View
653
Download
0
Category
Preview:
Citation preview
MY PATIENT IS IN SHOCK…NOW WHAT?
Chris Nickson FACEM FCICM Intensivist, The Alfred ICU
Financial Conflicts of Interest NO !
http://litfl.org/CONCEPTOS
OVE
RVIE
W
ResuscitationSeek & treat the cause!Fluid therapyVasoactive agents!Hemodynamic targetsRefractory Shock!
RESUSCITATION
(NOW WHAT?)
Shock is a state of !circulatory failure – !
tissue perfusion is inadequate !to meet the needs of the body!
Early recognition is vital!
Shock is not a diagnosis – !seek and treat the !underlying cause !
Requires a coordinated !team-based approach !
with simultaneous !assessment and management!
SEEK & TREAT THE CAUSE
(NOW WHAT?)
SHO
CK
C
AU
SES Pump
Rate / rhythmObstructiveVolumeEndocrineDistributive? (is there an error?)
Focused Assessment!
History!Examination!
Investigations!
Ultrasoundis!
Awesome!!
Courtesy of @emresus (Sam Ghali)!
SHO
CK
C
AU
SES Pump
Rate / rhythmObstructiveVolumeEndocrineDistributive? (is there an error?)
FLUID THERAPY
(NOW WHAT?)
“You can resuscitate a patient with
sterile dog piss if you want – just give the right amount of it!”!
Sir Malcolm Fisher!
Use crystalloids and !do not give “too much”!
Bolus and reassess…!usually up to about !
mL/kg20mL/kg!
Levitov and Marik (2012) PMC3171766!
Fluid responsiveness does not mean you should give fluid !
Give blood !if bleeding or significantly
anaemic
VASOACTIVE AGENTS
(NOW WHAT?)
Start early using !peripheral IV access!
Norepinephrine is first line vasoactive agent for
undifferentiated shock!(usually)!
HAEMODYNAMIC TARGETS
(NOW WHAT?)
MAP (mmHg)
65
Individualise targets according to !
the patient, the context!and the phase of illness!
Frequent assessment !of the whole patient is !more important than an!
invasive monitor
Other targets are !important too!!
!SaO2 PaCO2 pH glucose!
Lactate ScvO2!
REFRACTORY SHOCK
(NOW WHAT?)
Reassess frequently !and consider the !
underlying cause(s) !(PROVED?)!
Use Occam’s Razor but remember!
Hickam’s Dictum!!!!
“Let no one die without a !trial of steroids”!
!Hydrocortisone 50mg q6h!
Add vasoactive agents !and consider !
circulatory assist devices
SUM
MA
RY
ResuscitationSeek & treat the cause!Fluid therapyVasoactive agents!Hemodynamic targetsRefractory shock!
http://litfl.org/CONCEPTOS
Recommended