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References:Sarawak Handbook Of Medical Emergencies 3rd EditionGuide to The Essential in Emergency Medicine by Shirley Ooi.Parrillo & Dellinger: Critical Care Medicine, 3rd ed.Civetta, Taylor, & Kirby's: Critical Care, 4th Editionhttp://www.cc.nih.gov/ccc/pedweb/pedsstaff/ivf.html (Intravenous Fluid Management)

ShockLim Jun Sian Batch 12

DefinitionClinical syndrome that is results from Circulatory failure Reduction in oxygen deliverinadequate peripheral tissue and organ perfusion leading to a eventual cellular hypoxia with all its attendance sequalae.Clinically characterized byhypotension (Hemodynamic instability)SBP < 90mmHg or < 30mmHg from baseline Mean arterial pressure < 65mmHgOliguriaAltered mentationOrgan failure

(1) hypovolaemic, due to inadequate venous return (haemorrhage, dehydration), (2) cardiogenic, due to inadequate ventricular pump function (myocardial infarction), (3) obstructive, due to vascular obliteration (pulmonary embolism or tamponade), and (4) distributive, due to loss of vasoregulatory control (sepsis).3

Hypovolemic ShockPathophysiologyresulting from a decreased circulating blood volumeTypes of HypovolemiaBlood LossFluids/Plasma LossMost common type of shockDiagnosisReadily diagnosed based on the etiologyPitfall Difficult to differentiate from cardiogenicA normotensive patient maybe in shock ( hypertensive patient)

CausesMedicineDiarrhea, VomitingDKA, HHSDengue shock syndromeSurgeryAcute perforated appendicitisGIT Bleeding(peptic ulcer, esophageal varices)BurnPeritonitisAbdominal aortic aneurysm

Major operationOBGHyperemesis gravidarumRupture ectopic pregnancyAPH / PPHTraumaAbdominal Open fractureClosed fracture* (Shaft of femur)

Class IClass IIClass IIIClass IVBlood lossmL1500-200>2000%30-40>40Heart rate (beat/min)100>120>140Systolic blood pressureNormalNormalDecreasedDecreasedPulse pressureNormalDecreasedDecreasedDecreasedCapillary refill normalDelayedDelayedDelayedDelayedRespiratory rate (min)14-2020-3030-40>35Urine output (mL/h)>3020-305-15MinimalMental statusSlightly anxiousAnxiousConfusedConfused and lethargic

Cardiogenic Shock (Killip Class IV)Cardiogenic shock (CS) is characterized by systemic hypoperfusion due to cardiac pump failure caused by loss of myocardial contractilitysevere depression of the cardiac index [1 h and does not respond to fluid or pressor administrationPrinciple of mechanismPeripheral vasodilation and pooling of blood

Signs and SymptomsSymptoms: FEVER/hypothermia, depends on site of infection.Signs:Warm peripheral extremities (due to vasodilation)FebrilehypotensionTachypnea, tachycardiaOliguriaRash

History taking: comorbiditiesDM, Chronic lung diseasealcoholism, liver cirrhosis,Recent invasive procedure (especially in CKF)HIVImmunosuppressive agent (Steroid)Malignancy

Anaphylactic ShockAn allergic, IgE mediated, hypersensitivity response to a foreign substance to which a patient has been previously sensitizedType I hypersensitivityCauses:Drugs: penicillin, aspirin, streptomycinVaccines: measlesBlood productsInsect bites: beesFood: seafood

Clinical FeaturesOnset: Commonly: 5-60min of exposureDelayed onset: after few hoursBiphasic response: recurrence of symptoms 1-8 hrs later due to late phase reactionProtracted anaphylaxis : persistence of symptoms up to 48hrs despite therapySkin : Urticaria (200 cases):Area of focal dermal edemaangioedema (20cases): Localized non-pitting deeper edematous processPruritusTingling of face (usually at mouth)

Urticaria

Angioedema

Clinical FeaturesCVS:Arrhythimias RS:Laryngeal edema: hoarseness of voice, stridor, lump in the throatWheezeDyspnea due to bronchospasmCoughing: ominous sign portend onset of pulmonary edemaGITNausea, abdominal cramp

Neurogenic ShockCauses:Post-spinal surgerySpinal injuryClinical features:Bradycardia, hypotension, warm peripheral extremitiesCauses:Tension pneumothoraxCardiac tamponadePulmonary embolism

Obstructive Shock

Approach To Shock Patient History TakingComplaints:Trauma GIT:BleedingDiarrhea VomitingHematemesisMelena and hematochezia Abdominal pain

CVSChest painDyspneaPalpitationOBGPVBFeverPast medical HistoryComorbidity Drug and allergic historyMenstrual historyLast menstrual

Diagnosis of Various Types of Shock HypovolemniaCardiogenicNeurogenicSeptic Shock (hyperdynamic)AnaphylacticBPHypotensionHypotensionHypotensionHypotensionHypotensionSkin conditionPallor, clammy, coldClammy, coldWarmRigors, fever/warmwarmHeart RateTachycardiaDysrhythmias bradycardiaTachycardiaarrhythmiasOthersOpen fracturesVentricular failureTrauma to spine+/- Rash urticarialothersLimbs weaknessangioedemaUrinary and bladder incontinencewheezing

Guide to The Essential in Emergency Medicine by Shirley Ooi.

Complications of ShockCNSEncephalopathyCVSReduced myocardial contractilityRenalAcute Renal FailurePulmonaryARDSAtelectasis GITStress UlcerMesenteric IschemiaShock liverHematologyDIVCMetabolicHyperglycemiaLactic AcidosisSkeletalgangrene

Atelectasis - Recumbency and involuntary restriction of ventilation secondary to pain reduce functional residual capacity and may lead to atelectasisShock and, in particular, resuscitation-induced oxidant radical generation, is recognized as a major cause of acute lung injury and subsequent acute respiratory distress syndrome (ARDS;20

General Management of Shock

ManagementBP < 90mmHg (hemodynamic instability)Altered mentationoliguriaSuspect Shock ???Skin ConditionClammy ColdWarm

Hyoovolemic ShockCardiogenic ShockObstructive Shock Distrubutive ShockNeurogenic Shock

Hypovolemic ShockCardiogenic ShockObstructive Shock Distributive ShockNeurogenic ShockCheck the PulseTachycardiaDysrhythmias(by ECG)BradycardiaNeurogenicAnaphylacticCardiogenicSeptic Hypovolemic

Other Features:Traumadiarrhea vomitingOther Features:FeverRashothersOther Features:Post MISign of CCFOther Features:AllergyUrticarialangioedema

Other Features:Spinal injury

RS ExaminationTension Pneumothorax

Cardiac TamponadeBECKS TRIAD

Cardiac Tamponade - Electrical alternans (repetitive alternating change in P,QRS and T wave amplitudes

Airway MaintenanceIf GSC < 8 ETT intubationBreathing by SP02100% oxygen oyxgen to maintain PaO2 > 60mmHg or SaO2 > 90%Circulation2 large wide boreSize: 16GRoute: peripheral central line Intraosseos lineWide borePurpose:Give bolus or infuse fluidsDrugs administrationblood Investigation Get helps if didnt get within 2 minutes

Bladder catheterization

Supine or Trendelenburg positionRaise the leg upNon-cardiogenic ShockCardiogenic Shock

Fluids therapy(at least 1000ml)+/- Fluids therapy (500-1000ml max)

Investigation

CVP or PACFail to respond to Fluid therapy

SympathomimeticsMean arterial pressure >60-65 mm Hg (higher in the presence of coronary artery disease)Pulmonary wedge pressure 15-18 mm Hg (may be higher for cardiogenic shock)Cardiac index >2.1 L/min/m2 for cardiogenic and obstructive shockCardiac index >4-4.5 L/min/m2 for septic and resuscitated traumatic/hemorrhagic shock

CompartmentGlucose 5%NaCl 0.9%Normal COP ColloidsIntravascularInterstitialIntracellular

27

Choice of Fluid Resuscitation Principle:First: Restore intravascular volumeSecond: replete interstitial and intracellular volume

CompartmentGlucose 5%NaCl 0.9%Normal COP ColloidsIntravascularInterstitialIntracellular

Why Crystalloid???Crystalloid is preferred over than colloid because colloid :inhibition of the coagulation system; the risk for anaphylactoid reactions; inhibition of renal salt and water excretion; Over-administration risk of ARFexpensive

Choice of Fluid Resuscitation Choice of CrystalloidTheoretically: Ringer Lactate or Hartman solution is preferred over Normal saline Resemble the plasma electrolytes levelHowever, Normal saline is used because it is cheaper.Isotonic Normal saline 0.9% is used in all shock condition excepts:Burn shock (use Parkland formula)Dextrose 5% NS Maintenance therapy

Type of Fluid and its contents

1. The value of Glucose, Na, K must be memorized.Primarily used to maintain water balance in patients who are not able to take anything by mouthFor Fluid Resuscitation (shock, dehydration)Fluids Maintenance

Circulation - Correction of hypovolemia

Fluid ResuscitationFluids loss Fluids replacement : (NS) to restore the circulatory volumeAdult: at least1000ml over 30minutes bolus Pediatrics 20ml/kgCalculating the % lossAccording to the sign and symptom Dehyration mild moderate severeBlood loss class I,II, III, IVAccording to weight loss(Previous healthy weight current body weight) x 100%

Fluids maintenanceFluids maintenance: daily fluid loss (about 2L) + additional fluid deficit + ongoing loss (fever increase in 1degree celcius =10ml/hr loss)Paediatrics age group Must use Holliday-Segard FormulaAdult can use wt + 40 formulaMaximum fluid maintenance for normal daily loss : 120ml/ hr

Comparison

Rule of 4 -2-1 (Holliday-Segard Formula)- 4 ml per kg for the first 10 kg of body weight; - 2 ml per kg for the next 10 kg (11-20kg); - 1 ml per kg for any weight >20 kg Weight + 40Example: Calculating maintenance fluid requirements for 70 kg male. 0-10 kg: 10 * 4 ml = 40 mL 11-20 kg: 10 * 2 mL = 20 mL 21-70 kg: 50 * 1 mL = 50 mL Total = 110 mL/hrExample: Calculating maintenance fluid requirements for 70 kg male. 70+40 = 110mL/hr

Emergency Blood TransfusionIndicationsSevere hemorrhage > 30%Hb < 8%, Whole Blood is used.GXM 1 unit of blood = 450ml of bloodDuring initial resuscitation of acute blood loss and shock, crystalloid or colloid infused to restore circulatory volumeEmergency blood group O blood should not be used indiscrimatelyLook for side effect of transfusion

Emergency Blood TransfusionGroup O positive is used as emergency blood for man.Group O negative is used for female in reproductive age group.Category of blood according to urgency

Unmatch Emergency bloodRapid Match bloodFull matched bloodAvailabilityInstant5-10minutes30-45minutesCXM not donedoneDoneAntibody screennot donenot donedone

Guide to The Essential in Emergency Medicine by Shirley Ooi.

OthersPrevention of stress ulcerRanitidine or PPIPrevention of deep vein thrombosisUF heparin or LMW heparin if no C/IPrevention of ARFInduce diuresis by furosemide (make sure adequate fluid therapy) look for hyperkalemiaIV 2-5micro g/kg/minute of dopamine (low dose)Glucose controlInsulin to prevent DKA in DM patientMetabolic Acidosistreat in severe cases only.

Hypovolemic Shock

Management Specific to Hypovolemic Shock Blood investigationsFBC, RBSHCT is extremely unreliable test GXM BUSE and creatinine, lactateCardiac enzyme and TnTExclude acute MIABGMetabolic acidosis, elevated lactate(>5mmol/L) and significant base deficit are marker of poor prognosisCorrection of these abnormalities will improve outcome (by ABC)However, sodium bicarnoate is not used routinely because it does little to positively affect morbidity and survival.Coagulation profile , albuminECG and CXRFAST scan (Focused assessment with sonography for trauma)

Management Specific to Hypovolemic Shock Fluids Resuscitation -mainstayAll fluids need to be warmed to prevent iatro-genically induced hypothermia.

ABC + Bladder catheterization

Active bleeding Fluid Resuscitation

Dopamine +/- DobutamineCompression

E / NEHypotensionCVL / PACHypotension

OT if requiredIf MAP < 60mmHg CVL / PACsympathomimetic drugsexternal Internal

Cardiogenic Shock

Urgent Investigation For Cardiogenic ShockBlood InvestigationCardiac enzymeABGBUSE and creatinine FBC , RBSECGCXREchocardiography if cause is uncertain

Assessment of Venous Pressure: reflect Right ventricular filling pressurePulmonary capillary wedge pressure (PCWP) with Swan-Ganz catheter useful in suspected ARDS, exclusion of VSD, associated hypotension requiring inotrope to guide therapy

Swan-Ganz catheter

Supine or Trendelenburg position ABC + bladder catheterizationOyxgen 35-100% via facemask to maintain PaO2 > 60mmHg or SaO2 > 90%Continuous cardiac, BP, HR, Pulse oxymetry monitoringIncrease inspired oxygen to keep SaO2 > 90%Mechanical ventilation is indicated if hypercapnia hypoxiaPatient who are alert and cooperative may cope with (NIPPV)Correct severe metabolic acidosis (pH < 7.2) Reason: negative inotrophic and pro-arrhythmogenic effect

Treat underlying arrhythmias

Insert large cannula and give:Morphine IV 2.5-5mg + metoclopramide 10Mg IV or IM

Reduce anxiety and vasodilation (use carefully)Notice: SL GTN and frusemide are not used in Cardiogenic Shock if SBP < 90mmHg

NO CLINICAL OR HEMODYNAMIC PULMONARY CONGESTIONLook for sign of CCF

NO CLINICAL OR HEMODYNAMIC PULMONARY CONGESTION(Judicious fluid challenge)

Method of giving:Without invasive hemodynamic monitoring100ml NS or Hartmans Solution over 5-10min intervalReassessment of BP, HR, peripheral perfusion, breath sound between successive administrationMax : 500-1000mLWith invasive hemodynamic monitoringVolume is given until PCWP of 18mmHg is attained.

Investigation as above

Still Hypotension

DopaminePeripheral hypoperfusion and significant hypotension use dopamine increase MAP + restore renal and coronary perfusionUp to 15-20 g/kg/minCommon desired effect dosage: 7.5-15g/kg/min

Contraindicated DobutamineContraindicated in significant pulmonary congestion and only mild hypotension

Still Hypotension

Still Hypotension

NE/EPhosphodiesterase III inhibitors

ORNE/ENE: beta1 and alpha adrenergic increase contractility + vasoconstrictionUse if dopamine failsCaution: both are proarrhythmias (if AMI extensive myocardial injury)Phosphodiesterase III inhibitorsEg. Amrinone and milrinoneIndication: severe pulmonary congestion , PCWP > 24mmHg, dopamine and dobutamine fail.

Treat Pulmonary EdemaWith Frusemide / GTNSBP > 100mmHgAMI if present- Follow MI protocol

Management - OthersAminophylline (rarely use)Increase cardiac contractilityBronchodilatationVasodilatationMechanical circulatory supportIntra-aortic balloon counterpulsation in tertiary centersincreasesmyocardialoxygenperfusion while at the same time increasingcardiac output.

Septic Shock

Management of Septic Shock - InvestigationsTo establish the definitive diagnosis Blood Culture and sensitivity (2 sets)For IV line sepsis:1 set from suspected IV line, another from peripheral veinUrine C&SStool cultureSputum cultureUFEME

Blood InvestigationFBCABGCoagulation profile with DIVC screenBUSE with creatinineLFTRadiologicalCXRUSG abdomen (if indicated)CT(if indicated)LP (if indicated)

Management of Septic Shock

ABCWatch I/O carefully and be aware of other lossesContinuous ECG, BP, HR, Pulse oxymetry monitoringBladder catheterization Pulmonary arterial catheterization

Management of hemodynamic instability

Fluid Challenge Mainstay of hemodynamic supportsFast and rapid wide bore fluid resuscitationurine output rate should be kept at >0.5 mL/kg per hour by continuing fluid administrationcentral venous pressure should be maintained at 812 cmH2O

Rate of administration should be reduced if cardiac filling pressure increase without concurrent hemodynamic improvement

Give low dose of vasopressinincrease systemic arterial pressure tosustains the ability of the vasculature to autoregulate flow on a tissue and organ level prevent organ failureLow Dose vasopressor NE / Dopamine(not in low dose) 1st choiceAlternate: Epinephrine (if BP is poorly responds)Enhance sensitivity to vascular smooth muscle to catacholamine to minimize the side effect of using high dose vasopressorbeneficial in catecholamine-resistant septic shock following adequate volume resuscitation

severe sepsis or septic shock may demonstrate persistent vasomotor dysfunction characterized by regional perfusion deficits with or without systemic hypotension despite normal or increased CO. Clinical manifestations may include lactic acidosis and ongoing progression of organ failure.58

Management of InfectionC&S before empirical antibioticIntravenous broad-spectrum antimicrobials should be initiated immediately (preferably 24 or multi-organ failureEffect:AntithromboticAnti-inflammatoryPro-frinolytic Prerequisite: Platelet count > 30,000Main contraindication Active bleedingCRF

Acute Physiology and Chronic Health Evaluation61

Anaphylactic Shock

ABCBladder catheterizationECG,RR,BP,SaO2recumbent positionHigh flow Oxygen with facemask fail ETT difficult intubation due to severe laryngeal edema tracheastomy / cricothyroidotomy

Remove the inciting agent Prompt application of torniquet proximallyInsect: flick out insect stinger with a tongue bladeIngestion of allergen : gastric lavage and activated charcoal

IM aqueous epinephrine 0.3-0.5 ml of 1:1000Repeat every 20minutes

Epinephrine is the mainstay of initial management controlling symptoms and maintaining blood pressure.

IV Epinephrine 3 5ml 1:10 000Severe airway compromise / hypotension

Repeat every 5-10min

Epinephrine InfusionIf require multiple doses

Administer histamine antagonists block vasodilation, capillary leak, and shock H1 blockade, 2550 mg of diphenhydramine IV 6hrly; H2 blockade, 50 mg of ranitidine IV 6hrly

aggressive fluid resuscitation500-1000ml of crystalloid or colloid

in patients who remain hypotensive despite epinephrine.Still Hypotension

Still Hypotension

InotropesMaintain MAP > 60-65mmHgdopamine, isoprenaline infusion Pulmonary artery catheterization

OthersNebulizer BronchodilatorShort acting beta2 agonist every 15-30minutesDue to refractory to epinephrine Consider Corticosteroid250mg IV hydrocortisone, repeated 6 hourlyReduce protracted anaphylaxisnot effective therapy for the acute manifestations

-blockade antagonizes the beneficial -mediated effects of epinephrine therapy, thereby resulting in unopposed -adrenergic and reflex vagotonic effects: vasoconstriction, bronchoconstriction, and bradycardia67

Consider glucagon administration Indicated for those who receive B blocker therapy in anaphylactic shock antagonizes the beneficial -mediated effects of epinephrine therapy15 mg IV over 1 minute, then 15 mg/hour in a continuous infusion

PreventionContinuous ECG monitoringClose monitoring of ABG, CVP, BPAntihistamine 48-72hours to prevent relapseShort course of steroid for 7-10 daysCounseling

Neurogenic ShockClinical features:Bradycardia, hypotension, warm peripheral extremitiesMx:ABC + Supine position with leg elevatedFluid resuscitationNEAnal wink or bulbocarvenosus reflex

Thanks you

Dr. Charles Best (left) and Dr. Frederick Banting in 1924

J.C. Callaghan, W.G. Bigelow, - founder of heart pacemaker.