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This is a lecture by Dr. Patrick Carter from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
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Project: Ghana Emergency Medicine Collaborative Document Title: Shock Author(s): Patrick Carter (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
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CLASS I II III IV
BVL < 15% 15 - 30% 30 - 40% > 40%
AMOUNT 750 cc 750 - 1500 cc 1500 - 2000 cc > 2000 cc
PULSE <100 > 100 >120 >140
BP No change Narrowed pulse pressure
Consistent decrease in SBP
Decreased SBP and narrowed pulse pressure or no DBP
RESP No change 20-30 30-40 >35
CNS No change Anxiety Anxious, confused Confused. lethargic
Urine >30cc per hr 20-30cc per hr 5-15cc per hr negligible
TX Replace fluid loss
2L NS IV 2 L NS IV, usually requires blood transfusion
Rapid transfusion of blood and NS, requires immediate intervention to stop hemorrhage
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Rapid Response Transient Response
No Response
Vitals Return to normal Transient improvement with return to previous
Remain Abnormal
Estimated Blood loss
10-20% 20-40% with ongoing likely
Severe >40%
Need for more Fluid
Low High High
Need for Blood Type and cross Type specific O neg Need for surgery Possible Likely Highly likely
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B ,'=)(",-.(/"?5'7<6'2<"e8;.53<-6R"H3*'5+"'<"78l"4Vh^R"#cc!"B ,<FD:"<-7<"'G7632'D"F+'".@"72"'758:";.78"D35'(<'D"<-'57=:"78;.53<-6"<."<5'7<"=7)'2<+"I3<-"+'=)("+-.(/"W7+"D'12'D"%:"5'@57(<.5:"-:=.<'2+3.2".5"87(<7<'"o"JX"
B #SA"=7)'2<+"572D.68:"7++3;2'D"<."'3<-'5"<5'7<6'2<"756".5"<."+<72D75D"5'+F+(3<7).2"756+"W!Ac"*+l"!AAX"
B >.2<5.8"756"<5'7<'D"I3<-"+<72D75D"(75'"72D"7D63_'D"<."C>j"
B ?5'7<6'2<"756"@.88.I'D"=5.<.(.8"32"V0"@.5"S"-.F5+"72D"<-'2"7D63_'D"<."C>j"
B d32D32;+f$F<(.6'"B ?5'7<6'2<";5.F="5'('3*'D"6.5'"\F3D+"(.6=75'D"<."(.2<5.8";5.F="WP"i"*+l"AlP"iX"
B AlU"D7:+"8'++"32"-.+=3<78"@.5"<5'7<6'2<";5.F="B #"@.8D"8'++"(75D3.=F86.275:"(.6=83(7).2+"@.5"<5'7<6'2<";5.F="
B D&).2?&'#&8*12$0',0'+$#".),"7'$/'EFGFH'AP"
V758:"[.78"035'(<'D"?-'57=:"
H3*'5+"V"'<"78l"V758:";.78YD35'(<'D"<-'57=:"32"<-'"<5'7<6'2<".@"+'*'5'"+'=+3+"72D"
+'=)("+-.(/"4"V2;8"h"^'Dl"#cc!bAJPb!ASUY!ATTl"
"
AS"
e27=-:87()(",-.(/"
B e27=-:87G3+"B ,'*'5'"+:+<'63("
-:='5+'2+3)*3<:"5'7().2"
B >-757(<'53g'D"%:"6F8)+:+<'6"32*.8*'6'2<""
B C;V"6'D37<'D"
B e27=-:87(<.3D"5'7().2"B >8323(788:"32D3+)2;F3+-7%8'"@5.6"727=-:87G3+"
B 0.'+"2.<"5'EF35'"7"+'2+3)g32;"'G=.+F5'"
B 4.<"C;V"6'D37<'D"
Justin Beck, Flickr
AT"
e27=-:87()(",-.(/"O">8323(78"
^723@'+<7).2+"
• >8323(78",='(<5F6"– d35+<",:6=<.6+b""
• 95F53<F+"• d8F+-32;"• j5)(7537"
– 95.;5'++3.2b""• ?-5.7<"@F882'++"• e2G3'<:"• >-'+<");-<2'++"• ,-.5<2'++".@"%5'7<-"• i3;-<-'7D'D2'++"
– ,'*'5'",:6=<.6+b"""• e8<'5'D"6'2<78"+<7<F+"
• H'+=357<.5:"D3+<5'++"• >35(F87<.5:"(.887=+'"
• H3+/"@7(<.5+"@.5"@7<78"727=-:87G3+""– 9..58:"(.2<5.88'D"7+<-67"""
– 95'*3.F+"727=-:87G3+"""
• H'.((F55'2('"57<'+"– JcYScp"@.5"32+'(<"+)2;+"– #cYJcp"@.5"57D3.(.2<57+<"7;'2<+"
– !cY#cp"@.5"='23(38832""
• ^.+<"(.66.2"(7F+'+"– e2)%3.)(+"– C2+'(<+"– d..D""
AU"
e27=-:87()(",-.(/"Y"037;2.+3+"
• >8323(78"D37;2.+3+"– 0'12'D"%:"735I7:"(.6=5.63+'R"-:=.<'2+3.2R".5"
32*.8*'6'2<".@"(F<72'.F+R"5'+=357<.5:R".5"[C"+:+<'6+"
B ^38DR"8.(783g'D"F5)(7537"(72"=5.;5'++"<."@F88"727=-:87G3+"
B ,:6=<.6+"F+F788:"%';32"I3<-32"Sc"632F<'+".@"'G=.+F5'"
B d7+<'5".2+'<".@"+:6=<.6+"L"6.5'"+'*'5'"5'7().2"
B K3=-7+3("=5'+'2<7).2".((F5+"32"F="<."#cp".@"=7)'2<+"B ,:6=<.6+"I388"5'<F52"AYJ"-.F5+"7n'5"323)78"5'7().2"-7+"(8'75'D"
• i../"@.5"'G=.+F5'"<."D5F;R"@..DR".5"32+'(<"• i7%+"-7*'"2."5.8'"
A]"
e27=-:87()(",-.(/"Y"?5'7<6'2<"
• eK>q+"– H'+=357<.5:"(.6=5.63+'"5'EF35'"366'D37<'"
32<F%7).2"
• CNR">75D37("^.23<.5R"9F8+'"$G36'<5:"
• CNdq+R"$G:;'2"• V=32'=-532'"@.5"e27=-:87G3+f,-.(/"• ,'(.2D"832'"?-'57=3'+"
– >.5)(.+<'5.3D+"– Q!"72D"Q#"%8.(/'5+"
Jc"
e27=-:87()(",-.(/"Y"?5'7<6'2<"
• V=32'=-532'"– clA"6;"C^".5",>".@"!b!ccc"D38F).2"@.5"727=-:87G3+""
– H'='7<"'*'5:"PY!c"632"7+"2''D'D"
– >7F).2"3@"=7)'2<".2"%'<7"%8.(/'5+"DF'"<."F2.==.+'D"78=-7"+)6F87).2"72D"5'+F8<72<"+'*'5'"
-:='5<'2+3.2"
– d.5">N"(.887=+'"W3l'l"(75D37("755'+<XR"!"6;"CN".@"
!b!cRccc"W+76'"7+"e>i,"0.+'X"
– C@"5'@57(<.5:"-:=.<'2+3.2"72D"+-.(/R"+<75<"CN"D53="
J!"
e27=-:87()(",-.(/"Y"?5'7<6'2<"
• >.5)(.+<'5.3D+"– ^'<-:8=5'D23+.8.2'"!#P"6;"CN""
– 95'D23+.2'"Sc"6;"9$"
• e2)-3+<7632'+"
– Q!"%8.(/'5Y"03=-'2-:D57632'"#PYPc"6;"CN"
– Q#"%8.(/'5Y"H723)D32'"Pc"6;"CN"
• K5.2(-.D387<.5+"– e8%F<'5.8"2'%F83g'5"– e<5.*'2<"2'%F83g'5"– ^7;2'+3F6"+F8@7<'"#";"CN".*'5"#c"632F<'+""
"
J#"
>75D3.;'23(",-.(/"
B ^.5<783<:"=53.5"<."5'='5@F+3.2"
<-'57=:"L"PcYUcp"
B ,3;2+b"B >..8R"6._8'D"+/32"
B ?7(-:=2'7"B 9F86.275:"*7+(F875"(.2;'+).2""
B Q:=.<'2+3.2"B e8<'5'D"6'2<78"+<7<F+"
B 4755.I'D"=F8+'"=5'++F5'"B H78'+R"6F56F5"
B 0'12'D"7+b"B ,K9"m"]c"66Q;"
B >75D37("C2D'G"m"#l#"if6f6#"
B 9F86.275:">7=38875:"Z'D;'"
95'++F5'"W9>Z9X"o"!U"
66Q;"
Patrick J. Lynch, Wikimedia Commons JA"
>75D3.;'23(",-.(/""
• >75D3.;'23(",-.(/"V).8.;:"– e(F<'"^:.(75D378"C2@75().2"We^CX"
– ,'=+3+"– ^:.(75D3)+"
– ^:.(75D378">.2<F+3.2"
– e(F<'"e.5)("C2+F`(3'2(:"
– e.5)(".@"^3<578",<'2.+3+"
– Q:='5<5.=-3(">75D3.6:.=7<-:"
JJ"
>75D3.;'23(",-.(/"
• $n'2"5'+F8<+"@5.6"6:.(75D378"3+(-'637"
I3<-"8.++".@"8'n"*'2<53(F875"WiNX"@F2().2"
– >8323(78"+-.(/"'2+F'+"7n'5"8.++".@"Jcp"iN"• H'+F8)2;"(75D37(".F<=F<"5'DF().2"8'7D+"<."87()("7(3D.+3+"72D"-:=.G37"
• ,<5./'"*.8F6'"3+"5'DF('D""
– ?7(-:(75D37"D'*'8.=+"7+"(.6='2+7).2"@.5"
D'(5'7+'D",N"<."6732<732"(75D37(".F<=F<""
– C+(-'637"72D"32@75().2"I.5+'2+"(5'7)2;"
D.I2I75D"+=3578"
JP"
>75D3.;'23(",-.(/"Y"037;2.+3+"
• Vt["• >MH"• i7%.57<.5:b""
– >.6=8'<'"K8..D">.F2<"
– >-'63+<5:"972'8"WV8'(<5.8:<'+R"Kj4f>HX"
– >75D37("'2g:6'+"W^:.;8.%32R">tR">tY^KR"?5.=.232X"
– >.7;F87).2"+<FD3'+"• V(-.(75D3.;576"
JS"
>75D3.;'23(",-.(/"Y"?5'7<6'2<"
• ?5'7<6'2<"[.78+"
– e35I7:"(.2<5.8"W3@"2'('++75:X"– C6=5.*32;"6:.(75D378"=F6="@F2().2"
– H'='5@F+3.2"W3@"7*7387%8'X"– 95'*'2)2;"@F5<-'5"6:.(75D378"D767;'"
• ^.23<.532;""
– >75D37("6.23<.5"
– 9F8+'"$G36'<5:"
• ,F==8'6'2<78".G:;'2R"CN"7(('++"
• C2<F%7).2"D'(5'7+'+"=5'8.7D"72D"(7F+'+"-:=.<'2+3.2"""
– ^7:"2''D"<.";3*'"\F3D"%.8F+"<."(.6='2+7<'"3@"32<F%7)2;"
JT"
>75D3.;'23(",-.(/"Y"?5'7<6'2<"
• e^C"
– e+=3532R"K'<7Y%8.(/'5R"^.5=-32'R"Q'=7532"
– 43<5.;8:('532"@.5"=732"(.2<5.8"W7*.3D"32"32@'53.5"^CX"
– C@"2."=F86.275:"'D'67R"67:"<5:"CN"\F3D"@.5"K9"+F==.5<"
– C@"=F86.275:"'D'67"
• 0.=7632'"O"I388"x"QH"72D"<-F+"(75D37("I.5/"
• 0.%F<7632'"O"^7:"D5.="%8..D"=5'++F5'"DF'"<."='53=-'578"
*7+.D387<7).2"
• >.6%327).2"<-'57=:"67:"%'"6.5'"'a'()*'"
– H'='5@F+3.2"?-'57=:"W3@",?V^C"72D"7*7387%8'"32"<-'"(8323(78"
+'y2;X"
• >75D37("(7<-'<'53g7).2"I3<-"32<'5*'2).2""• ?-5.6%.8:)(+"
"JU"
4'F5.;'23(",-.(/"
• H'+F8<+"@5.6"+=3278"(.5D"32&F5:"I3<-"+-.(/"
87+)2;"@5.6"!YA"I''/+"
• i.++".@"+:6=7<-')("<.2'"72D"5'+F8<72<"
F2.==.+'D"*7;78"<.2'"
• 0'(5'7+'D"*7+.6.<.5"<.2'""
• H'+F8<+"32"-:=.<'2+3.2"72D"%57D:(75D37"
• 97)'2<+"67:"5'6732"78'5<R"I756R"72D"D5:"
D'+=3<'"<-'"-:=.<'2+3.2"
• ,=3278"+-.(/"
– ?'6=.575:"8.++".@"+=3278"5'\'G"7()*3<:"
%'8.I"7"<.<78".5"2'75"<.<78"+=3278"(.5D"
32&F5:"
– 4.<"<-'"+76'"7+"2'F5.;'23("+-.(/R"<-'"
<'56+"75'"2.<"32<'5(-72;'7%8'"
gunkyboy, Wikimedia Commons
J]"
4'F5.;'23(",-.(/Y"?5'7<6'2<"
• eRKR>+"– H'6'6%'5">Y+=32'"=5'(7F).2+"
– Q3;-">Y+=32'"32&F53'+"5'EF35'"6'(-723(78"*'2)87).2""
• >AY>JY>P"O"9-5'23("4'5*'"322'5*7).2"• d8F3D"5'+F+(3<7).2"
– t''="^e9"7<"UPY]c"66"Q;"@.5"15+<"T"D7:+"
– ^32363g'"+'(.2D75:"(.5D"32&F5:"
– C@"(5:+<788.3D"3+"32+F`(3'2<"F+'"*7+.=5'++.5+"
• ,'75(-"@.5".<-'5"(7F+'+".@"-:=.<'2+3.2"– $n'2R",>C"5'+F8<+"@5.6"<57F67"L"5f."Q'6.55-7;3(",-.(/"
• d.5"%57D:(75D37"– e<5.=32'"– 97('67/'5""
Pc"
$%+<5F()*'",-.(/"
• ?'2+3.2"92'F6.<-.57G"
• >75D37("?76=.27D'"
• 9F86.275:"V6%.83+6"
• ,'*'5'"e.5)(",<'2.+3+"
P!"
$%+<5F()*'",-.(/"
B ?'2+3.2"=2'F6.<-.57G"
B e35"<57=='D"32"=8'F578"+=7('"I3<-"!"I7:"*78*'R"735f=5'++F5'"%F38D+"F="
B ^'D37+)2F6"+-3n'D"36='D32;"
*'2.F+"5'<F52"
B >-'+<"=732R",$KR"D'(5'7+'D"%5'7<-"+.F2D+"
B 4."<'+<+"2''D'Df(8323(78"D37;2.+3+"B ?5'7<6'2<b"4''D8'"D'(.6=5'++3.2"
@.88.I'D"%:"(-'+<"<F%'"Source: www.meddean.luc.edu/lumenMedEd/medicine/pulmonar/cxr/pneumo1.htm
Delldot, Wikimedia Commons
P#"
$%+<5F()*'",-.(/"
B >75D37("<76=.27D'"
B K8..D"32"='53(75D378"+7("=5'*'2<+"*'2.F+"5'<F52"<."72D"(.2<57().2".@"
-'75<"
B V).8.;:b""?57F67R"9'53(75D3)+R"^C"
B K'(/q+"<537Db""B Q:=.<'2+3.2R"6Fz'D"-'75<"+.F2D+R"hN0"
B 037;2.+3+b"i75;'"-'75<">MHR"'(-."B ?5'7<6'2<b"9'53(75D3.('2<'+3+"
K8..D"
9'53(75D3F6"
V=3(75D3F6"
Aceofhearts1968, Wikimedia Commons
PA"
$%+<5F()*'",-.(/"
• 9F86.275:"'6%.83+6"
– N35(-.I"<537Db""• Q:='5(.7;F87%8'"• N'2.F+"32&F5:"• N'2.+<7+3+"
– ,3;2+b""• ?7(-:=2'7""• ?7(-:(75D37"• Q:=.G37"
– i.I"53+/b"0YD36'5"
– Q3;-'5"53+/b">?"(-'+<".5"Nk"+(72"
– ?5'7<6'2<b""Q'=7532"
• >.2+3D'5"<-5.6%.8:)(+"3@"+-.(/"
@5.6"9V"
Hellerhoff, Wikimedia Commons
PJ"
$%+<5F()*'",-.(/"
B e.5)("+<'2.+3+"B H'+3+<72('"<."+:+<.83("'&'().2"(7F+'+"D'(5'7+'D"(75D37("@F2().2"
B >-'+<"=732"I3<-"+:2(.='"B ,:+<.83("'&'().2"6F56F5"
B 0'123)*'"D37;2.+3+"I3<-"'(-."B N7+.D387<.5+"W4?[X"I388"D5.="=5'++F5'"B ?5'7<6'2<b"e.5)("*78*'"+F5;'5:"
PP"
Z-3(-"=5'++.5"+-.F8D"C"(-..+'r"
! Q:=.*.8'63("+-.(/"
– Fluids and Blood
! >75D3.;'23("+-.(/"– Dobutamine - !1 agonist
! Increases squeeze and heart rate
! 4'F5.;'23("+-.(/"– Fluids, phenylephrine, Levophed,
look for another type of shock if it is persistent
! e27=-:87()("+-.(/"– Fluids and epinephrine
! ,'=)("+-.(/"– Neosynephrine - alpha agonist
! Increases SVR by arteriolar constriction
– Norepinephrine/Levophed - alpha and beta agonists
! 0.=7632'"
– Low Dose - increases renal blood supply
– Medium Dose - beta effects (increases heart rate and squeeze)
– High Dose - alpha effects (arteriolar constriction)
PS"
kF'+).2+r"
Dkscully, Flickr PT"