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