Hypotension, Shock, Hemorrhage

and IV Fluid Resuscitation

1. Definition, diagnosis and types of shock
2. Hemorrhagic shock ( I-IV )
3. Initial management of patients in Hemorrhagic shock
Algorithm for the identifying of the location of bleeding
IV access and resuscitation of Trauma patients
4. Initial assessment of patients in non-Hemorrhagic shock
5. Diagnosis of the various types of non-Hemorrhagic shock
6. Management of non-Hemorrhagic shock
7. Case Scenarios
The real goal however.
is to avoid .
 Definition: Inadequate tissue Perfusion and
Oxygenation

Effect: Cellular injury, Organ failure, Death

Causes: hemorrhagic and non-hemorrhagic

?
S Septic & Spinal

H Hypovolemic & Hemorrhagic

O Obstructive

C Cardiogenic

K Anaphylactic
 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)

 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
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
 Other Pitfalls.
Urine output adequate
despite shock

Alcohol
Hyperglycemia
Home medication: diuretics..
Therapeutic intervention: Mannitol
IV contrast: CT, Angio
Residual urine
DI
Etc
 Definition, diagnosis and types of shock

Hemorrhagic shock: Classes and Resuscitation

 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
 Hemorrhagic Shock: The Classes

Class I Class II Class III Class IV

EBL EBL EBL EBL

<750cc 750cc 1500cc 1.5L 2L >2L

<15% of TBV 15 30% of TBV 30 40% of TBV >40% of TBV

S&S S&S S&S

S&S
HR: increased
HR: increased HR: increased
BP: decreased
None/minimal Pulse Pressure: decreased BP: decreased (<60)
MS: agitated
BP: no change MS: decreased
Urine Output: decreased

Tx Tx Tx Tx

1. Crystalloid (1 2L) 1. Crystalloid (2L)

Crystalloids Crystalloids 2. Transfusion (1 2units) 2. Transfusion (2 4 units)
3. Identify source of Bleed(*5) 3. Identify source of Bleed(*5)
4. OR
 Definition, diagnosis
and types of shock
Classes of Hemorrhagic shock

Initial management of patients in Hemorrhagic

shock
 GOAL #1 GOAL #2

ID and Tx the cause Support the patient

1 - ID and Tx the cause 2 - Support the patient

Locate the source of Establish IV access

bleeding

Control it Fluid Resuscitation

A-Locate the source of bleeding

B-Control it
 Algorithm to Identify the Bleeding Source
in a Hypotensive Trauma Patient

5 Possible locations
for significant bleeding

1 2 3 4 5

Chest cavity Abdominal Cavity Pelvis/Retroperitoneum External Bleeding Long Bones

Clue: Clue: Clue: Clue:

Clue:
-Abdominal/Pelvic trauma Blood on Floor 1) Deformed extremity
-Chest trauma - Abdominal trauma 2) Crush injury
- Diminished breath sounds -Flank ecchymosis Check head/scalp
- Distended abdomen 3) Mangled extremity
-Unstable pelvis Check extremity
- Desaturation, O2 requirement
-Hematuria

Place chest tube Chest Extremity EBL

DPL (+) First do DPL Pelvic Scalp
On affected side X-Ray Bleed Femur Fx 750cc1L
(+) Ptx-Htx FAST -Gross blood (supra umbilical) X-Ray bleed
Tib Fx 500-750cc
Free fluid r/o intrabdominal (+) Fx
- >105 RBCs
bleed
Chest tube Whip-stitch Pressure Consult Ortho
1L of Blood DPL (+) DPL (-)
with
and
nylon suture
Elevation Immobilization and
minimal manipulation
1) Wrap sheet around pelvis Bleeding not of injured extremity
OR Thoracotomy 2) Pelvic angiography controlled using splint (3Ps)
OR Exploratory laparotomy

(+) Blush/Extravasation Tourniquet proximal

to injury Be alert for
compartment
- set > systolic BP
syndrome
Angioembolization
A-Establish IV access

B-Fluid Resuscitation
Establish IV access before it is too late
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!)
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
 Electrolyte composition of crystalloid solutions

pH Na Cl Lactate Ca K Osm
Fluid (mEq/L) (mEq/L) (mEq/l) (mEq/L) (mEq/L) (mOsm/L)

LR 6.7 130 109 28 3 4 279

NS 6.0 154 154 0 0 0 308

LR, lactated Ringers solution; NS, normal saline solution

 Intravascular effect
3 for 1 rule of Volume replacement: Volume lost
 Clinical parameters:
MS: return of
CVS: HR, MAP
Urinary output

Laboratory parameters:
BD, Acid/base balance
Lactate
Three possible responses:

1. Responders
Bleeding has stopped

2. Transient responders
Something is still slowly bleeding!

3. Non responders:
Ongoing significant bleeding!
Immediate need for intervention!
 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
WHY IS THE PATIENT HYPOTENSIVE ?

Dont Get The Floor WET !!!!

 Hypotension/Shock

Diagnosis
1. Hypotension (SBP<100)
2. Tachycardia
3. Tachypnea; Sa O2 <90%
4. Oliguria
5. Change in mental status (confusion, agitation)
6. 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

1. Make sure patient is on ECG monitor and Pulse Ox.

First Step in MGT
2. Administer O2
3. Insure adequate IV access
4. Place foley catheter
5. Place CVP line (when indicated)
6. Order EKG
7. Chest X-ray r/o Ptx
 Shock
1 2 3

Hemodynamic findings Hemodynamic findings Hemodynamic findings

CVP, PCW: decreased CVP, PCW: decreased CVP, PCW: increased
CO: decreased CO: increased then decreased CO: decreased
SVR: increased SVR: decreased SVR: increased

Hypovolemic Hemorrhagic Cardiogenic Shock

Shock Shock
Spinal Shock Septic Shock

Cause
1. External fluid loss Cause Cause Obstructive Non-obstructive
2. 3rd Spacing Cause
SCI (>T4 level) Infection
DDX
1. Trauma (*5) Cause
2. Post-op bleeding 1. Tension PX
1. AMI
3. GI bleeding 2. Cardiac tamponade
Treatment Treatment 2. CHF
3. PE
1. Fluid resuscitation Supportive Care
2. Control/replace Fluid to fill the tank
fluid losses Vaso pressors Treatment
(Phenylephirine, Norepinephrine) Treatment
1. CT placement
2. Pericardiocentesis 1. Diuresis
Treatment
3. IV Heparin - Lasix
1. Fluid resuscitation Treatment 2. Afterload reduction
2. Find source of - Nitroprusside, Nitroglycerine
1. Identify & drain source of infection
bleeding and control it - ACE inhibitor
2. Start appropriate Abx
3. Correct coagulopathy 3. Inotropic support
3. Supportive care
- Fluid resuscitation - Dobutamine, Milrinone
- Vaso pressors
(Phenylephirine, Norepinephrine)
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, Large open wounds

2 main goals
1- ID and Tx the cause
Tx: Control fluid losses: surgical, wound coverage
2- Support the Patient
 Hemodynamics:
*Low to normal PCW (due to fluid losses)
Normal or Decreased CO
High SVR (compensation)
Management:
Fluids
No pressors
*primary process
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

Two main goals

1 - ID and Tx the cause
Tx: Source Control (surgical, IR) + start antibiotics early
2 - Support the Patient
Hemodynamics:
Low to normal PCW (vasodilatation and fluid losses)
Normal or increased CO (late; decrease CO)
*Low SVR
Management:
Fluids
Pressors
*primary process
 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 main goals:

1- ID and Tx the cause: Cardiac Cath
Tx: Heparin..
2 - Support the Patient
Hemodynamics:
Elevated filling pressures
*Diminished cardiac output due to pump failure
Increased SVR (compensation)
Management
Diuresis
Afterload reduction
Inotropes
*primary process
 No intrinsic cardiac pathology (Non - MI)
Pump failure due to inflow or outflow obstruction
Cause :
Tension Pneumothorax
PE
Cardiac Temponade
Air embolus (rare)
Dx and Management specific to each process
Spinal cord injuries produce hypotension due to a loss of
sympathetic tone
Seen in one third of patients with SCI, usually seen in patients with
an injury above T4 level
Hypotension without tachycardia or cutaneous vasoconstriction

Two main goals:

1- ID cause, no specific Tx
2 - Support the Patient

Pearl: Must rule out other causes of shock in trauma patients with a spinal cord injury
Hemodynamics:
Normal to low PCW due to peripheral venous pooling
Normal to low CO- cannot compensate
*Decreased SVR due to loss of vasomotor tone
Management:
R/o Bleeding
Fluid and pressors
*primary process
 Shock
1 2 3

Hemodynamic findings Hemodynamic findings Hemodynamic findings

CVP, PCW: decreased CVP, PCW: decreased CVP, PCW: increased
CO: decreased CO: increased then decreased CO: decreased
SVR: increased SVR: decreased SVR: increased

Hypovolemic Hemorrhagic Cardiogenic Shock

Shock Shock
Spinal Shock Septic Shock

Cause
1. External fluid loss Cause Cause Obstructive Non-obstructive
2. 3rd Spacing Cause
SCI (>T4 level) Infection
DDX
1. Trauma (*5) Cause
2. Post-op bleeding 1. Tension PX
1. AMI
3. GI bleeding 2. Cardiac tamponade
Treatment Treatment 2. CHF
3. PE
1. Fluid resuscitation Supportive Care
2. Control/replace Fluid to fill the tank
fluid losses Vaso pressors Treatment
(Phenylephirine, Norepinephrine) Treatment
1. CT placement
2. Pericardiocentesis 1. Diuresis
Treatment
3. IV Heparin - Lasix
1. Fluid resuscitation Treatment 2. Afterload reduction
2. Find source of - Nitroprusside, Nitroglycerine
1. Identify & drain source of infection
bleeding and control it - ACE inhibitor
2. Start appropriate Abx
3. Correct coagulopathy 3. Inotropic support
3. Supportive care
- Fluid resuscitation - Dobutamine, Milrinone
- Vaso pressors
(Phenylephirine, Norepinephrine)
1. How to recognize and diagnose shock
2. Types of shock (SHOCK): hemorrhagic & non-hemorrhagic
3. Hemorrhagic Shock:
Classes of hemorrhagic shock
Algorithm to find the location of bleeding and control it
4. Non-hemorrhagic shocks
the 2 key Goals in the management of any shock
Hemodynamic findings and support
?