Shock Emergency approach andEarly management

The 1st priority in any pt. with shock is stabilization of their A-B-C

Kumpol ,MDEmergency medicineThammasat University

Diagnostic evaluation should occur at the same time as RESUSCITATION

Early management

AIRWAY and BREATHING

Stabilize respiration; Oxygen , intubation

Assess perfusion

Delayed fluid resuscitation

• Different types of shock can coexist.

• Follow pathophysiology of shock

• Decrease Total effective plasma volume

• Relative intravascular hypovolemia

• Elderly, DM, take B-blocker, hypertension

Restore perfusion

• Choice of replacement fluid

• Rate and assessment of fluid repletion

• Central monitoring or assessment

• Vasopressors and inotrops

Colloid versus crystalloid• Saline versus Albumin Fluid Evaluation(SAFE) trial, 6997

severe sepsis critically. No diff between groups for any end point (mortality)

Finfer, S, Bellomo, et al. A comparison of albumin and saline for fluid resuscitation : a systematic review. Crit care med 1999; 358-2247.

• Randomized trial compared penstarch to modified RLS in severe sepsis; no difference in 28 day mortality.

Brunkhorst, FM et al. intensive therapy in sepsis, N Engl J Med 2008;385:125.

• Crystalloid versus colloid – clinic trials have failed to consistently demonstrate a difference between colloid and crystalloid in treatment of septic shock.

choi, PT, Yip, G. crystalloid vs. colloids in fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350:2247.

Choice of replacement fluid

Colloid versus crystalloid

shock MAP< 60 ,

After initial 20-40cc/k starch, 40-60cc/k NSS

• Not possible to precisely predict the total fluid deficit

• Rapid and large volume infusion

Table Isotonic Crystalloid Intravenous Infusion Rates

IV Access Gravity (80-cm Height) Pressure (300 mm Hg)

18 g peripheral IV 50–60 mL/min 120–180 mL/min

16 g peripheral IV 90–125 mL/min 200–250 mL/min

14 g peripheral IV 125–160 mL/min 250–300 mL/min

8.5 Fr 200 mL/min 400–500 mL central venous introducer

Fluid challenge test

500Evaluate evidenced HF10 cc/kg in 5-10 min

Fluid challenge test

1000 Evaluate evidenced HF20 cc/kg

Fluid challenge test

2000

Evaluate evidenced HF40 cc/kg

Consider Central monitoring

Fluid challenge test 3000 Need

Central monitoring

Evaluate evidenced HF60 cc/kg

Fail to respond to initial fluid resuscitation.

• CVP

• Pulmonary capillary wedge pressure

Inotropes and vasopressors

• CVP 8 to 12 mmHg• MAP > 65 , SBP > 90

mmHg• Central venous oxygen

saturation >70%• Hematocrit > 30%• Proper antibiotic

ShockSignificant reduction of systemic

tissue perfusion

Emergency approach

Hypovolemic

DistributiveCardiogenic

Septic shock

Physiology

Compensation

Stages of shock

Stages of shock

Recommended approach

Diagnostic evaluation should occur at the same time as RESUSCITATION

• Medical history

• Physical examination

• Laboratory evaluation(esp. undifferentiated shock)

Definition

• Systemic inflammatory response syndrome (SIRs)

• Sepsis

• Severe sepsis

• Septic shock

• Refractory septic shock

+MAP < 60 ====+after 20-40 cc/k starch+ 40-60 cc/k NSS+PCWP 12-20+DA>5u/k/minNE/E<0.25u/k/min---MAP> 60

-mottled skin-cap. Refill > 3s-U/O < 0.5 cc/k/h-lactate > 2-Plt < 100,000-cardiac dysf.

Sepsis +InfectionSIRs

Severe sepsis

+ Organ

hypoperfusion

Septic shock

+

Refractory septic shockSeptic shock + DA > 15 u/k/min, NE/E >0.25---MAP>60

Septic shock MAP< 60

After

20-40cc/k starch

40-60cc/k NSS