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ACS

Shock
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ACS

Objectives
Define shock
Recognize the shock state
Determine the cause
Apply treatment principles
Apply principles of fluid management
Monitor patients response
Employ options for vascular access
Recognize complications of vascular access
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ACS

Key Issues : Shock Management

Recognize inadequate organ perfusion
Identify the cause
Hemorrhagic vs nonhemorrhagic
Treatment
Stop the bleeding!
Restore volume
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ACS

Cardiac Physiology

CO = SV x HR

Preload Contractility Afterload

Venous Vascular
dp / dt
Capacitance Tone
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ACS
Pathophysiology
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ACS

Cellular Alteration in shock

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ACS
Recognition of Shock State
1. Tachycardia
2. Vasoconstriction
2. Cardiac output
Narrow pulse pressure
3. Map
3. Blood Flow

Caution : Compensatory mechanisms

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ACS

Pitfalls in shock Recognition

Extremes of age
Athletes
Pregnancy
Medications
Hematocrit / hemoglobin concentration
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ACS

Etiology of Shock
Hemorrhagic Nonhemorrhagic
Most common Tension

Clinical clues pneumothorax

Cardiogenic
H&P
Neurogenic
Selected
Septic
diagnostic tests
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ACS

Hemorrhagic Shock
Loss of circulating blood volume
Normal blood volume
Adult 7% of ideal weight
Child: 9 % of ideal weight
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ACS

Classification of Hemorrhage
Class I-IV
Not absolute
Only a clinical guide
Subsequent treatment determined by
patient response
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ACS

Class I Hemorrhage
750 mL BVL
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ACS
Class II Hemorrhage
750 1500 mL BVL
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ACS

Class III Hemorrhage

1500 2000 mL BVL
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ACS

Class IV Hemorrhage
2000 mL BVL
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ACS
Fluid Shifts : Soft tissue Injury

Blood loss into Tissue

injury site edema

Compounds
intravascular loss
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ACS

Assessment and Management

Recognize shock
Stop the bleeding !
Replenish intravascular volume
Restore organ perfusion
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ACS
Assessment and Management
Airway and Breathing
Oxygenate and ventilate
PaO2 > 80 mm Hg (10.6 kPa)
Circulation
Assess
Control
Treat
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ACS

Assessment and Management

Disability cerebral perfusion
Exposure / Environment
Associated injuries
Prevent hypothermia
Gastric and bladder decompression
Urinary output
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ACS
Management : Vascular Access
2 large caliber, peripheral IVs
Central access
Femoral
Jugular
Subclavian
Intraosseous
Obtain blood for crossmatch
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ACS
Management : Fluid Therapy

Warmed crystalloid solution

Rapid fluid bolus Ringers lactate
Adult : 2 liters Ringers lactate
Child : 20 ml /kg Ringers lactate
Monitor response to initial therapy
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ACS

Reevaluate Organ perfusion

Monitor
Vital signs

CNS status

Skin perfusion

Urinary output

Pulse oximetry
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ACS

Resuscitation Evaluation
Hourly Urinary Output
Inadequate output suggests
inadequate resuscitation
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ACS

Acid Base Abnormalities

Monitor with ABGs
Usual etiology
Adult : Acidosis due to inadequate
perfusion
Child : Acidosis due to inadequate
ventilation
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ACS

Acid Base Abnormalities

Treatment
Oxygenate and ventilate
Stop the bleeding !
Consider inadequate volume
restoration
Bicarbonate rarely indicated
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ACS

Therapeutic Decisions
Patient response determines
subsequent therapy
Hemodynamically normal vs

hemodynamically stable
Recognize need to resuscitate in

operating room
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ACS
Therapeutic Decisions

Rapid Response
< 20% blood loss

Responds to fluid replacement

Surgical consultation evaluation

Continue to monitor
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ACS

Therapeutic Decisions
Transient Response
20% - 40% blood loss

Deteriorates after initial fluids

Surgical consultation evaluation

Continued fluid plus blood

Continued hemorrhage : Operation

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ACS

Therapeutic Decisions
Minimal to No Response
> 40% blood loss

No response to fluid resuscitation

Immediate surgical consultation

Exclude nonhemorrhagic shock

Immediate operation
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Volume Replacement ACS

Warmed fluids
Crossmatched PRBCs

Type specific

Type O, Rh negative

Autotransfusion

Coagulopathy
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ACS
Pitfalls

Equating Bp
Athletes
Pregnancy
with cardiac
output Medications

Extremes of age Pacemaker

Hypothermia
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ACS
Avoiding Complications
Continued hemorrhage
Fluid overload

Invasive monitoring (ICU)

CVP
Pulmonary artery catheter
Other problems
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ACS

Keys to Successful Treatment

Early control of hemorrhage

Euvolemia

Continuous reevaluation
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ACS

Questions

?
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ACS
Summary
Restore organ perfusion
Early recognition of the shock state
Oxygenate and ventilate
Stop the bleeding
Restore volume
Continuous monitoring of response
Anticipate pitfalls