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 July 30, 2010

2. The Goals Definition and diagnosis of shock Classes of hemorrhagic shock and resuscitation Algorithm for the identifying of the location of bleeding IV access and resuscitation in a Trauma patient Initial management of patients in non-hemorrhagic shock Diagnosis of the various types of non-hemorrhagic shock Management of non-hemorrhagic shock

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

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

5. Types of Shock

6. 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

7. 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

8. 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

9. Other Pitfalls…. • Urine output adequate • despite shock • Alcohol • Hyperglycemia • Home medication: diuretic.. • Therapeutic intervention: Manitol • IV contrast: CT, Angio • Old residual urine… • Etc…

10. General Outline • Definition, diagnosis and types of shock • Classes of Hemorrhagic shock and resuscitation

11. 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

12. 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

13. General Outline • Definition, diagnosis and types of shock • Classes of Hemorrhagic shock • Algorithm for identifying the location of bleeding

14. 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

15. Two Goals in the management of Hemorrhagic Shock

16. Goal #1

17. 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

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. Goal #2

20. Goal #2

21. Establish IV access before it is too late

22. Resuscitation:Establish 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!)

23. Goal #2

24. Fluid Resuscitation • Initial fluid bolus • 1-2 liters in adults • 20mL/kg in children • Intravascular effect • 3 for 1 rule of volume replacement: volume lost • 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. The 3:1 Rule

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 • Non responders: • Something is still bleeding! • Need for invasive monitoring

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

30. Case #1 38 year old male ped-struck found unresponsive. He gets intubated by EMS and is reported to have a BP of 90/60 at the scene. He has a small head laceration as well as obvious abrasions over his chest. In the ED, he is noted to have decreased BS on the left side and his O2Sats are 92% on 100% NR. What’s next?

31. Portable CXR

32. Case #1 • Diagnosis? • Management?

33. Case #1: CT Chest

34. Case #2 18 year old male involved in a high speed MVC found unresponsive with a BP of 80/P at the scene. He has a large head laceration that is actively bleeding, an obvious abrasions over the pelvis and bilateral lower ext deform. In the ED, he is immediately intubated, he has equal BS and his sats are 100%. He is actively bleeding from his scalp and left leg. BP 80/60 P 140.

35. Case #2 Dx? Type of shock? Class? Initial Management ?

36. Whip Stitch head laceration

37. What is missing ?

38. The Tourniquet

39. ??? WHY IS THE PATIENT HYPOTENSIVE ? AVOID GETTING THE FLOOR WET !!!!

40. Case #2 Still hypotensive!!! He has received: 2 L crystalloids 2 units PRBCs CXR: Normal

41. Portable Pelvic X-Ray

42. Before After

43. General Outline • Definition, diagnosis and types of shock • Classes of 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

44. 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

45. 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)

46. Hypovolemic Shock • Most common cause of shock in surgical patients • Excessive fluid losses (internal or external) • Internal: Pancreatitis, bowel ischemia, bowel edema, ascites.. • External: Burns, E-C Fistula, Open wounds… • Again : 2 goals • 1- ID and Tx the cause • Control fluid losses: surgical, wound coverage… • 2- Support the Patient

47. Hypovolemic Shock • Hemodynamically: • *Low to normal PCW (due to fluid losses) • Normal or Decreased CO • High SVR (compensation)

48. Septic Shock • Second most common cause of shock in surgical patients • Vasoregulatory substances released produce a decrease in systemic vascular resistance, manifested by warm pink skin with peripheral vasodilatation • Again 2 goals • 1- ID and Tx the cause • Source Control: surgical, IR + start early antibiotics • 2- Support the Patient

49. Septic Shock • Hemodynamically: • Low to normal PCW (vasodilatation and fluid losses) • Normal or increased CO • *Low SVR (primary condition!)

50. Cardiogenic Shock • Forward blood flow is inadequate secondary to pump failure • Most common cause is acute myocardial infarction (AMI) • Other causes include: • Myocardial contusion, Aortic insufficiency, End-stage cardiomyopathy • Two goals: • 1- ID and Tx the cause: Heparin, Cardiac Cath… • 2- Support the Patient