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?

How useful and sensitive are clinical findings in the diagnosis of shock?

• Introduction

• Methods

• How useful?

• How sensitive?

• Conclusions

Introduction

Shock represents the failure of the

circulatory systems to maintain adequate

delivery of oxygen and other nutrients to

tissues.

Classification of Shock

Distributive(septic shock)

Obstructive(pulmonary embolism)

Cardiogenic(myocardial infarction)

Hypovolemic(hemorrhage)

PA

OP

CO

S

VR

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

Are clinical findingsuseful in the diagnosis of

Shock?

Clinical Findings

Hypotension Tachycardia Altered mental status Delayed capillary refill Decreased urine output Cool skin Cold extremities

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.

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.

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.

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.

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

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.

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

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

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

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.

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

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

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

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]

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

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

Are clinical findingssensitive in the diagnosis of

Shock?

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%

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

What can we learn from shock clinical trials?

• Cardiogenic Shock

• Septic Shock

• Obstructive Shock

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.

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

+ 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.

Outcomes in Pulmonary Embolism

100 %

0 %

10 %

30 %

70 %

Mortality

Sudden Death

Cardiac Arrest

Shock

Severity

Embolism Size CardiopulmonaryStatus

Wood KE. CHEST 2002

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

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.

Useful?

Yes.

Sensitive?

No.

“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