Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist

1. Managing Hemorrhagic Shock Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

2. Managing Hemorrhagic Shock Definition • tissue perfusion that is inadequate to maintain normal metabolic and nutritional functions • potentially fatal if not identified & treated

3. Managing Hemorrhagic Shock Introduction • 12% to 18% of patients presenting initially in severe shock have increased mortality or morbidity related to secondary organ failure

4. Managing Hemorrhagic Shock

5. Managing Hemorrhagic Shock Clinical Signs of Shock Preterminal Stages • severe hypotension • agonal respirations • thready pulse • tachy or bradydysrhythmias

6. Managing Hemorrhagic Shock Shock Index • HR / systolic blood pressure • inversely related to LVSW • abnormal > 0.9 • application: persistently abnormal shock index in patient with normal VS suggests need for more invasive monitoring Rady (1992) Resuscitation 23:227 - 234

7. Managing Hemorrhagic Shock • most important feature to the care of a critically ill patient is delivery of oxygen to the cells Oxygen Delivery

8. O2 Delivery • CO X CaO2 X 10 • CaO2 = Hgb x SaO2 x 1.38 • Normal 900 - 1100 mL/min • DO2I = 360 - 550 mL/min/m2

9. O2 Consumption oxygen consumption • CO x (SaO2 - SvO2) Hgb x 1.38 x 10 • VO2 = 220 - 290 mL/min • VO2I = 108 - 165 mL/min/m2

10. Delivery & Consumption Relationships • normally VO2 is 25% of DO2

11. Delivery & Consumption Relationships • SvO2 • SaO2 • Hgb • CO • VO2

12. Oxygen Extraction Ratio • amount of oxygen extracted from blood as it passes through the tissues • (CaO2 - CvO2 )/ CaO2 • values > 0.30 abnormal • > 0.35 serious • normal 22% to 27%

13. Oxygen Extraction Ratio • > 0.35 • increased VO2 • decreased DO2 • both

14. Supranormal Values • CI 4.5 L/min/m2 • DO2I 600 L/min/m2 • VO2I 170 mL/min/m2

15. Decreased Oxygen Delivery • inadequate pulmonary gas exchange • inadequate oxygen carrying capacity • inadequate CO

17. Increased Oxygen Consumption • conditions and activities that alter demand and consumption

18. Oxygen Consumption < Oxygen Demand • critically low DO2 • vasodilated state • vaso-obstructed state • diffusion distances • affinity of Hgb for O2

19. Compensatory Responses • increased extraction • once extraction maximized – consumption is dependent on delivery • demand > consumption = O2 debt

20. Lactate Levels • may be  or normal in presence of hypoxia • not reliable reflection of tissue hypoxia • reliable indicator of tissue perfusion

21. Lactate Levels • arterial more precise • normal < 1 mEq/L • > 3 - 4 mEq/L significant hypoperfusion • will decrease 5 - 10% / hr when appropriate therapy used

22. Tonometry • pHi • early warning of inadequate splanchnic tissue oxygenation • low pH = poor prognosis (consistently < 7.3)

23. Base Deficit Lab Studies • Normal value: - 2 to + 2 • reflects the extent to which the body buffers have been exhausted • rapidity of normalizing base deficit decreases morbidity & mortality

24. Therapeutic Endpoints of Resuscitation Most Reliable Perfusion Markers • Serum lactate • Base deficit

25. Managing Hemorrhagic Shock StO2 • near infrared light illuminates tissue • light scatters and is absorbed differently by oxygenated and deoxygenated hemoglobin in the microcirculation • light returns to sensor and is analyzed and displayed as % StO2

26. Managing Hemorrhagic Shock StO2

27. Managing Hemorrhagic Shock StO2 .75 - .90

28. Therapeutic Strategies • volume • inotropes • vasodilators • assess peripheral circulation

29. Nursing Interventions • Identify potentially inadequate DO2 states • clinical evidence of shock • SvO2 < 50% • O2ER > 30%

30. Nursing Interventions • Identify pathological flow dependency state •  DO2 with fluids or inotrope • recalculate VO2 • VO2 > 10-20 L/m2

31. Calculations of Oxygen Delivery & Consumption • ensure accurate parameters • index to body size • eliminate sources of error • use parameters with < 5-10% variance

32. Oxygen Supply/Demand Determinants • calculate actual VO2 • estimate potential VO2 (look at factors that demand)

33. Estimate Oxygen Debt • delivery needs to  by at least same percentage as demand

34. Traumatic Shock • O2 demands are  30-50% • triggers systemic inflammatory response

35. Traumatic Shock • Hgb/Hct < 11/33 is associated with delivery-dependence •  mortality if therapeutic targets reached < 12 - 24 hours

36. Traumatic Shock • CI > 4.5 • DOI2 700 • VOI2 170

37. Shock Endpoints Case Study • 46 - year old male • motor vehicle crash • injuries: aortic disruption, severe bilateral pulmonary contusions, bilateral rib fractures, splenic fracture • traumatic shock due to injuries

38. Shock Endpoints Case Study Which hemodynamic findings are abnormal?

39. Shock Endpoints Case Study HR 67 BP 122/64/82 RAP / PAOP 10/11 CI 4.6 PVRI / SVRI 143/317 RVSWI / LVSWI 17/61 PAP 46/22/32

40. Shock Endpoints Case Study EDV / EDVI 237/107 EF 60% O2ER 26.8 SvO2 .74 DO2 / DO2I 1603/722 VO2 / VO2I 430/194

41. Shock Endpoints Case Study ABGs (.40 FiO2) pH 7.31 pCO2 42 pO2 157 SaO2 .99 HCO3 20.8 SvO2 74% P/F ratio 314.0

42. Shock Endpoints Case Study Lab Values Hgb 12.1 Hct 31.0 Sodium 139 Chloride 112 Magnesium 1.7 Lactate 5.1 Base Deficit -5.1

43. Shock Endpoints Case Study What is the underlying pathophysiology?

44. Shock Endpoints Case Study What is are the priority interventions?

45. 33 yr with GSW to chest 4 units of PRBC due to Hct of 27 SVO2 – 70 after blood administration StO2 – 80% Lactate 1.2 Does he need further treatment? Shock Endpoints Case Study StO2 and Hemodynamic Monitoring

46. Shock Endpoints Case Study Questions