EM II Shock

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Answer

Shock

Inadequate oxygen delivery to meet the metabolic needs of the tissues (CO or O2 carrying capacity); Inability to metabolize oxygen;

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Hypovolemic Hemorrhagic Shock

Trauma: external (floor) or internal bleeding (hematoma, hemothorax, hemoperitoneum, placental abruption, etc)Atraumatic: GIB, Ruptured AAA, Ruptured aortic dissection, ruptured ectopic

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Severe Dehydration hypovolemic Shock

BurnsDKAAdrenal crisisVomiting, diarrhea, hyperosmolar statesPancreatitis, ascites, obstruction

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Distributive Shock

abnormal distribution of vascular volume. Decreased SVR, Increased permeability. Increased vascular compartment. AKA "warm shock".

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Examples of Distributive Shock

Classic examples: Sepsis, Anaphylaxis, NeurogenicOthers: any other class of shock that is prolonged enough that vasoconstriction cannot be maintainedCarbon Monoxide and cyanide

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cardiogenic

Rate (CO=HRxSV), Pump Failure (decreased HR or decreasd contractility): AMI, CHF, Arrhythmias, Cardiomyopathy, Myocarditis, Ruptured Septum or papillary muscle, acute aortic insufficiency, myocardial contusion, prosthetic valve dysfunction

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Obstructive Shock

Blocked blood flow into or out of the heart: Decreased RV filling (decreased preload) or Systemic obstruction

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Causes of Obstructive Shock

Tension PTX,Pericardial Disease (tamponade),Pulmonary obstruction (massive PE),Cardiac disease (atrial myxoma, HOCM, subacute bacterial endocarditis)

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Early on, the ____ is able to compensate for shock to maintain perfusion to the heart (coronary) and brain (cerebral)

ANS

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Early on in shock, the ANS stimulates vascular baroreceptors in order to:

arteriorlar vasoconstriction: blood is shunted from skin, sk mm, and splanchnic vascular beds,Venous constriction resulting in increased preload,Increased HR and contractility,Release of Epi, NE, DA, Cortisol as well as ADH and stimulation of RAAS

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Compensated

Body is able to continue to perfuse vital organs.Blood shunted away from skin/muscle, then liver, kidneys.Clinically: the diastolic pressure is increased, tachycardic, pale, diaphoretic, decreased UOP

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Decompensated

Continued cellular impairment overwhelms the body's ability to shunt, Severe AMS, Hypotension, death

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SIRS

early sepsis. 2+ of the followin: temp >38 or <36, P>90bpm, RR>20 or PaCO2<32mmHg, WBC>12,000 or <4,000 or 10% bands

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Sepsis

SIRS + evidence of infection

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Severe Sepsis

evidence of organ dysfunction (AMS, oliguria, liver failure, ARDS) Usually has hypotension that is responsive to fluids. Person does not look well! Need IVs for fluid and Abx

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Severe Septic Shock

sepsis that does not respond to fluid resuscitation. Ex: systolic bp still 80 after fluids delivered..this is when you are giving pressers

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Class I

up to 750 cc blood loss (up to 15% blood vol), P<100, BP nl, PP nl or increased, RR:14-20, UOP (cc/hr)>30, Mental: slightly anxious, crystalloid

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Class II

750-1500cc blood loss (15-30%), P>100, BP nl, PP: decreased, RR:20-30, UOP (cc/hr):20-30, Mental:mildly anxious, Crystalloid

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Class III

1500-2000cc blood loss (30-45%), P:>120, BP: decreased, PP:decreased, RR:30-40, UOP(cc/hr):5-25, Mental:anxious, confused. Crystalloid and blood

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Class IV

<2000cc blood loss (>45%), P:>140, BP: decreased, PP: decreased, RR.35, UOP(cc/hr): negligible. Mental: Confused, lethargic. Crystalloid and emergency released blood

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Assessing Shock

tachycardia (early sign), Narrowed Pulse Pressure, Adrenergic Responses: cool, diaphoretic, delayed capillary refill, livedo reticularis, agitated. AMS; anxiety, confusion, lethargy; Hypotension: late sign due to compensation

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Where can you hide blood?

chest, belly, retroperitoneal space, pelvis, thigh, floor

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First and second steps in assessing shock

1) recognize shock; 2)determine etiology

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Most injured patients in shock are suffering from

hypovolemic shock

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3 main types of shock

cardiogenic (tamponade, myocardial contusions, MI); Obstructive Shock (tension PTX with penetrating thoracic injury); Neurogenic Shock (injury to spinal cord). Also, septic shock

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Hemorrhagic shock tx

Volume resuscitation, stop hemorrhage, avoid pressors

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Cardiogenic Shock Presentation in Blunt trauma/deceleration injury:

Cardiac Tamponade (beck's triad: hypotension, distended neck veins, muffled heart sounds), cardiac contusion, air embolus, Acute MI

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Cardiogenic Shock Presentation in Penetrating injury (ex: stabwound in sub xyphoid position)

cardiac tamponade most common

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Intracranial injuries do not cause

neurogenic shock

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Spinal cord injury may cause loss of

sympathetic tone resulting in vasodilation below the injury and bradycardia. Spinal cord injury pts frequently are hypovolemic as well, so initial management is IVF. Tx: fluid, methylpredinisolone, atropine as needed, possibly DA

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Septic Shock tx

IVf, abx, EGDT once hemorrhage is controlled

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Airway managment when assessing shock in trauma

if the pt is obtunded (GCS<8) or too agitated to allow a physical exam then intubate the patient, C-spine immobilization

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Breathing assessment in trauma shock pt includes: breath sounds (abdomen, lungs), trachea midline, end title CO2 detectors, capnography, vocal cord visualization (seeing tube going through the cords) and

pulse ox, equal chest rise and fall, breath sounds heard bilaterally, ABGs, is pt tachypneic

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Tension Pneumothorax management

large bore IV catheter (14 gauge) needle decompression (midclavicular line 2nd intercostal space). Should correct marked vital signs, especially hypotension

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Circulation management when assessing shock in trauma

pulses? (radial disappears w/ sbp<80, absent pulses give clues as to where vascular injuries have occurred), pt tachy? hypotensive, what kind of IV access does pt have? Where is blood being lost?

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IV's

start with large peripheral, next central line (triple lumen), cortis? (can put 1L in 45 sec), intraosseus (tibia to marrow)

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Bolus fluid

1-2L in an adult. Peds: 20cc/kg, then give fluids according to the level of shock.

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If patient is unstable, what type of scan is used?

US to tell where bleeding is from

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If patient is stable, what type of scan is used?

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Labs to order in shock

shock panel, CBC, Chem 7, Type and Cross

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Tx of hypovolemic shock when blood is hidden in the chest (each hemithorax can hold 2L)

Has there been a deceleration injury? arotic Angiogram is goldstandard. Associated wtih Aortixc tears. CXR widened mediastinum, Chest CT if stable. Rib fx/clavicular fx may cause lung or vascular lacerations. Tx: large bore chest tube to drain blood, OR

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Tx of hypovolemic shock when blood is in the abdomen/pelvis

nl CXR and no external bleeding=assume intra-abdominal/retroperitoneal hemorrhage. FAST or CT

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Four places to look with FAST US probe

Cardiac, LUQ, RUQ, Bladder. (check for fluid around them). Can bleed out into the retroperitoneum and not see it on the FAST exam

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Assessing hypovolemic shock when blood is in the pelvis/thighs

MAST trousers, pelvic binder, tightly wrapped bedsheets, VIR for pelvic bleeding. Goal is to stabilize and compress

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Each thigh can hold _____ L of blood

3-4 L

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Disability assessment in shock

Brief neuro: GCS, pupillary response, motor and sensory response (10-15sec). Alterations in CNS fxn may only be due to inadequate cerebral perfusion, and cannot be ascribed to intracranial injury until adequate volume resuscitation has been achieved.

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Lowest GCS score

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ABCDEFG

airway, breathing, circulation, disability, Exposure, Fingers and Foley, Gastric Decrompression

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Shock without a hx of trauma

usually exhibit a stress response: appear ill, pale, diaphoretic, tachycardic, tachypneic. 4/6 Rosen's criteria

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Rosen's Criteria

ill appearing or AMS, HR>100, RR>22 or PaCO2<32, Base deficit<-5 or lactate >4, UOP<.5cc/hr, Hypotn for >20min

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evaluating shock without h/o trauma causes

hypovolemic, distributive, cardiogenic and obstructive

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Shock without trauma GI clues (GIB, vomiting, diarrhea)

GI tract=hematemesis, melena, (NG tube, hemoccult); Ectopic Pregnancy=young women, pelvic pain, vaginal bleeding, verified by US (culdocentesis). BhCG>1600 with no IUP=assume ectopic.

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TX for GI cause of shock without trauma

Tx is volume resuscitation. GI eval for GIB & shock. Octreotide and protonix for bleeding varices. OR for ruptured ectopic

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Abdominal or Low Back Pain is concerning for

suddent onset back/abd pain in patient with htn: think arotic dissectio. Abd pain, distension, palpable abdominal mass think ruptured AAA. Rigid abdomen think peritonitis

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If there is a concern for ruptured AAA or peritonitis you should

call surgery

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EGDT

early goal directed therapy

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Number one cause of ICU death

Sepsis

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In assessing shock, check for

fever and hypothermia, wheezing, hives, skin flushing

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Central venous pressure (CVP) monitoring

assesses intravascular volume

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Tx of shock without h/o trauma may include: fluids, abx, surgical (abscess, obstructive cholangitis), corticosteroids (high dose steroids) and

Activated Protein C (XIGRIS) - decreases mortality from sepsis, decreases production of thrombin and increases fibrinolysis

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Cardiogenic Shock without trauma (treat as cardiogenic shock from myocardial ischemia)

ABCs, O2, IV and cardiac monitoring (EKG and CXR stat), tx focuses on increasing inotropy, avoid benzo's and narcotics as they negate inotropy (use etomidate), tx emergent dysrhthmias per ACLS, for pressor support use dobutamine and DA

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If pharmacologic support fails in cardiogenic shock (without h/o trauma), then

the pt needs to be in an ICU for intra-aoric balloon pump counterpulsation (IABPC). This increases diastolic coronary perfusion which disrupts hypotension induced myocardial perfusion.

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Large pericardial sac effusions may occur in patients with

recent viral URI’s, TB, neoplasms, recent cardiac surgery, or chest radiation (among others).

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Sx presentation in cardiogenic shock without h/o of trauma

pleuritic CP and SOB, Becks triad, pulsus paradoxus, CXR shows enlarged cardiac silhouette, EKG with low voltage, electrical alternans. Tx: pericardiocentesis

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Persistent Hypoxemia or Hypercapnea

r/o PE with CT (or VQ), If too unstable, look for signs of R heart strain (bedside US shows dilated RV, EKG may show S1, Q3, T3 if there is considerable R heart strain, PE requires anticoag with heparin. If pt is in shock may require thrombolytics

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15% of PEs have what EKG changes?

S1Q3T3

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Unexplained bradycardia with hypotension

Return

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Actions of Histamine

mucous membrane secretion, increased bronchial smooth muscle tone, decreased vascular muscle tone, capillary, urticarial skin lesions

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Early clinical signs of Anaphylaxis and Anaphylactic Shock

Early – apprehension, urticaria, cough, coryza, bronchospasm/hoarse/stridor

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Severe clinical signs of Anaphylaxis and Anaphlyactic Shock

hypotension, AMS, mydriasis, incontinence, death

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Tx of Anaphylaxis

ABCs, d/c exposure, Airway/breathing: continous pulse ox, supplemental oxygen, ETT if needed, epi and antihistamines (to keep airway open), albuterol if wheezing, steroids, cardiac monitoring, bolus fluid if hypotn, if pt taking BB use glucagon

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Dose of Epi for anaphylaxis

IM .3-.5mg

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Preventing Anaphylaxis

inquire about drug allergies, May admit to ICU for desensitization if no other drug choices are available, give parenteral meds slowly and observe for at least 30min after injection, home kits (epi-pen)

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Bedside study to r/o ectopic pregnancy

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Created by: ltm12