SHOCK

1. SHOCK Case presentations and CVS Monitoring

2. Case 4 A 29‑year‑old lady (72 kg) arrives in the resuscitation room drowsy with the following vital signs: ABG: BP 80/50 mmHg, pH 7.31 pulse 130 per minute, Pa02 35.5 kPa RR 28 per minute, PaC02 3.5 kPa Sa02 95% on 10 L/min O2 bicarb 12.7mmol/L via a reservoir bag mask, BE‑10. temperature 38.5°C. She has a petechial rash on her trunk. She responds to voice and there is no neck stiffness. Her bedside glucose measurement is 6.2 mmol/L Q1: What is your diagnosis? Q2: What is your management?

3. Case 4 “A” - ensure a patent and protected airway, give a high concentration of oxygen (for example, 15 L/minute via a reservoir bag mask), “B” - assess and treat any breathing problems, “C” - assess and treat any circulation problems, “D” - assess conscious level and check for Temp & UO. The petechial rash is a clue to the possible cause of sepsis – think meningococcal and/or staphylococcal infections. A full examination and appropriate investigations (including CT/MRI, CSF and other cultures) should follow.

4. Modified Early Warning Score (MEWS) –useful tool in recognition of patients with presumed infection Score 3 2 1 0 1 2 3 BP SYS< 80 80-89 90-109 110-160 161-180 181-200 >200 PULSE <40 - 40-50 51-100 101-110 111-129 >130 RESP.< 8 - - 8-20 21-25 26-30 >30 TEMP.-<35 - 35.1-37.9 38.0-38.4 >38.5 - AVPUAlert Voice Pain Unrespon sive ----------------------------------------------------------------------------- If Score 3 in one category or total Score 4 - Think infection! New Weakness New Confusion

5. 2 Signs and symptoms of infection (SSI)plus presumed infection = Sepsis Two or more of the following: Tachycardia> 90 bpm Core temperature > 38.3°C < 36°C Tachypnoea> 20 bpm WCC >12,000 or <4,000 or >10% immature neutrophils Hyperglycaemia in the absence of Diabetis Mellitus Q: Is there at least one organ failure already?

6. Septic shock - Acute circulatory failure unexplained by other causes. Severesepsis Sepsis Death SSI Infection Sepsis with signs of at least one acute organ dysfunction (organ failure) Septic shock– is defined asSevere sepsis with hypotension refractory to adequate volume resuscitation, Hypotension is defined as a systolic blood pressure of <90mmHg or a reduction of >40mmHg from baseline) • Cardiovascular • Unexplained metabolic acidosis • Central nervous system • Respiratory • Renal • Hepatic • Haematologica SSI - Signs and symptoms of infection

7. Case 4 Patient has Severe Sepsis according to the SSC. Fluid resuscitation using crystalloids or colloids 20-40 ml/kg/hr Blood cultures and Lactate taken ASAP Antibiotics administered within 1 hour If BP is not responsive to fluids or if serum lactate is still elevated consider CVP, Invasive Arterial line for ABG and CVS monitoring Repeated boluses of crystalloid/colloid 250-500 ml every 30 min until CVP 8-12 mmHg Vasopressors via central line if MAP < 65 mm Hg during and after adequate fluid resuscitation - Noradrenaline (4 mg in 50 ml of 5% Dextrose - start at 0.05 mcg/kg/min) or Metaraminol infusion. If Scv O2 < 70 % after adequate fluid replacement and Noradrenaline running, start Isotopes(Dobutamine at 2.5 mcg/kg/min or Adrenaline infusion via central line) and/or give RBC’s (to keep Ht above 30)

8. Case 5 A 53 year old motorcyclist is brought by Air Ambulance having been involved in a high speed RTA with a truck. Blood pressure is unrecordable, pulse is not palpable, except in carotid and femoral regions A 14G cannula has been inserted by ‘cutdown’ in the left great saphenous vein, NaCl 0.9% running He is intubated and ventilated Q1: What are the possible causes of his low BP? Q2: What should the management comprise?

9. Case 5 • Management plan: • ABC approach • Volume resuscitation • Achieve stability • Transfer to CT scan for ‘Trauma series’ • Act upon findings • A and B are checked and cleared • No pneumothorax detected clinically • CXR confirms no extrapulmonary air

10. Case 5 • Circulation: • Despite on-going IV fluid infusion, BP is difficult to record via NIBP monitor • Additional venous access obtained (14G) - bloods are taken and Hartmann’s 1000 ml given stat. • Radial Arterial line inserted, showing invasive pressure of 76/42 mmHg Q1: What might be happening? Q2: What could be done to investigate?

11. Case 5 • FAST scan • Suggests some free fluid in abdomen • Small amount of fluid in pericardium • Otherwise normal but empty heart appearance • BP is very low - patient is not stable for CT scanner or theatre. Q1: How does this help you? Q2: What could be done, in view of the continuing instability?

12. Case 5 • In view of possible intra abdominal bleeding 2 units of O (I) Neg blood and 1L Colloids given, • In order to support BP: • Metaraminol IV boluses given every 3-5 mins, • Subclavian CVC line is obtained and Noradrenaline infusion started by ITU Registrar • But HR is now 150, BP is 46-51 mmHg systolic. • Patient is in PEA arrest, +/- drug induced SVT ?? • CPR started with Adrenaline given every 3 min. Q: What else could be done to save life?

13. Case 5 • CPR: • 3 minute cycles with 1 mg Adrenaline given each time • BP is unresponsive to drugs, only to CPR • Massive Transfusion Protocol (MTP) is activated and another 6 u-ts of O (I) Neg blood given • Thoracotomy for open compressions in A&E • Descending Aorta clamped • Blood pressure improves somewhat (110/60) • Heart is pumping well, massage stopped • Patient is more stable now, can go to CT scanner

14. Case 5 • CT results • Small splenic and liver injuries (both Grade 2) • Undisplaced T6 spinal fracture, no brain injury • Femoral fractures • Went to Theatre for Laparotomy + Orthopaedics • Spleenectomy, but only mild blood loss in abdomen • Aortic clamp removed, chest drain placed • Ex-fix placed on femur to prevent bleeding • CVP reading is low CVP (~2 mmHg) • Requiring moderate dose of noradrenaline to maintain adequate blood pressure Q: Why is the blood pressure still poor?

15. Case 5 • In Critical Care • Intubated, ventilate, positive fluid balance is almost 10.5 litres; • Patient noted to be moving arms but not legs; • When woken up from sedation completely, still could not move legs • MRI shows cord damage at T6 level • Discharged from ITU in 2 weeks with some neurological improvement Presumably spine was displaced enough to damage cord then returned to normal anatomical position

16. Questions