1. Shock management Mahnaz Amanat.MD

2.  A 37 YO FEMALE WITH HX OF TL PRESENT WITH ABDOMINAL PAIN,SPOTTING,AGITATION,TACHYCARDIA,TACKYPNEA AND HYPOTENTION

3. Is this pation in shock?  Ill appearance or altered mental status  Haert rate>100  RR>20 Or Paco2<32mm Hg  Arterial base deficit 4  Urine output<0.5 ml/kg/hr  Hypotention> 30 continus minutes duratione

4. Goals of treatment  ABCDE airway control work of breathing optimaize circulation assure adequate oxygen delivery achive end point of resuscitation

5. Airway  Determine need for intubation but remember: Intubation can worsen hypotension Sedatives can worsen hypotention Positive pressure ventilation decreased preload  Resuscitation prior to intubation to avoid hemodynamic collapse

6. Control work of breathing  Mechnical ventilation and sedation allow for adequate oxygenation, improvement of hypercapnia and assistedcontrolled synchoronized ventilation.  MV decreased WOB and improved survival.

7. Optimaizing the circulation  Two large borre peripheral venouseline  Fluid resuscitation should begin with isotonic crystalloid.*  The exception is the patient in cardiogenicshock and pulmonary edema.  Usually require an initial 20 to 30 ml/kg  Central venuse acces may need.  Vasopressors are used when inadequate response to volume resuscitation.

8. Maintaining oxygen delivery  Decreased oxygen demand  Provide analgesia and anxiolytics to relax muscle and avoid shivering  Maintain arterial oxygen saturation  Give supplement oxygen  Maintain Hb>10  Serial lactate level or central venouse oxygen saturation

9. End point of resuscitation  Goal of resuscitation is increase survivaland decrease morbidity.  Goal direct approach : Urine output>0.5ml/kg cvp 8-12mmHg MAP 65 to 90 mmHg Scvo2>70

10. Persistent hypotention  Assesment of equipment and monitoring  Inadequate volume resuscitation  Pnemothorax  Cardiac tamponade  Hidden bleeding  Adrenal insufficiency  Medication allergy  PTE,MI,….

11. Practically speaking…  Keep one eye on these patient  Frequent vital sign monitoring  Let your nurses know that these patient are sick

12. What type of shock is this ؟  68 YO M WITH HX OF HTN AND DM PRESENTS TO THE ER WITH ABRUBT ONSET OF DIFFUSE ABDOMINAL PAIN WITH RADIATION TO HIS LOW BACK. THE PT IS HYPOTENSIVE, TACHCARDIC, AFEBRILE,WITH COOL BUT DRY SKIN

13. Hypovolemic shock  Non hemorrhgic vomiting Diarrhea Burns neglect,……  Hemorrhagic Gibleeding trauma AAA rupture Ectopic pregnancy,postpartum bleeding,…

14. Evaluation of hypovolemic shock  CBC  ABG/Lactate  BHCG  BUN,Cr  Coagolation studies  As indicated  CXR  US  Chest ct,…..

15. Hypovolemic shock  ABCD  2large bore IV or Cvline  Crystlloid  RBCs  Control any bleeding  Arrang definitive traetment

16. What type of shock?  A 81 yo F resident of nursing home present to ED with altered mental status. Febrile and hypotensive with tachycardia

17. SEPTIC SHOCK  Two or more of SIRS criteria T>38 Or <36 c HR>90 RR>20 or Paco2<32 mmHg WBC>12000 Or 10%  Septic shock SIRS with suspected or confirmed infection with hypotension despite adquate fluid resuscitation

18. Ancillary Studies  Cardiac monitoring  Pulse oximetry  CBC,…  LFT, lipase  ABG lactate  BC*2, UA UC  CXR  Foley cathetr

19. Septic shock managment  Airway management  Ensure adequate oxygenation  2 large bore IVS + IVF 1-2 L bolus  As indicated CV line insertion  Begin antimicrobial therapy  Begin PRBC infusion for Hb<8  Vasopressor support

20. Early goal directed therapy

21. What type of shock is this ؟  A 8 yo child presents to the ER after dining at a restaurant where shortly after erting the first few bites of her meal, became anxious, diaforetic, began wheezing, noted diffuse pruritic rash, nausea, and a sensation of her “ throut closing off”. She is currently hypotensive, tachycardic and ill appearing.

22. Anaphylactic shock

23. Anaphylactic shock treatment

24. Traumatic shock  Resuscitation begins in the prehospital  Treatment of life-threatening condions  Rapidt transport  For the henorrhaging traumatic patient:  Securing an airway and Cspain  Adequate ventilation and oxygenation  Controlling external bleeding  Check of GCS

25. AIRWAY CONTROL, VENTILATION, …  Supplment o2  Intubate as needed  Ventilate to achieve o2 sat>94%  Treat potential respiratory conditions:  Tension Pneumothorax  Hemotroax

26. Circulation  IV access*2 large bore  Cardiac monitoring  Pulse oximetri  IV fluid  Bedside US  …

27. HEMOSTATIC HYPOTENSIVE RESUSCITATION  Bp goals are SBP of 80-90 mmHg and 90-95 mmHg in head injury (why?)  A loss of 1 L of blood would reqire about 3 L of isotonic crystalloid  Initial fluid resuscitation administei 2to3 L of crystalloid  Hypertonic salin has been crystalloid alternative that would limit the tissue edema  PRBCs when Hb<7

28. ANY QUESTION ?