Shock: Emergency approach and management

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Shock: Emergency approach and management

  1. 1. 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
  2. 2. Diagnostic evaluation should occur at the same time as RESUSCITATION
  3. 3. Early management AIRWAY and BREATHING Stabilize respiration; Oxygen , intubation
  4. 4. Assess perfusion
  5. 5. Delayed fluid resuscitation
  6. 6. • Different types of shock can coexist. • Follow pathophysiology of shock • Decrease Total effective plasma volume • Relative intravascular hypovolemia • Elderly, DM, take B-blocker, hypertension
  7. 7. Restore perfusion • Choice of replacement fluid • Rate and assessment of fluid repletion • Central monitoring or assessment • Vasopressors and inotrops
  8. 8. 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.
  9. 9. Choice of replacement fluid Colloid versus crystalloid
  10. 10. 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
  11. 11. 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
  12. 12. Fluid challenge test Evaluate evidenced HF 500 10 cc/kg in 5-10 min
  13. 13. Fluid challenge test 1000 Evaluate evidenced HF 20 cc/kg
  14. 14. Fluid challenge test Consider 2000 Central monitoring Evaluate evidenced HF 40 cc/kg
  15. 15. Fluid challenge test 3000 Need Central monitoring Evaluate evidenced HF 60 cc/kg
  16. 16. Fail to respond to initial fluid resuscitation. • CVP • Pulmonary capillary wedge pressure
  17. 17. Inotropes and vasopressors
  18. 18. • CVP 8 to 12 mmHg • MAP > 65 , SBP > 90 mmHg • Central venous oxygen saturation >70% • Hematocrit > 30% • Proper antibiotic
  19. 19. Shock Significant reduction of systemic tissue perfusion
  20. 20. Emergency approach Hypovolemic Cardiogenic Distributive
  21. 21. Septic shock
  22. 22. Physiology
  23. 23. Compensation
  24. 24. Stages of shock
  25. 25. Stages of shock
  26. 26. Recommended approach Diagnostic evaluation should occur at the same time as RESUSCITATION • Medical history • Physical examination • Laboratory evaluation(esp. undifferentiated shock)
  27. 27. Definition • Systemic inflammatory response syndrome (SIRs) • Sepsis • Severe sepsis • Septic shock • Refractory septic shock
  28. 28. 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
  29. 29. After Septic shock MAP< 60 20-40cc/k starch 40-60cc/k NSS

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