Hypotension, Shock, Hemorrhage

and IV Fluid Resuscitation

Learning Objectives
1. Definition, diagnosis and types of shock
2. Hemorrhagic shock ( I-IV )
3. Initial management of patients in Hemorrhagic shock
Algorithm for the identifying of the location of bleeding
IV access and resuscitation of Trauma patients
4. Initial assessment of patients in non-Hemorrhagic shock
5. Diagnosis of the various types of non-Hemorrhagic shock
6. Management of non-Hemorrhagic shock
7. Case Scenarios
The real goal however.
is to avoid .
Shock
Definition: Inadequate tissue Perfusion and
Oxygenation

Effect: Cellular injury, Organ failure, Death

Causes: hemorrhagic and non-hemorrhagic

Types of Shock
?
Types of Shock
S Septic & Spinal
H Hypovolemic & Hemorrhagic
O Obstructive
C Cardiogenic
K Anaphylactic
Shock: Clinical Diagnosis
CNS: Altered MS 2 extremes (Dr M. presentation)
CVS
1
: Tachycardia, diastolic BP, pulse pressure
CVS
2:
MAP, cardiac output
Resp: Tachypnea and O
2
requirement (Dr M. presentation)
GU: Decrease U/O
GI: Ileus?
Skin: Progressive vasoconstriction-cool extremities

History (for clues)
Shock: Laboratory Support
Metabolic acidosis
ABG: Acidosis, BD > -2
Chem-7: Bicarb
Lactate: >2

Metabolic acidosis 2
nd
to
Inadequate tissue perfusion
Shift to anaerobic metabolism
Production of lactic acid

Pitfalls


Extremes of age
Infant>160; preschool 140; school age 120; adult 100

Athletes

Pregnancy

Medications
Beta blockers, pacemaker

Hgb/Hct concentration
Unreliable for acute blood loss
Other Pitfalls.
Urine output adequate
despite shock

Alcohol
Hyperglycemia
Home medication: diuretics..
Therapeutic intervention: Mannitol
IV contrast: CT, Angio
Residual urine
DI
Etc
General Outline
Definition, diagnosis and types of shock

Hemorrhagic shock: Classes and Resuscitation

Hemorrhage & Trauma
Normal blood volume
Adults: 7% of ideal weight
70 kg man had blood volume of 5 liters
Child: 9% of ideal weight

Hemorrhage
Loss of circulating blood volume
How much volume loss to cause shock?
Classes of hemorrhage I-IV

Hemorrhagic Shock: The Classes
Class I Class II Class III Class IV
<750cc
<15% of TBV
None/minimal
Crystalloids
750cc 1500cc
15 30% of TBV
HR: increased
Pulse Pressure: decreased
BP: no change
Crystalloids
1.5L 2L
30 40% of TBV
HR: increased
BP: decreased
MS: agitated
Urine Output: decreased
1. Crystalloid (1 2L)
2. Transfusion (1 2units)
3. Identify source of Bleed(*5)
>2L
>40% of TBV
HR: increased
BP: decreased (<60)
MS: decreased
1. Crystalloid (2L)
2. Transfusion (2 4 units)
3. Identify source of Bleed(*5)
4. OR
Tx
Tx Tx Tx
S&S
S&S
S&S S&S
EBL
EBL EBL EBL
General Outline
Definition, diagnosis and types of shock
Classes of Hemorrhagic shock

Initial management of patients in Hemorrhagic shock
Two Goals in the management of
any Shock

GOAL #2

Support the patient
GOAL #1

ID and Tx the cause
Two Goals in the management of
Hemorrhagic Shock

2 - Support the patient
Establish IV access
Fluid Resuscitation
1 - ID and Tx the cause
Locate the source of
bleeding
Control it
Goal #1
Identification and Treatment of the cause


A-Locate the source of bleeding


B-Control it
Algorithm to Identify the Bleeding Source
in a Hypotensive Trauma Patient
Whip-stitch
with
nylon suture
Extremity
Bleed
Scalp
bleed
Blood on Floor
Check head/scalp
Check extremity
Long Bones
OR Exploratory laparotomy
DPL (+)
-Gross blood
- >10
5
RBCs
FAST
Free fluid
- Abdominal trauma
- Distended abdomen
Abdominal Cavity
OR Thoracotomy
Chest tube
1L of Blood
Place chest tube
On affected side
-Chest trauma
- Diminished breath sounds
- Desaturation, O
2
requirement
Chest cavity Pelvis/Retroperitoneum External Bleeding
-Abdominal/Pelvic trauma
-Flank ecchymosis
-Unstable pelvis
-Hematuria
First do DPL
(supra umbilical)
r/o intrabdominal
bleed
1) Wrap sheet around pelvis
2) Pelvic angiography
(+) Blush/Extravasation
1) Deformed extremity
2) Crush injury
3) Mangled extremity

EBL
Femur Fx 750cc1L
Tib Fx 500-750cc
Immobilization and
minimal manipulation
of injured extremity
using splint (3Ps)
Tourniquet proximal
to injury
- set > systolic BP
Pressure
and
Elevation
5 Possible locations
for significant bleeding
Clue:
Clue:
Clue: Clue:
Clue:
DPL (-) DPL (+)
Angioembolization
Bleeding not
controlled
Be alert for
compartment
syndrome
Consult Ortho
1 2
3 4 5
Chest
X-Ray
(+) Ptx-Htx
Pelvic
X-Ray
(+) Fx
Algorithm to Identify the Bleeding Source
in a Hypotensive Trauma Patient
Long Bones Abdominal Cavity Chest cavity Pelvis/Retroperitoneum

External Bleeding
floor

5 Possible locations
for significant bleeding
1 2
3 4 5
Algorithm to Identify the Bleeding Source
in a Hypotensive Trauma Patient
Whip-stitch
with
nylon suture
Extremity
Bleed
Scalp
bleed
Blood on Floor
Check head/scalp
Check extremity
Long Bones
OR Exploratory laparotomy
DPL (+)
-Gross blood
- >10
5
RBCs
FAST
Free fluid
- Abdominal trauma
- Distended abdomen
Abdominal Cavity
OR Thoracotomy
Chest tube
1L of Blood
Place chest tube
On affected side
-Chest trauma
- Diminished breath sounds
- Desaturation, O
2
requirement
Chest cavity Pelvis/Retroperitoneum
External Bleeding
floor
-Abdominal/Pelvic trauma
-Flank ecchymosis
-Unstable pelvis
-Hematuria
First do DPL
(supra umbilical)
r/o intrabdominal
bleed
1) Wrap sheet around pelvis
2) Pelvic angiography
(+) Blush/Extravasation
1) Deformed extremity
2) Crush injury
3) Mangled extremity

EBL
Femur Fx 750cc1L
Tib Fx 500-750cc
Immobilization and
minimal manipulation
of injured extremity
using splint (3Ps)
Tourniquet proximal
to injury
- set > systolic BP
Pressure
and
Elevation
5 Possible locations
for significant bleeding
Clue:
Clue:
Clue: Clue:
Clue:
DPL (-) DPL (+)
Angioembolization
Bleeding not
controlled
Be alert for
compartment
syndrome
Consult Ortho
1 2
3 4 5
Chest
X-Ray
(+) Ptx-Htx
Pelvic
X-Ray
(+) Fx
Goal #2

Support the patient


A-Establish IV access

B-Fluid Resuscitation
Establish IV access before it is too late
A - Establish good IV access

Must insure good vascular access:
2 large caliber: 14-16-gauge IV
-Rate of flow is proportional to r
4
and is inversely proportional to the length
-Short large caliber peripheral IVs are the best for resuscitation
Central Access: Central line or Cordis
-Cannot obtain peripheral access
-IVDA, severe hypovolemia, extremity injury
-Massive bleeding
-Preferred Site: Femoral *
(*Unless pelvic or abdominal vascular injury suspected!)

B - Fluid Resuscitation

Initial fluid bolus
1-2 liters in adults
20mL/kg in children

Type of fluid for resuscitation
-Isotonic electrolyte solution
Lactated ringers vs. normal saline
Electrolyte composition of crystalloid solutions

Fluid
pH Na
(mEq/L)
Cl
(mEq/L)
Lactate
(mEq/l)
Ca
(mEq/L)
K
(mEq/L)
Osm
(mOsm/L)
LR

6.7 130 109 28 3 4 279
NS 6.0 154 154 0 0 0 308
LR, lactated Ringers solution; NS, normal saline solution
B - Fluid Resuscitation

Intravascular effect
3 for 1 rule of Volume replacement: Volume lost

The effect of the 3:1 Rule

Assess patients response to fluid
resuscitation

Clinical parameters:
MS: return of
CVS: HR, MAP
Urinary output

Laboratory parameters:
BD, Acid/base balance
Lactate


Assess patients response to fluid
resuscitation

Three possible responses:

1. Responders
Bleeding has stopped

2. Transient responders
Something is still slowly bleeding!

3. Non responders:
Ongoing significant bleeding!
Immediate need for intervention!


Avoid the Lethal Triad
Coagulopathy
Consumption of clotting factor
Dilution of platelets and clotting factors: transfusion of PRBCs
MTP (now in place at UMDNJ!)
Factor VIIa

Hypothermia
Perpetuates coagulopathy
Most forgotten vital sign in resuscitation (check foley!)

Acidosis
Inadequate resuscitation and tissue perfusion
Anaerobic metabolism and of lactic acid production

Case #1
38 year old male ped-struck is found unresponsive. He gets intubated
by EMS. On arrival to the ED his BP is 90/60, HR 130.

Is the patient in Shock? Type of Shock? Class?


He is noted to have decreased BS on the left side and his O
2

Sats are
92% on an FiO2 of 100%.

Whats next?

Portable CXR
Whats wrong with this x-ray??
Case #1
Whats next?

Chest tube puts out 1 liter of blood.

Whats next?
Case #1 : CT Chest
Case #2
18 year old male involved in a high speed MVC found unresponsive
with a BP of 60/P at the scene. He has a large head laceration that
is actively bleeding, an obvious abrasions over the pelvis and
bilateral mangled lower extremities.

In the ED, he is immediately intubated, he has equal BS, his sats are
100%. He is actively bleeding from his scalp and legs. His pelvis is
unstable. BP 70/40 P 150.

Is the patient in Shock?
Type of Shock?
Class?

Case #2
Management ?

Goal #1
A- Locate the source of bleeding
B- Control it

Goal #2
A- Establish IV access
B- Fluid Resuscitation

???
WHY I S THE PATI ENT HYPOTENSI VE ?
Dont Get The Floor WET !!!!
SOURCE of
BLEEDING
? ? ?
Case #2
Whip Stitch scalp laceration
What is missing ?
Bilateral Tourniquets
Case #2
Still hypotensive despite bilateral tourniquets
and despite whipstiching the scalp laceration
He has received: 2 L crystalloids 2 units PRBCs
CXR: Normal
NEXT???
DPL? FAST?

Pelvic X-ray?
Portable Pelvic X-Ray
Whats next?
Before
Whats next??
After
Wrapping the pelvis with a sheet

Pelvic: Angiogram
Bleeding Controlled by Angio-Embolization
General Outline
Definition, diagnosis and types of shock
Classes of Hemorrhagic shock
Initial management of patients in hemorrhagic shock
Algorithm for identifying the location of bleeding
IV Access and Resuscitation in a Trauma patient

Initial Management of patients in non-hemorrhagic shock
Management of non-hemorrhagic shock
Case Scenarios
Hypotension/Shock
Diagnosis
1. Hypotension (SBP<100)
2. Tachycardia
3. Tachypnea; Sa O
2
<90%
4. Oliguria
5. Change in mental status (confusion, agitation)
6. Labs: Acidosis, Basic Deficit, Anion Gap, Lactate
Quick evaluation of A,B,C
*Notify senior resident on call and place the patient on ECG Monitor and pulse oximeter

A. Assess airway:
if inadequate
- BVM; call anesthesia to intubate if needed
B. Assess breathing:
if breath sounds
- CXR (stable pt)
- Place chest tube (unstable pt)
C. Assess circulation:
- No pulse CPR
- Check rate rhythm unstable arrhythmia ACLS Protocol
First Step in MGT
1. Make sure patient is on ECG monitor and Pulse Ox.
2. Administer O
2
3. Insure adequate IV access
4. Place foley catheter
5. Place CVP line (when indicated)
6. Order EKG
7. Chest X-ray r/o Ptx
Yes (patient is in shock)
Shock
Hypovolemic
Shock
Spinal Shock
Cardiogenic Shock
1. External fluid loss
2. 3
rd
Spacing
CVP, PCW: decreased
CO: decreased
SVR: increased
1. Fluid resuscitation
2. Control/replace
fluid losses

Infection

Obstructive
CVP, PCW: decreased
CO: increased then decreased
SVR: decreased
1. Tension PX
2. Cardiac tamponade
3. PE
Non-obstructive
CVP, PCW: increased
CO: decreased
SVR: increased
1. Identify & drain source of infection
2. Start appropriate Abx
3. Supportive care
- Fluid resuscitation
- Vaso pressors
(Phenylephirine, Norepinephrine)
Cause
Cause
Hemodynamic findings Hemodynamic findings Hemodynamic findings
Treatment
Treatment
1 2 3
1. CT placement
2. Pericardiocentesis
3. IV Heparin
1. Diuresis
- Lasix
2. Afterload reduction
- Nitroprusside, Nitroglycerine
- ACE inhibitor
3. Inotropic support
- Dobutamine, Milrinone
Treatment
Treatment
DDX
1. AMI
2. CHF
Cause
SCI (>T4 level)
Cause
Supportive Care
Fluid to fill the tank
Vaso pressors
(Phenylephirine, Norepinephrine)
Treatment
Hemorrhagic
Shock
Septic Shock
1. Trauma (*5)
2. Post-op bleeding
3. GI bleeding
Cause
1. Fluid resuscitation
2. Find source of
bleeding and control it
3. Correct coagulopathy

Treatment
Hypovolemic Shock
Most common cause of shock in surgical patients
Excessive fluid losses (internal or external)
Internal: Pancreatitis, bowel ischemia, bowel edema, ascites..
External: Burns, E-C Fistula, Large open wounds

2 main goals
1- ID and Tx the cause
Tx: Control fluid losses: surgical, wound coverage
2- Support the Patient

Hypovolemic Shock
Hemodynamics:
*Low to normal PCW (due to fluid losses)
Normal or Decreased CO
High SVR (compensation)
Management:
Fluids
No pressors
*primary process

Septic Shock
Second most common cause of shock in surgical patients
Vasoregulatory substances released produce a decrease in systemic
vascular resistance, manifested by warm pink skin with peripheral
vasodilatation
Two main goals
1 - ID and Tx the cause
Tx: Source Control (surgical, IR) + start antibiotics early
2 - Support the Patient

Septic Shock
Hemodynamics:
Low to normal PCW (vasodilatation and fluid losses)
Normal or increased CO (late; decrease CO)
*Low SVR
Management:
Fluids
Pressors
*primary process



Cardiogenic Shock
Forward blood flow is inadequate secondary to pump failure
Most common cause is acute myocardial infarction (AMI)
Other causes include:
Myocardial contusion, Aortic insufficiency, End-stage cardiomyopathy

Two main goals:
1- ID and Tx the cause: Cardiac Cath
Tx: Heparin..
2 - Support the Patient

Cardiogenic Shock
Hemodynamics:
Elevated filling pressures
*Diminished cardiac output due to pump failure
Increased SVR (compensation)
Management
Diuresis
Afterload reduction
Inotropes
*primary process

Obstructive Cardiogenic Shock
No intrinsic cardiac pathology (Non - MI)
Pump failure due to inflow or outflow obstruction
Cause :
Tension Pneumothorax
PE
Cardiac Temponade
Air embolus (rare)
Dx and Management specific to each process

Neurogenic Shock
Spinal cord injuries produce hypotension due to a loss of
sympathetic tone
Seen in one third of patients with SCI, usually seen in patients with
an injury above T4 level
Hypotension without tachycardia or cutaneous vasoconstriction

Two main goals:
1- ID cause, no specific Tx
2 - Support the Patient

Pearl: Must rule out other causes of shock in trauma patients with a spinal cord injury

Neurogenic Shock
Hemodynamics:
Normal to low PCW due to peripheral venous pooling
Normal to low CO- cannot compensate
*Decreased SVR due to loss of vasomotor tone
Management:
R/o Bleeding
Fluid and pressors
*primary process

Shock
Hypovolemic
Shock
Spinal Shock
Cardiogenic Shock
1. External fluid loss
2. 3
rd
Spacing
CVP, PCW: decreased
CO: decreased
SVR: increased
1. Fluid resuscitation
2. Control/replace
fluid losses

Infection

Obstructive
CVP, PCW: decreased
CO: increased then decreased
SVR: decreased
1. Tension PX
2. Cardiac tamponade
3. PE
Non-obstructive
CVP, PCW: increased
CO: decreased
SVR: increased
1. Identify & drain source of infection
2. Start appropriate Abx
3. Supportive care
- Fluid resuscitation
- Vaso pressors
(Phenylephirine, Norepinephrine)
Cause
Cause
Hemodynamic findings Hemodynamic findings Hemodynamic findings
Treatment
Treatment
1 2 3
1. CT placement
2. Pericardiocentesis
3. IV Heparin
1. Diuresis
- Lasix
2. Afterload reduction
- Nitroprusside, Nitroglycerine
- ACE inhibitor
3. Inotropic support
- Dobutamine, Milrinone
Treatment
Treatment
DDX
1. AMI
2. CHF
Cause
SCI (>T4 level)
Cause
Supportive Care
Fluid to fill the tank
Vaso pressors
(Phenylephirine, Norepinephrine)
Treatment
Hemorrhagic
Shock
Septic Shock
1. Trauma (*5)
2. Post-op bleeding
3. GI bleeding
Cause
1. Fluid resuscitation
2. Find source of
bleeding and control it
3. Correct coagulopathy

Treatment
CASE # 3
A 50 year old woman with unresectable pancreatic CA
with a T-Bili of 20 returns from IR after upsizing of her
PTC drains. She is confused, febrile, hypotension and
has decreased urine output. She is intubated and
transferred to the SICU.

What is your Dx? Shock? Type?
What is your management?
1. Goal #1 Source control, antibiotics
2. Goal #2 Hemodynamic Support
Swan #: CVP = 5 PCW = 8 C0= 10 SVR = 300




CASE # 4
A 88 y/o F s/p AAA repair, post-op day 1 in the ICU, she is
intubated. The nurse reports that she is hypotensive, BP 80/40,
pulse 120 and her urine output is equal to less than 10 cc/H for the
past 2 hours. She remains hypotensive despite 2 liters of fluid,
labs; hemoglobin is 10, Hgb 10, Cr 1.0 and lactate 4, BD -5. CVP
is 15.

What is your Dx? Shock? Type?
What is your management?
1. Goal #1 r/o MI & start appropriate treatment for MI
2. Goal #2 Hemodynamic Support
Swan #: CVP = 15 PCW = 18 C0= 3 SVR = 1300


Conclusion:

1. How to recognize and diagnose shock
2. Types of shock (SHOCK): hemorrhagic & non-hemorrhagic
3. Hemorrhagic Shock:
Classes of hemorrhagic shock
Algorithm to find the location of bleeding and control it
4. Non-hemorrhagic shocks
the 2 key Goals in the management of any shock
Hemodynamic findings and support
THANK YOU

?

THANK YOU

&

GOOD LUCK