Shock: Mazen Kherallah, MD, FCCP

Shock

Mazen Kherallah, MD, FCCP Internal Medicine, Infectious Disease and Critical Care Medicine

First Step
Recognize its Presence

No Laboratory Test Diagnoses Shock
Shock Syndromes
Cardiogenic
Hypovolemic
Distributive
Obstructive
LVF
Hemorrhagic Nonhemorrhagic
Septic
P. Embolism
Arrhythmias
Neurogenic
Pneumothorax
Adrenal
Aortic Stenosis
Clinical Appreciation of the Presence of
Inadequate Organ Perfusion and Tissue Oxygenation
Second Step
Identify the Probable Causes
Traumatized and Shocked Patients

Hypovolemic shock Cardiogenic shock Neurogenic shock Septic shock
Treatment should be initiated simultaneously with the identification of probable cause of the shock state
Hemorrhage is the most common cause of shock in the injured patient
I. Initial Patient Assessment

Recognition of Shock
Tachycardia and cutaneous vasoconstriction are the usual and early physiologic response to volume loss Tachypnea Narrowed pulse pressure Hypotension when patients blood volume loss is more than 30% Hematocrit or hemoglobin concentration are not reliable

Recognition of Shock Tachycardia Greater than 160 in infant Greater than 140 in preschool age child Greater than 120 in school age child Greater than 100 in an adult

Recognition of Shock Unable to produce Tachycardia Limited cardiac response to catecholamine stimulation: elderly Concurrent use of beta-adrenergic blocking agents The presence of a pacemaker

Clinical Differentiation of Etiology of Shock Hemorrhagic Shock The most common cause of shock after injury All patients with multiple injuries have an element of hypovolemia Most patients with nonhemorrhagic shock state respond partially or briefly to volume resuscitation All patients with shock should initially be treated with volume replacement

Clinical Differentiation of Etiology of Shock Nonhemorrhagic Shock
Cardiogenic shock Tension pneumothorax Neurogenic shock Septic shock
Nonhemorrhagic Shock
Cardiogenic Shock
Blunt cardiac injury Cardiac tamponade Air embolus Myocardial infarction
Tension Pneumothorax Acute respiratory distress Subcutaneous emphysema Absent breath sounds Hyperresonance to percussion Tracheal shift
Neurogenic Shock Isolated intracranial injuries do not cause shock Spinal cord injury may produce hypotension due to loss of sympathetic tone Hypotension without tachycardia or cutaneous vasoconstriction
Septic Shock
Uncommon after injury May occur if patients arrival to ER is delayed several hours Penetrating abdominal injuries and contamination of the peritoneal cavity with intestinal contents Normal circulating volume, modest tachycardia, warm and pink skin, and a wide pulse pressure
II. Hemorrhagic Shock in the Injured Patient

Definition of Hemorrhage Acute loss of circulating blood volume Normal adult blood volume is 7% of body weight Normal pediatric blood volume is 8-9% of the body weight Calculation is based on ideal body weight

Direct Effect of Hemorrhage The distinction between classes may not be apparent in an individual patient Volume replacement should be directed by the response to initial therapy rather than by relying solely on the initial classification Several confounding factors profoundly alter the classic hemodynamic response
Confounding Factors that alter the Classic Hemodynamic Response
The patients age Severity of the injury Type and anatomical location of the injury Time lapse between injury and initiation of treatment Prehospital therapy Medication used for chronic conditions
Classification of Hemorrhagic Shock

Class I Blood loss (ml) Blood loss (%) Pulse rate Up to 750 Up to 15% <100 Class II 750-1500 15-30% >100 Normal Decreased 20-30 20-30 Class III 1500-2000 30-40% >120 Decreased Decreased 30-40 5-15 Class IV >2000 >40% >140 Decreased Decreased >35 Negligible Confused/ lethargic Crystalloid/ Blood
Blood pressure Normal Pulse pressure Respiratory rate Urine output (ml/h) CNS/mental status Fluid replacement Normal 14-20 >30 Slightly anxious Crystalloid
Mildly Anxious/ anxious confused Crystalloid Crystalloid/ blood

Fluid Changes Secondary to Soft Tissue Injury
Blood loss at the site of injury:

Fractured tibia: 750 ml of blood loss Fractured femur: 1500 ml of blood loss Retroperitneal hematoma: several liters
Obligatory edema
III. Initial Management of Hemorrhagic Shock

Physical Examination
Airway and breathing Circulation: Hemorrhage control Disability: Neurologic examination Exposure: Complete examination Gastric dilatation: decompression Urinary catheter insertion
Contraindication to Insertion of Transurethral catheter prior to Radiological confirmation of an intact Urethra

Blood at the urethral meatus High-riding, mobile, or nonpalpable prostate

Vascular Access Lines
Must be obtained promptly Two large-caliber (minimum of 16 gauge) peripheral intravenous catheters Large-caliber, central venous access Central lines should be changed in more controlled environment as soon as patients condition permits

Initial Fluid Therapy
Ringers lactate solution is the initial fluid of choice Normal saline is the second choice Normal saline has the potential of causing hyperchloremic acidosis Initial fluid bolus is given as rapidly as possible, 1-2 liters for an adult and 20 mg/kg for pediatric patient 3 for 1 rule: each mL of blood loss is replaced with 3 mL of crystalloid fluid
Estimated Fluid and Blood Losses

Class I Blood loss (ml) Blood loss (%) Pulse rate Up to 750 Up to 15% <100 Class II 750-1500 15-30% >100 Normal Decreased 20-30 20-30 Class III 1500-2000 30-40% >120 Decreased Decreased 30-40 5-15 Class IV >2000 >40% >140 Decreased Decreased >35 Negligible Confused/ lethargic Crystalloid/ Blood
Blood pressure Normal Pulse pressure Respiratory rate Urine output (ml/h) CNS/mental status Fluid replacement Normal 14-20 >30 Slightly anxious Crystalloid
Mildly Anxious/ anxious confused Crystalloid Crystalloid/ blood
IV. Evaluation of Fluid Resuscitation and Organ Perfusion

General
Blood pressure Pulse pressure Pulse rate Central nervous system status Skin circulation Changes in central venous pressure line Changes in PCWP and cardiac output

Urinary Output
Adequate volume replacement should produce a urinary output of approximately 0.5 mL/kg/hour in the adult One mL/kg/hour is an adequate urinary output for the pediatric patients 2 mL/kg/hour for children under 1 year of age

Acid/Base Balance
Respiratory alkalosis followed by metabolic acidosis is seen in patients with early hypovolemic shock Severe metabolic acidosis may develop from long-standing shock Persistent acidosis is due to inadequate resuscitation or ongoing blood loss
V. Response to Initial Fluid Resuscitation

2000 mL Ringers lactate in adults or 20 mL/kg bolus in children
Rapid Response Transient Response Return to normal Recurrence of BP Vital signs and HR Moderate and Estimated blood Minimal (1020%) ongoing (20-40%) loss High Need for more Low crystalloid Moderate to high Need for blood Low Blood preperation Need for operation Early presence of surgeon Type and crossmatch Possible Yes Type-specific Likely Yes No Response Remain abnormal Severe (>40%) High Immediate Emergency blood release Highly likely Yes
VI. Blood Replacement

Packed Red Blood Cells Versus Whole Blood Therapy
Restore the oxygen-carrying capacity of the intravascular volume Either whole blood or packed red cells can be used. Component therapy is used to maximize blood product availability

Crossmatched, Type-specific, and Type O Blood
Crossmatched blood is preferable but it requires approximately 1 hour to be completed: should be used for patients who stabilize rapidly Type-specific blood can be provided in 10 minutes: this blood is compatible with ABO an Rh blood types Type O blood can be used in patients with exanguinating hemorrhage when typespecific is not available

Warming Fluids-Plasma and Crystalloid
In patients receiving massive volume of crystalloid, heat the fluid to 39 C before using it to prevent hypothermia Storage of crystalloids in a warmer with the use of microwave oven Blood products cannot be warmed in the microwave ovenbut can be heated with the passage through intravenous fluid warmer

Autotransfusion
Patients with a major hemothoarax Sterile collection of blood through standard tube thoracotomy collection devices Anticoagulation with sodium-citrate solution, not heparin Retransfusion of shed blood

Coagulopathy
Dilution of platelets and clotting factors Averse effect of hypothermia on platelets aggregation Release of tissue thromboplastin by the damaged neural tissue in patients with closed head injury

Calcium Administration
Most patients receiving blood transfusion do not need calcium supplementation Excessive calcium supplementation may be harmful

Shock: Mazen Kherallah, MD, FCCP

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Shock: Mazen Kherallah, MD, FCCP

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Shock

No Laboratory Test Diagnoses Shock

Clinical Appreciation of the Presence of

Inadequate Organ Perfusion and Tissue Oxygenation

Traumatized and Shocked Patients

Hemorrhage is the most common cause of shock in the injured patient

I. Initial Patient Assessment

I. Initial Patient Assessment

I. Initial Patient Assessment

I. Initial Patient Assessment

I. Initial Patient Assessment

Cardiogenic shock Tension pneumothorax Neurogenic shock Septic shock

Blunt cardiac injury Cardiac tamponade Air embolus Myocardial infarction

II. Hemorrhagic Shock in the Injured Patient

II. Hemorrhagic Shock in the Injured Patient

Confounding Factors that alter the Classic Hemodynamic Response

Classification of Hemorrhagic Shock

Mildly Anxious/ anxious confused Crystalloid Crystalloid/ blood

II. Hemorrhagic Shock in the Injured Patient

Blood loss at the site of injury:

III. Initial Management of Hemorrhagic Shock

Contraindication to Insertion of Transurethral catheter prior to Radiological confirmation of an intact Urethra

III. Initial Management of Hemorrhagic Shock

III. Initial Management of Hemorrhagic Shock

Estimated Fluid and Blood Losses

Mildly Anxious/ anxious confused Crystalloid Crystalloid/ blood

IV. Evaluation of Fluid Resuscitation and Organ Perfusion

IV. Evaluation of Fluid Resuscitation and Organ Perfusion

IV. Evaluation of Fluid Resuscitation and Organ Perfusion

V. Response to Initial Fluid Resuscitation

VI. Blood Replacement

VI. Blood Replacement

VI. Blood Replacement

VI. Blood Replacement

VI. Blood Replacement

VI. Blood Replacement

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