Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation Ziad Sifri, MD Surgical Fundamentals and Algorithmic Approach

1. Hypotension, Shock, Hemorrhage and IV Fluid Resuscitation Ziad Sifri, MD Surgical Fundamentals and Algorithmic Approach to Patient Care Session#7: August 17, 2007

2. Learning Objectives Definition, diagnosis and types of shock Hemorrhagic shock ( I-IV ) Initial management of patients in Hemorrhagic shock Algorithm for the identifying of the location of bleeding IV access and resuscitation of Trauma patients Initial assessment of patients in non-Hemorrhagic shock Diagnosis of the various types of non-Hemorrhagic shock Management of non-Hemorrhagic shock Case Scenarios

3. The real goal however……. is to avoid ….

4. “Shock” • Definition: Inadequate tissue Perfusion and Oxygenation • Effect: Cellular injury, Organ failure, Death • Causes: hemorrhagic and non-hemorrhagic

5. Types of Shock ?

6. Types of Shock

7. Shock: “Clinical Diagnosis’ • CNS: Altered MS – 2 extremes (Dr M. presentation) • CVS1: Tachycardia, ↑ diastolic BP, ↓ pulse pressure • CVS2:↓ MAP, ↓ cardiac output • Resp: Tachypnea and ↑O2 requirement (Dr M. presentation) • GU: Decrease U/O • GI: Ileus? • Skin: Progressive vasoconstriction-cool extremities • History (for clues)

8. Shock: “Laboratory Support” • Metabolic acidosis • ABG: Acidosis, BD > -2 • Chem-7: ↓Bicarb • Lactate: >2 • Metabolic acidosis 2nd to • Inadequate tissue perfusion • Shift to anaerobic metabolism • Production of lactic acid

9. Pitfalls • Extremes of age • Infant>160; preschool 140; school age 120; adult 100 • Athletes • Pregnancy • Medications • Beta blockers, pacemaker • Hgb/Hct concentration • Unreliable for acute blood loss

10. Other Pitfalls…. • Urine output adequate • despite shock • Alcohol • Hyperglycemia • Home medication: diuretics.. • Therapeutic intervention: Mannitol • IV contrast: CT, Angio • Residual urine… • DI • Etc…

11. General Outline • Definition, diagnosis and types of shock • Hemorrhagic shock: Classes and Resuscitation

12. Hemorrhage & Trauma • Normal blood volume • Adults: 7% of ideal weight • 70 kg man had blood volume of 5 liters • Child: 9% of ideal weight • Hemorrhage • Loss of circulating blood volume • How much volume loss to cause shock? • Classes of hemorrhage I-IV

13. Hemorrhagic Shock: “The Classes” “Class I” “Class II” “ClassIII” “Class IV” EBL EBL EBL EBL <750cc <15% of TBV 750cc – 1500cc 15 – 30% of TBV 1.5L – 2L 30 – 40% of TBV >2L >40% of TBV S&S S&S S&S S&S HR: increased Pulse Pressure: decreased BP: no change HR: increased BP: decreased MS: agitated Urine Output: decreased None/minimal HR: increased BP: decreased (<60) MS: decreased Tx Tx Tx Tx Crystalloids Crystalloids 1. Crystalloid (1 – 2L) 2. Transfusion (1 – 2units) 3. Identify source of Bleed(*5) 1. Crystalloid (2L) 2. Transfusion (2 – 4 units) 3. Identify source of Bleed(*5) 4. OR

14. General Outline • Definition, diagnosis and types of shock • Classes of Hemorrhagic shock • Initial management of patients in Hemorrhagic shock

15. Two Goals in the management of “any” Shock

16. Two Goals in the management of Hemorrhagic Shock

17. Goal #1 “Identification and Treatment of the cause”

18. Algorithm to Identify the Bleeding Source in a Hypotensive Trauma Patient 5 Possible locations for significant bleeding 1 2 5 3 4 Abdominal Cavity Pelvis/Retroperitoneum External Bleeding Long Bones Chest cavity Clue: Clue: Clue: Clue: Clue: 1) Deformed extremity 2) Crush injury 3) Mangled extremity • Abdominal trauma • Distended abdomen • Abdominal/Pelvic trauma • Flank ecchymosis • Unstable pelvis • Hematuria Blood on Floor → Check head/scalp → Check extremity • Chest trauma • Diminished breath sounds • Desaturation, ↑O2 requirement Place chest tube On affected side EBL Femur Fx 750cc–1L Tib Fx 500-750cc Chest X-Ray (+) Ptx-Htx Scalp bleed Extremity Bleed First do DPL (supra umbilical) r/o intrabdominal bleed Pelvic X-Ray (+) Fx FAST → Free fluid • DPL → (+) • Gross blood • >105 RBCs Chest tube ≥ 1L of Blood Consult Ortho Whip-stitch with nylon suture Pressure and Elevation DPL (+) DPL (-) Immobilization and minimal manipulation of injured extremity using splint (3Ps) 1) Wrap sheet around pelvis 2) Pelvic angiography OR →Thoracotomy Bleeding not controlled OR →Exploratory laparotomy (+) Blush/Extravasation • Tourniquet proximal • to injury • set > systolic BP Be alert for compartment syndrome Angioembolization

19. Algorithm to Identify the Bleeding Source in a Hypotensive Trauma Patient 5 Possible locations for significant bleeding 1 2 5 3 4 Abdominal Cavity Pelvis/Retroperitoneum External Bleeding “floor” Long Bones Chest cavity

20. Algorithm to Identify the Bleeding Source in a Hypotensive Trauma Patient 5 Possible locations for significant bleeding 1 2 5 3 4 Abdominal Cavity Pelvis/Retroperitoneum External Bleeding “floor” Long Bones Chest cavity Clue: Clue: Clue: Clue: Clue: 1) Deformed extremity 2) Crush injury 3) Mangled extremity • Abdominal trauma • Distended abdomen • Abdominal/Pelvic trauma • Flank ecchymosis • Unstable pelvis • Hematuria Blood on Floor → Check head/scalp → Check extremity • Chest trauma • Diminished breath sounds • Desaturation, ↑O2 requirement Place chest tube On affected side EBL Femur Fx 750cc–1L Tib Fx 500-750cc Chest X-Ray (+) Ptx-Htx Scalp bleed Extremity Bleed First do DPL (supra umbilical) r/o intrabdominal bleed Pelvic X-Ray (+) Fx FAST → Free fluid • DPL → (+) • Gross blood • >105 RBCs Chest tube ≥ 1L of Blood Consult Ortho Whip-stitch with nylon suture Pressure and Elevation DPL (+) DPL (-) Immobilization and minimal manipulation of injured extremity using splint (3Ps) 1) Wrap sheet around pelvis 2) Pelvic angiography OR →Thoracotomy Bleeding not controlled OR →Exploratory laparotomy (+) Blush/Extravasation • Tourniquet proximal • to injury • set > systolic BP Be alert for compartment syndrome Angioembolization

21. Goal #2 “Support the patient”

22. Establish IV access before it is too late

23. A - Establish good IV access • Must insure good vascular access: • 2 large caliber: 14-16-gauge IV -Rate of flow is proportional to r4 and is inversely proportional to the length -Short large caliber peripheral IVs are the best for resuscitation • Central Access: Central line or Cordis -Cannot obtain peripheral access -IVDA, severe hypovolemia, extremity injury -Massive bleeding -Preferred Site: Femoral * (*Unless pelvic or abdominal vascular injury suspected!)

24. B - Fluid Resuscitation • Initial fluid bolus • 1-2 liters in adults • 20mL/kg in children • Type of fluid for resuscitation -Isotonic electrolyte solution Lactated ringers vs. normal saline

25. Electrolyte composition of crystalloid solutions LR, lactated Ringer’s solution; NS, normal saline solution

26. B - Fluid Resuscitation • Intravascular effect • 3 for 1 rule of Volume replacement: Volume lost

27. The effect of the 3:1 Rule

28. Assess patient’s response to fluid resuscitation • Clinical parameters: • MS: return of • CVS: HR, MAP • Urinary output • Laboratory parameters: • BD, Acid/base balance • Lactate

29. Assess patient’s response to fluid resuscitation Three possible responses: • Responders • Bleeding has stopped • Transient responders • Something is still slowly bleeding! • Non responders: • Ongoing significant bleeding! • Immediate need for intervention!

30. Avoid the “Lethal Triad” • Coagulopathy • Consumption of clotting factor • Dilution of platelets and clotting factors: transfusion of PRBCs • MTP (now in place at UMDNJ!) • Factor VIIa • Hypothermia • Perpetuates coagulopathy • Most forgotten vital sign in resuscitation (check foley!) • Acidosis • Inadequate resuscitation and tissue perfusion • Anaerobic metabolism and of lactic acid production

31. Case #1 38 year old male ped-struck is found unresponsive. He gets intubated by EMS. On arrival to the ED his BP is 90/60, HR 130. Is the patient in Shock? Type of Shock? Class? He is noted to have decreased BS on the left side and his O2Sats are 92% on an FiO2 of 100%. What’s next?

32. Portable CXR What’s wrong with this x-ray??

33. Case #1 • What’s next? Chest tube puts out 1 liter of blood. • What’s next?

34. Case #1: CT Chest

35. ?

36. Case #2 18 year old male involved in a high speed MVC found unresponsive with a BP of 60/P at the scene. He has a large head laceration that is actively bleeding, an obvious abrasions over the pelvis and bilateral mangled lower extremities. In the ED, he is immediately intubated, he has equal BS, his sats are 100%. He is actively bleeding from his scalp and legs. His pelvis is unstable. BP 70/40 P 150. Is the patient in Shock? Type of Shock? Class?

37. Case #2 Management ? • Goal #1 A- Locate the source of bleeding B- Control it • Goal #2 A- Establish IV access B- Fluid Resuscitation

38. ??? WHY IS THE PATIENT HYPOTENSIVE ? Don’t Get The Floor WET !!!!

39. Case #2 SOURCE of BLEEDING ? ? ?

40. Whip Stitch scalp laceration

41. What is missing ?

42. Bilateral Tourniquets

43. Case #2 • Still hypotensive despite bilateral tourniquets and despite whipstiching the scalp laceration • He has received: 2 L crystalloids 2 units PRBCs • CXR: Normal

44. NEXT??? • DPL? FAST? • Pelvic X-ray?

45. Portable Pelvic X-Ray What’s next?

46. Wrapping the pelvis with a sheet Before After What’s next??

47. Pelvic: Angiogram Bleeding Controlled by Angio-Embolization

48. General Outline • Definition, diagnosis and types of shock • Classes of Hemorrhagic shock • Initial management of patients in hemorrhagic shock • Algorithm for identifying the location of bleeding • IV Access and Resuscitation in a Trauma patient • Initial Management of patients in non-hemorrhagic shock • Management of non-hemorrhagic shock • Case Scenarios

49. Hypotension/Shock Diagnosis • Hypotension (SBP<100) • Tachycardia • Tachypnea; Sa O2 <90% • Oliguria • Change in mental status (confusion, agitation) • Labs: Acidosis, Basic Deficit, Anion Gap, Lactate Yes (patient is in shock) Quick evaluation of A,B,C *Notify senior resident on call and place the patient on ECG Monitor and pulse oximeter A. Assess airway: if inadequate - BVM; call anesthesia to intubate if needed B. Assess breathing: if ↓ breath sounds - CXR (stable pt) - Place chest tube (unstable pt) C. Assess circulation: - No pulse → CPR - Check rate rhythm →unstable arrhythmia → ACLS Protocol • Make sure patient is on ECG monitor and Pulse Ox. • Administer O2 • Insure adequate IV access • Place foley catheter • Place CVP line (when indicated) • Order EKG • Chest X-ray r/o Ptx First Step in MGT

50. Shock 1 2 3 Hemodynamic findings Hemodynamic findings Hemodynamic findings CVP, PCW: decreased CO: decreased SVR: increased CVP, PCW: decreased CO: increased then decreased SVR: decreased CVP, PCW: increased CO: decreased SVR: increased Hypovolemic Shock Hemorrhagic Shock Cardiogenic Shock Spinal Shock Septic Shock Cause 1. External fluid loss 2. 3rd Spacing Cause Cause Obstructive Non-obstructive Cause SCI (>T4 level) Infection DDX 1. Trauma (*5) 2. Post-op bleeding 3. GI bleeding Cause 1. Tension PX 2. Cardiac tamponade 3. PE 1. AMI 2. CHF Treatment Treatment 1. Fluid resuscitation 2.Control/replace fluid losses Supportive Care →Fluid “to fill the tank” → Vaso pressors (Phenylephirine, Norepinephrine) Treatment Treatment 1. CT placement 2. Pericardiocentesis 3. IV Heparin 1. Diuresis - Lasix 2. Afterload reduction - Nitroprusside, Nitroglycerine - ACE inhibitor 3. Inotropic support - Dobutamine, Milrinone Treatment 1.Fluid resuscitation 2.Find source of bleeding and control it 3.Correct coagulopathy Treatment 1. Identify & drain source of infection 2. Start appropriate Abx 3. Supportive care - Fluid resuscitation - Vaso pressors (Phenylephirine, Norepinephrine)