Approach to a case of hypotension and shock

1. Approach to a case of Hypotension and Shock Introductory Lecture Series Department of Medicine Dr C Khati

2. Shock is an Emergency Assessment and resuscitation go hand in hand because time is critical

3. Learning Objectives • To learn definition and meanings of related terms • To be able to list the steps in pathogenesis of shock • To be able to list the 3 major categories of shock, and 3 others • To be able to enumerate common causes of shock in each of the 3 major categories

4. Learning Objectives • To comprehend that more than one mechanisms may operate in a given patient • To list steps in rapid initial assessment • To enumerate broad steps in resuscitation of shock

5. Definitions and Meanings • Stroke Volume (SV): Amount of blood pumped out with each systole. Pulse pressure correlates well with SV • Heart Rate (HR): Number of ventricular contractions per minute • Cardiac Output(CO): Amount of blood pumped out in each minute. CO = SV X HR

9. Definitions and Meanings Systolic Blood Pressure (SBP) Diastolic Blood Pressure (DBP)

10. Definitions and Meanings Pulse Pressure (PP): SBP – DBP correlates well with Stroke Volume . Mean Arterial Pressure (MAP): DBP + 1/3 PP

11. Definition and Meanings • Hypotension is diagnosed if blood pressure falls below 90/50 mmHg in adults. • Hypotension may also be diagnosed if an individual has a sudden drop in SBP of 30 - 40 mmHg or more from their baseline, or • An orthostatic (postural) drop in DBP of 15 mm Hg

14. Remember Hypotension is a late manifestation of shock

15. Definitions and Meanings • The Jugular Venous Pressure (JVP) is an observed pressure over the jugular veins • The Central Venous Pressure (CVP) is a measured pressure in the right atrium by means of a catheter attached to a manometer

18. Definitions and Meanings Capillary Nail Refill Test • Pressure is applied to the nail bed until it turns white (blanching). Then pressure is removed. • Time taken for return of pink colour to the nail is considered (capillary refill). • Blanch time > 2 seconds is a delayed response. –Dehydration –Shock – Peripheral vascular disease (PVD) – Hypothermia

19. Definitions and Meanings Capillary Nail Refill Test • Pressure is applied to the nail bed until it turns white (blanching). Then pressure is removed. • Time taken for return of pink colour to the nail is considered (capillary refill). • Blanch time > 2 seconds is a delayed response. –Dehydration –Shock –Peripheral vascular disease (PVD) –Hypothermia

20. Definitions and Meanings Shock or circulatory failure is the clinical syndrome that results from generalized inadequate tissue perfusion lasting for some time. Where oxygen delivery fails to meet metabolic requirements of the tissues. It is defined by the presence of multisystem, end organ hypo perfusion causing cellular injury. Cellular injury further compromises perfusion through functional and structural changes in the microvasculature through mediators Thus, setting up a vicious cycle.

23. Hypoperfusion Demand supply mismatch Cellular Dysfunction Release of mediators Structural and functional changes in microvasculature

27. Definition and Meanings • Early Shock • No significant organ failure • Late Shock • Multi-organ failure. > 80% mortality

30. Definitions and Meanings • Systemic Vascular Resistance (SVR): An index of arteriolar constriction throughout the body • Calculated by dividing the blood pressure by the cardiac output. MAP/ CO = SVR • Pulmonary Vascular Resistance (PVR): An index of arteriolar constriction in the pulmonary circulation

34. Pathogenesis of Shock MAP = CO X SVR

35. Pathogenesis of Shock MAP = CO X SVR or MAP/ CO = SVR

36. Pathogenesis of Shock MAP= CO X SVR MAP- Mean Arterial Pressure (Measurable:DBP +1/3 PP)

37. Pathogenesis of Shock MAP= CO X SVR MAP- Mean Arterial Pressure -Measurable (DBP + 1/3 PP) CO- Cardiac Output -Inferable (Pulse Pressure =SBP- DBP)

38. Pathogenesis of Shock MAP= CO X SVR MAP- Mean Arterial Pressure (Measurable: SBP + DBP/ 2) CO- Cardiac Output (Inferable; Pulse Pressure= SBP- DBP) SVR-Systemic Vascular Resistance: (can be calculated)

39. Pathogenesis of Shock • Diminished Cardiac Output

40. Is the Heart full or empty?

41. Pathogenesis of Shock • Diminished Cardiac Output • Heart Full (Cardiogenic) • Heart Empty (Hypovolemic)

42. Pathogenesis of Shock • Diminished Cardiac Output • Heart Full (Cardiogenic) • Heart Empty (Hypovolemic) • Increased Cardiac Output

43. Pathogenesis of Shock Diminished Cardiac Output MAP/ CO = SVR • Narrow Pulse Pressure (PP correlates well with SV) • Low volume pulse • Cool extremities • Delayed capillary refill

44. Pathogenesis of Shock Increased Cardiac Output MAP/ CO = SVR • Wide Pulse Pressure (esp. low DBP) • Bounding pulse • Warm extremities • Rapid capillary refill

45. Pathogenesis of Shock ( CO) MAP = CO X SVR or MAP/ CO = SVR • If an hypotensive patient has high CO, it can be inferred that reduced BP is a result of decreased SVR

46. Pathogenesis of Shock ( CO) MAP = CO X SVR or MAP/ CO = SVR • If a hypotensive patient has high CO, it can be inferred that reduced BP is a result of decreased SVR

47. Pathogenesis of Shock ( CO) • Low Intravascular and Cardiac Volume • Increased Intravascular and Cardiac Volume

48. Is the Heart full or empty?

49. Pathogenesis of Shock ( CO) Low Intravascular and Cardiac Volume • Hemorrhage • Volume Losses (vomiting, diarrhea, Polyuria) • JVP/ CVP is reduced • What do you think the other findings will be?

50. Pathogenesis of Shock ( CO) Low Intravascular and Cardiac Volume • Hemorrhage • Volume Losses (vomiting, diarrhea, Polyuria) • JVP/ CVP is reduced • What do you think the other findings will be?

51. Pathogenesis of Shock( CO) Increased Intravascular and Cardiac Volume • Increased JVP/ CVP • Extremity edema • S3/ S4 gallops • Basal crepitations • X Ray – Cardiomegaly – Widened vascular pedicles, Kerley B Lines – Pulmonary edema

52. Common Categories of Shock 1. Cardiogenic 2. Hypovolemic 3. High CO with decreased SVR (Warm Shock) 4. Neurogenic- Major brain or spinal injury- 5. Hypoadrenal- Refractory Shock 6. Obstructive- Tamponade, Pulmonary Embolism, Tension Pneumothorax

53. Common Categories of Shock 1. Cardiogenic 2. Hypovolemic 3. High CO with decreased SVR (Warm Shock) 4. Neurogenic- Major brain or spinal injury- 5. Hypoadrenal- Refractory Shock 6. Obstructive- Tamponade, Pulmonary Embolism, Tension Pneumothorax

54. Basic Changes in Each Category Cardiogenic Hypovolemic High CO with decreased SVR CO Low Low High

55. Basic Changes in Each Category Cardiogenic Hypovolemic High CO with decreased SVR CO Low Low High SVR High High Low/ High (late)

56. Basic Changes in Each Category Cardiogenic Hypovolemic High CO with decreased SVR CO Low Low High SVR High High Low/ High (late) MAP Low Low Normal/ Low

57. Basic Changes in Each Category Cardiogenic Hypovolemic High CO with decreased SVR CO Low Low High SVR High High Low/ High (late) MAP Low Low Normal/ Low CVP High Low Low/ High (late)

58. Basic Changes in Each Category Cardiogenic Hypovolemic High CO with decreased SVR CO Low Low High SVR High High Low/ High (late) MAP Low Low Normal/ Low CVP High Low Low/ High (late) Venous Oxygen saturation Low Low High

59. Common Causes of Shock Cardiogenic Hypovolemic High CO with decreased SVR MI GI Losses SIRS Arrhythmias Heat stroke Sepsis Myocarditis Hemorrhage Pancreatitis Anaphylaxis Tamponade Trauma Thyrotoxicosis (storm) Injuries Burns Burns AV Shunts Liver Failure

60. Steps in rapid initial assessment • Confirm shock and assess severity • Assess category of shock • Low CO or high CO (Heart empty or full) • Start resuscitation simultaneously

63. Goal of Resuscitation ? • Re establish adequate tissue perfusion to prevent or minimize end- organ injury

64. Goal of Resuscitation • Re establish adequate tissue perfusion to prevent or minimize end- organ injury

65. Resuscitation is different in each category Cardiogenic Hypovolemic High CO with decreased SVR Treatment for Ischemia IV Fluids Antibiotics Ionotropes Colloids EGDT* After load reduction Low dose steroids Activated Protein C

66. Steps in rapid initial assessment • Patient and clinical situation assessment • Vitals and quick examination to assess category of shock- • Core temperature • Cold or warm peripheries • Pulse- bounding or low volume • Capillary filling- slow/ rapid • Raised JVP, S3 and basal crepts in cardiogenic • Respiration • Urine Output

67. Steps in rapid initial assessment • Patient and clinical situation assessment • Vitals and quick examination to assess category of shock- –Core temperature –Cold or warm peripheries –Pulse- bounding or low volume –Capillary filling- slow/ rapid –Raised JVP, S3 and basal crepts in cardiogenic –Respiration –Urine Output

68. Terms in Assessment/ Treatment • APACHE II Score- Acute Physiology and Chronic Health Evaluation II (with points for age and co-morbidity) • Glasgow Coma Score • ACLS- Advanced Cardiac Life Support • Old acronym- ABC (still valid)

69. General Features of Shock • Hypotension (SBP < 100) • Tachycardia (>100) • Cold clammy skin (Low CO) • Rapid shallow respiration • Drowsiness, confusion and irritability • Oliguria (<30ml/hr) • Elevated / reduced CVP • Multi- organ failure

70. Steps in Resuscitation • Airway and Respiration • Circulation • Early Goal Directed Therapy (EGDT) • Multisystem organ support

71. 32 year old young lady, on NSAIDS • Dyspepsia X 5 days • Dark tarry stools X 2 days • Profound weakness X 2 days • Syncope this morning • Cold clammy and sweating, Poor capp refill • BP 70/50 mm Hg lying; 60/ 35 mm standing • Pulse 140/ min, thready • Resp- 36/ min • Pallor

72. 40 year busy doctor, HT • Chest Pain X 1 Hour • Sweating, palpitations and breathlessness • Restless, sweating, cold and clammy • BP 100/76 mm, Pulse 110/ min, low volume • Resp- 26/ min, prefers to be propped up • Poor capillary refill • JVP/ CVP raised

73. 45 year old diabetic male • Fever, cough and rusty sputum X 2 days • Weakness X 1 day • No urine X12 hours • Temp- 40 degrees C, warm extremities • Pulse 120/ min, good volume • BP 108/30 mm, Resp rate 40/ min • Cyanosis +, JVP not raised • Capp refill good

74. Take Home Messages • Shock is an Emergency. Assessment and resuscitation go hand in hand because time is critical • Hypotension is a late feature of shock. Do not wait for hypotension before starting treatment • Clinical setting and simple examination of MAP, pulse pressure, heart rate, JVP and nail cappillary bed refill can give vital clues. Tachypnea and sweating should also make you alert.

75. Take Home Messages • Urine output is a good indicator of renal (tissue) perfusion • Goal of resucitatation is to re establish adequate tissue perfusion to prevent or minimize end- organ injury

Approach to a case of hypotension and shock

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