Shock: Emergency approach and management

Shock Emergency approach and Early management The 1st priority in any pt. with shock is stabilization of their A-B-C Kumpol ,MD Emergency medicine Thammasat 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 Evaluate evidenced HF 500 10 cc/kg in 5-10 min

Fluid challenge test 1000 Evaluate evidenced HF 20 cc/kg

Fluid challenge test Consider 2000 Central monitoring Evaluate evidenced HF 40 cc/kg

Fluid challenge test 3000 Need Central monitoring Evaluate evidenced HF 60 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

Shock Significant reduction of systemic tissue perfusion

Emergency approach Hypovolemic Cardiogenic Distributive

Septic shock

Physiology

Compensation

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

SIRs +Infection Sepsis + Organ Severe hypoperfusion sepsis -mottled skin -cap. Refill > 3s Septic -U/O < 0.5 cc/k/h + -lactate > 2 shock -Plt < 100,000 +MAP < 60 ==== -cardiac dysf. +after 20-40 cc/k starch + 40-60 cc/k NSS +PCWP 12-20 +DA>5u/k/min NE/E<0.25u/k/min --- MAP> 60 Septic shock + DA > 15 u/k/min, NE/E >0.25--- MAP>60 Refractory septic shock

After Septic shock MAP< 60 20-40cc/k starch 40-60cc/k NSS

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Shock: Emergency approach and management

by Society of Thai Emergency Physicians on Aug 11, 2009

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