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Resuscitation and Shock. LSU Medical Student Clerkship, New Orleans, LA. 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 - PowerPoint PPT Presentation
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Resuscitation and Shock
LSU Medical Student Clerkship, New Orleans, LA
Resuscitation
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
Resuscitation
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).
Resuscitation
Pathophysiology of Shock
Imbalance between tissue supply and demand Anaerobic Metabolism Lactic Acid Production
Resuscitation
Emergency Medicine Always Starts with the ABC’s
Compressions
A – Airway
B - Breathing
C - Circulation
Resuscitation
Airway
Remove any obstructions Head tilt, chin lift Jaw Thrust Oropharyngeal and nasopharyngeal airways Orotracheal and nasotracheal intubation Cricothyroidotomy and Tracheotomy
ResuscitationJaw Thrust
ResuscitationHead Tilt
ResuscitationNasopharygeal airway
ResuscitationOrotracheal airway
ResuscitationSupraglottic devices
ResuscitationOrotracheal
ResuscitationNeck airways
Resuscitationchallenges…
Resuscitation
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
Resuscitation
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
ResuscitationRSI Indications
Airway Protection
Respiratory Failure
Expected Clinical Course
Resuscitation
Breathing
Hypoxic Respiratory Failure
Hypercapnic Respiratory Failure
Mechanical Respiratory Failure
Resuscitation
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
ResuscitationNasal cannula/ Venturi mask
Resuscitation
ResuscitationPositive pressure ventilation
Resuscitation
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
Resuscitation
Types of Shock
Hypovolemic Cardiogenic Distributive Obstructive
Resuscitation
Hypovolemic Shock
Caused by inadequate circulating volume (decreased preload)
Hemorrhage (trauma, ruptured AAA, GI bleeding) Fluid loss (diarrhea, vomiting, poor intake, burns,
third spacing)
Resuscitation
Cardiogenic Shock
Caused by pump failure (decreased cardiac output) Myopathic – systolic dysfunction, diastolic
dysfunction Dysrrythmic – disorganized cardiac activity
Resuscitation
Distributive Shock
Caused by maldistribution of bloodflow from peripheral vasodilatation and decrease in SVR (decreased afterload)
Sepsis Neurogenic Anaphylaxis Toxic shock syndrome
ResuscitationObstructive shock
Caused by extracardiac obstruction to blood flow
Cardiac tamponade, tension pneumothorax, pulmonary embolus
ResuscitationClinical 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!!!!
Resuscitation
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
ResuscitationSystemic 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
ResuscitationMulti organ disease
myocardial depression adult respiratory distress syndrome, disseminated intravascular coagulation, hepatic failure renal failure.
ResuscitationEarly Goal Directed Shock Therapy
Resuscitation
Treating Shock - Breathing
Maximize oxygenation (Keep Sa02 > 93%) Control the work of breathing. Respiratory muscles
are highly metabolic and can greatly increase oxygen demand.
ResuscitationTreating 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
Resuscitation
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
Resuscitation
Treating Shock – Vasopressors
Resuscitation
Treating Shock – Endpoints
No therapeutic end point is universally effective, and only a few have been tested in prospective trials, with mixed results.
Resuscitation
Treating Shock – EndpointsTable 30-8 Hemodynamic Resuscitation End Points Modality Goals
CVP 10–12 mm Hg Preload
PAOP 12–18 mm Hg
MAP 90–100 mm Hg Afterload
SVR = (MAP – CVP/CO)(80)
800–1400 dyne s/cm5
CO 5.0 L/min
CI 2.5–4.5 L per min m2
Contractility
SV = CO/heart rate 50–60 mL per min
Heart rate 60–100 bpm Avoid >100 bpm; this will decrease SV and increase myocardial oxygen consumption
Coronary perfusion pressure
CPP = DBP – CVP (or PAOP)
>60 mm Hg
ScvO2 or SmvO2
>70% Tissue oxygenation
Serum lactate <2mM/L
Resuscitation
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!!!!!!!