracts relevant articles were retrieved
Bibliographies of articles and of physical diagnosis or shock articles/textbooks
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Are clinical findingsuseful in the diagnosis of
Shock?
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Clinical Findings
Hypotension Tachycardia Altered mental status Delayed capillary refill Decreased urine output Cool skin Cold extremities
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Blood pressure measurements in Shock.J. Cohn. JAMA 1967; 199:972.
Patients with hypotension or clinical diagnosis of shock.
If vasopressors were started, they were discontinued and BP was allowed to stabilize.
BP measures; Directly: Femoral or radial artery cannulation Indirectly: By auscultation/palpation method.
CO measured by indirect dilution method. PVR was calculated.
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Differences between direct and indirect BP measurements
SBP 33.1 mm Hg (+169 to –20) Direct pulse pressure 43 mm Hg Indirect pulse pressure 19 mm Hg
J. Cohn. JAMA 1967; 199:972.
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Blood Pressure Measurement in Shock
120
100
80
60
40
20
Pressure (mm Hg)
High PVR
Low PVR
Cuff Arterial Cuff Arterial
J. Cohn. JAMA 1967; 199:972.
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Clinical parameters for estimating severity of circulatory shock
Stage BP HR CR
(2min)
Urine
ml/h
Mental
Status
%
Loss
1 Normal Normal < 2 >39 Normal or anxious
< 15
2 Tilt + > 100 > 2 20 Anxious > 20
3 > 120 > 2 5 – 15 Confused > 30
4 > 140 > 2 0 – 5 Lethargic > 40
Weil, MH . Defining Hemodynamic Instability. Functional Hemodynamic Monitoring
2005 Springer.
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Capillary Refill: What is normal?Patient Group
Median False / + Rate
Upper Limit (95 % CI)
Y Fem. 0.7 sec 4.0%
Y Male 0.8 sec 4.0%
A Male 1.0 sec 4.0%
A Fem. 1.2 sec 13.7% 2.9 sec
E Male 1.5 sec 29.0% 4.5 sec
E Fem. 1.8 sec 29.0% 4.5 sec
Schriger DL. Ann Emerg Med 1998; 17:932
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Capillary Refill – Is it a Useful Predictor of Hypovolemic States? Schriger. Ann Emerg Med 1991; 20:601
Design: prospective, nonrandomized study. Patients:
(1) ED patients with history of hypovolemia + one: orthostatic vital signs (n 19) hypotension (n 13)
(2) Blood donors (n 47) Intervention: capillary refill measurement.
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Capillary Refill TimesMean (sec) SD Range
Blood donors
Before 1.9 0.7 0.6 – 3.7
After 1.1 0.7 0.9 – 4.0
Clinical pts.
Orthostatic 1.9 0.7 0.8 – 3.3
Hypotension 2.8 1.2 1.1 – 5.1
Total 2.2 1.0 0.8 – 5.1
Schriger. Ann Emerg Med 1991; 20:601
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Two-Second
Sens. Spec. Sens. Spec.
450 ml blood loss
11% 89% 6% 93%
Orthostatic 47% 86% 26% 95%
Hypotension 77% 86% 46% 95%
Total 59% 86% 34% 95%
Adjusted
Capillary refill in hypovolemia
Schriger. Ann Emerg Med 1991; 20:601
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Probability of Hypovolemia
Accuracy PPV NPV
10% 89% 43% 93%
25% 80% 69% 81%
50% 64% 87% 59%
90% 40% 98% 14%
Capillary refill in hypovolemia
Schriger. Ann Emerg Med 1991; 20:601
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Toe Temperature
Henning, R.J.,et al., Measurement of toe temperature for assessing the severity of acute circulatory failure. Surg Gynecol Obstet, 1979. 149(1); p. 1-7.
Joly, H.R. and M.H. Weil, Temperature of the great toe as an indication of the severity of shock. Circulation, 1969. 39(1); p. 131-8.
Ibsen B. Treatment of shock with vasodilators measuring skin temperature on the big toe. Dis Chest, 1967. 52:425.
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24 28 32 36
4
0
2
TOE TEMPERATURE °C
r = 0.71
CI= - 5.24 + T toe (0.286)
Ca
rdia
c In
dex
L
/min
/m2
Correlation between CI and Toe Temperature
Joly HR. Weil MH. Circulation 1969
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Cº TOE-AMBIENT
Henning RJ. Et al. Surg Gynecol Obstet.1979;149:1-7
AMI
Adm. Max. Pre-DC
Bacteremia
Adm. Max. Pre-DC
Hypovolemia
Adm. Max. Pre-DC
10
5
0
Cº
10
5
0
Cº
10
5
0
Cº
Survivors
Fatalities
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Toe temperature versus transcutaneous oxygen tension monitoring during acute circulatory failure. Vincent JL. Intensive Care Med 1988; 14:64
• Cardiogenic Shock Toe-ambient T gradient: strong correlation
with CI, stroke index, oxygen transport.
Toe-ambient T gradient > PTCO2
• Septic Shock Both techniques were poor indicators of
blood flow indexes
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Start with a subjective assessment of skin temperature to identify hypoperfusion in ICU patients. Kaplan CJ, et al. J Trauma 2001; 50:620-28
• Objective: Determine whether physical examination alone or with biochemical markers can accurately dx hypoperfusion.
• Design: retrospective data collection (n 264)• Two groups:
Cool skin temperature [CST] Warm skin temperature [WST]
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Value Cool Warm p
Cardiac output (L/min)
5.3 ± 2.2 8.2 ± 2.6 < 0.05
Cardiac index (L/min/m2)
2.9 ± 1.2 4.3 ± 1.2 < 0.05
pH 7.32 ± 0.2 7.39 ± 0.07 < 0.05
TCO2 (mEq/dL) 19.5 ± 3.1 25.1 ± 4.8 < 0.05
Svo2 (%) 60.2 ± 4.4 68.2 ± 7.8 < 0.05
Lactate (mmol/L) 4.7 ± 1.5 2.2 ± 1.6 < 0.05
Kaplan CJ, et al. J Trauma 2001
Hemodynamic and Biochemical Parameters
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Temperature
• All patients: Cool extremityPPV 39 % NPV 92 %
• CST group + HCO3 < 21 meg/dLPPV 98 % NPV 97 %
• Sepsis + cool extremity PPV 51.3 % NPV 88.9 %
• Sepsis + cool extremity + low HCO3PPV 68 % NPV 90 %
Kaplan CJ, et al. J Trauma 2001
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Are clinical findingssensitive in the diagnosis of
Shock?
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How good are our clinical skills?
Cardiac output
Wedge pressure
Connors
(NEJM ‘83)
ICU pts
44%
42%
Eisenberg
(CCM ‘84)
ICU pts
50%
33%
Bayliss
(BMJ ‘83)
CCU pts
71%
62%
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Diagnostic Accuracy of SBP < 95 mm Hg for Acute Blood Loss
Source, year Moderate BLSensitivity
(95 % CI)
Large BLSensitivity
(95 % CI)
Before BLSpecificity
(95 % CI)
Warren, 1945 13 … 100
Shenkin, 1944 … 36 100
Wallace, 1941 … 32 96
Skillman, 1967 … 56 100
Bergenwalkd, 1977 … 13 …
Summary measure ‡ 13 (0-50) 33 (21-47) 97 (90-100)
McGee S. JAMA 1999; 281:1022
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What can we learn from shock clinical trials?
• Cardiogenic Shock
• Septic Shock
• Obstructive Shock
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Clinical Profile of Suspected Cardiogenic Shock
• Report from SHOCK trial registry
• 28% of patients with shock had no pulmonary congestion.
• Mortality for these patients was 70%
Menon V. et al. J Am Coll Cardiol 2000; 36:1071.
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Early Goal-Directed Therapy for
Severe Sepsis and Septic Shock
Severe Sepsis +↓↓Blood Pressure or
↑↑Lactic acid
Standard (n 133)
Mortality 46.5%
EGDT (n 130)
Mortality 30.5%
Rivers et al. N Engl J Med 2001;345:1368-77
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+ MAP > 100 mmHg + Lactate > 4 mmol/L
Sepsis
MAP (mmHg)
ScVO2
Mortality
Control (n 23)
EGDT (n 25)
116
45 %
61 %
118
44 %
20 %
Donnino, MW et al. CHEST 2003; 124:90S.
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Outcomes in Pulmonary Embolism
100 %
0 %
10 %
30 %
70 %
Mortality
Sudden Death
Cardiac Arrest
Shock
Severity
Embolism Size CardiopulmonaryStatus
Wood KE. CHEST 2002
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Clinical Outcome of Patients With
Acute Pulmonary Embolism.
• 31% normotensive with RV dysfunction
10% developed PE related shock
Higher mortality than normotensive group
Grifoni S, et al. Circulation 2000;101:2817
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Conclusions
• Rigorous conclusions about the value of clinical findings in the diagnosis of shock are difficult to make because there are very few studies on this matter.
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Useful?
Yes.
Sensitive?
No.
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“the nose sharp, the eyes sunken, the temples fallen in, the ears cold and drawn in and their lobes distorted, the skin of
the face hard, stretched, and dry, and the color of the face
pale or dusky”
Hippocrates, 400 BC