Approach

to shock
and
fluid resuscitation
Definition
• Clinical syndrome that is results from
• Circulatory failure
• Reduction in oxygen delivery
• inadequate peripheral tissue and organ perfusion leading to a
eventual cellular hypoxia with all its attendance sequalae.
• Clinically characterized by
• hypotension (Hemodynamic instability)
• SBP < 90mmHg or < 30mmHg from baseline
• Mean arterial pressure < 65mmHg
• Oliguria
• Altered mentation
• Organ failure
Classification of shock

Hypovolemic

Cardiogenic

Obstructive

Distributive

Septic

Anaphylactic

Neurogenic
Hypovolemic Shock
Pathophysiology
• resulting from a decreased circulating blood volume
Types of Hypovolemia
• Blood Loss
• Fluids/Plasma Loss
Most common type of shock
Causes
• Medical • Major operation
• Diarrhea, Vomiting • OBG
• DKA, Dengue shock syndrome • Hyperemesis gravidarum
• SurgeryHHS • Rupture ectopic pregnancy
• APH / PPH
• Acute perforated appendicitis • Trauma
• GIT Bleeding(peptic ulcer, • Abdominal
esophageal varices) • Open fracture
• Burn • Closed fracture* (Shaft of femur)
• Peritonitis
 Class I Class II Class III Class IV
Blood loss
mL <750 750-1500 >1500-200 >2000
% <15 15-30 >30-40 >40
Heart rate <100 >100 >120 >140
(beat/min)
Systolic Normal Normal Decreased Decreased
blood
pressure
Pulse Normal Decreased Decreased Decreased
pressure
Capillary Delayed Delayed Delayed Delayed
refill normal
Respiratory 14-20 20-30 30-40 >35
rate (min)
Urine output >30 20-30 5-15 Minimal
(mL/h)
Mental status Slightly Anxious Confused Confused and
anxious lethargic
Cardiogenic Shock (Killip Class IV)
• Cardiogenic shock (CS) is characterized by systemic
hypoperfusion due to
• cardiac pump failure caused by loss of myocardial contractility
• Most common cause: MI
Causes
• Coronary artery disease • Dilated cardiomyopathy
• Acute MI • Thyrotoxicosis
• RVF • Acromegaly
• Secondary to AMI • Phaeochromocytoma
• Hypertension • Pregnancy and peripartum
• Congenital Heart disease • Pericardium tamponade
• ASD, VSD • AF
• Valvular heart Disease
• Mitral valve (rupture)
• Aortic valve disease
Definition
• Septic Shock:
• sepsis-induced hypotension (systolic blood pressure <90 mm
Hg [or a drop of >40 mm Hg]) with
• signs of tissue hypoperfusion
• despite adequate fluid resuscitation

• Principle of mechanism
1. Peripheral vasodilation and pooling of blood
Signs and Symptoms
• Symptoms: FEVER/hypothermia, • History taking: comorbidities
depends on site of infection. • DM,
• Signs: • Chronic lung disease
• Warm peripheral extremities (due to • alcoholism,
vasodilation) • liver cirrhosis,
• Febrile • Recent invasive procedure (especially
• hypotension in CKF)
• Tachypnea, tachycardia • HIV
• Oliguria • Immunosuppressive agent (Steroid)
• Rash • Malignancy
Anaphylactic Shock
• An allergic, IgE mediated, hypersensitivity response to a foreign
substance to which a patient has been previously sensitized
• Type I hypersensitivity
• Causes:
• Drugs: penicillin, aspirin, streptomycin
• Vaccines: measles
• Blood products
• Insect bites: bees
• Food: seafood
 Clinical Features
• Onset:
• Commonly: 5-60min of exposure
• Skin :
• Urticaria: Area of focal dermal edema
• angioedema :Localized non-pitting deeper layer of the skin
(edematous process)
• Pruritus
• Tingling of face (usually at mouth)
Urticaria
Angioedema
Clinical Features
• CVS:
• Arrhythimias
• RS:
• Laryngeal edema: hoarseness of voice, stridor, “lump in the throat”
• Wheeze
• Dyspnea due to bronchospasm
• Coughing: ominous sign  onset of pulmonary edema
• GIT
• Nausea, abdominal cramp
Neurogenic Shock Obstructive Shock
• Causes: • Causes:
• Post-spinal surgery • Tension pneumothorax

• Spinal injury • Cardiac tamponade

• Pulmonary embolism
• Clinical features:
• Bradycardia, hypotension, warm
peripheral extremities
Approach To Shock Patient – History Taking
• Complaints: • CVS
• Chest pain
• Trauma • Dyspnea
• GIT: • Palpitation
• OBG
• Bleeding
• PVB
• Diarrhea • Fever
• Vomiting • Past medical History
• Hematemesis • Comorbidity
• Melena and hematochezia • Drug and allergic history
• Abdominal pain • Menstrual history
• Last menstrual
Diagnosis of Various Types of Shock
Hypovolemn Cardiogenic Neurogenic Septic Shock Anaphylactic
ia (hyperdynam
ic)
BP Hypotension Hypotension Hypotension Hypotension Hypotension
Skin Pallor, Clammy, Warm Rigors, warm
condition clammy, cold cold fever/warm
Heart Rate Tachycardia Dysrhythmia bradycardia Tachycardia arrhythmias
s
Others Open Ventricular Trauma to +/- Rash urticarial
fractures failure spine
others Limbs angioedema
weakness
Urinary and wheezing
bladder
incontinence
Guide to The Essential in Emergency Medicine
by Shirley Ooi.
Complications of Shock
• CNS • GIT
• Encephalopathy • Stress Ulcer
• CVS • Mesenteric Ischemia
• Reduced myocardial contractility • Hematology
• Renal • DIVC
• Acute Renal Failure • Metabolic
• Pulmonary • Hyperglycemia
• ARDS • Lactic Acidosis
• Atelectasis • Skeletal
• gangrene
General Management of Shock
Management
• BP < 90mmHg
(hemodynamic instability)
• Altered mentation
• oliguria

Suspect Shock ???

Skin Condition

Clammy Cold Warm

Hyoovolemic Shock
Distrubutive Shock
Cardiogenic Shock
Neurogenic Shock
Obstructive Shock
 Hypovolemic Shock
Distributive Shock
Cardiogenic Shock
Neurogenic Shock
Obstructive Shock
RS
Examination BECK’S TRIAD

Tension Cardiac
Check the Pulse
Pneumothora Tamponade
x
Dysrhythmias Bradycardia
Tachycardia
(by ECG)

Hypovolemic Septic Cardiogenic Anaphylactic Neurogenic

Other Other Other

Other Features: Other
Features: Features:
Features: Allergy Features:
Trauma Fever
Post – MI Urticarial Spinal
diarrhea Rash
Sign of CCF angioedema injury
vomiting others
Airway Maintenance If GSC < 8 ETT intubation

Breathing – by SP02
100% oxygen oyxgen to maintain PaO2 > 60mmHg

or SaO2 > 90%

• Size: 16G
Circulation
2 large wide bore
• Route: peripheral  central
line  Intraosseos line
• Wide bore
• Purpose:
• Give bolus or infuse
fluids
• Drugs administration
Bladder catheterization • blood Investigation
 Non- • Mean arterial pressure >60-65
Cardiogenic
cardiogenic mm Hg (higher in the presence
Shock
Shock
of coronary artery disease)

+/- Fluids therapy

Fluids therapy
(500-1000ml
(at least 1000ml)
max)

Investigation CVP or PAC Sympathomimetics

Fail to respond to Fluid therapy

Choice of Fluid Resuscitation
• Principle:
• First: Restore intravascular volume
• Second: replete interstitial and intracellular volume

Normal COP
Compartment Glucose 5% NaCl 0.9% Colloids
Intravascular ↑ ↑ ↑↑
Interstitial ↑↑ ↑↑ —
Intracellular ↑↑↑ — —
Why Crystalloid???
• Crystalloid is preferred over than colloid because colloid :
1. inhibition of the coagulation system;
2. the risk for anaphylactoid reactions;
3. inhibition of renal salt and water excretion;
4. Over-administration  risk of ARF
5. expensive
Type of Fluid and1. The
itsvaluecontents
of Glucose, Na, K must be
memorized.

• Primarily used to
For Fluid Resuscitation
maintain water balance
(shock, dehydration)in patients who are not
able to take anything
by mouth
Fluids
Maintenance
Example of IV Fluids

Crystalloids Colloid
Normal Saline Gelatin
Hartmann Saline Dextrans
HSD5 Albumin
D10, D5 Fresh frozen plasma
Circulation - Correction of
hypovolemia

Fluid Fluid
Resuscitation Maintenance

Electrolyte
Emergency Blood Transfusion
• Indications
• Severe hemorrhage > 30%
• Hb < 8%,
• Whole Blood is used.
• GXM
• 1 unit of blood = 450ml of blood
• During initial resuscitation of acute blood loss and shock, crystalloid or colloid
infused to restore circulatory volume
• Emergency blood group “O” blood should not be used indiscrimately
• Look for side effect of transfusion
Emergency Blood Transfusion
• Group O “positive” is used as emergency blood for man.
• Group O “negative” is used for female in reproductive age group.
• Category of blood according to urgency

Unmatch Rapid Match Full matched

Emergency blood blood
blood
Availability Instant 5-10minutes 30-45minutes
CXM not done done Done
Antibody not done not done done
screen

Guide to The Essential in Emergency Medicine

by Shirley Ooi.
Hypovolemic Shock
Management Specific to Hypovolemic Shock
• Blood investigations
• FBC, RBS
• HCT is extremely unreliable test
• GXM
• BUSE and creatinine, lactate
• Cardiac enzyme and TnT
• Exclude acute MI
• ABG
• Metabolic acidosis, elevated lactate(>5mmol/L) and significant base deficit
are marker of poor prognosis
• Correction of these abnormalities will improve outcome (by ABC)
• However, sodium bicarnoate is not used routinely because it does little to positively
affect morbidity and survival.
• Coagulation profile , albumin
• ECG and CXR
• FAST scan (Focused assessment with sonography for trauma)
Management Specific to Hypovolemic Shock
ABC + Bladder • Fluids Resuscitation -
catheterization
mainstay
• All fluids need to be
Active warmed to prevent
Fluid iatro-genically induced
Resuscitation bleeding Internal
external hypothermia.
CVL / PAC Hypotension
Compressio
Dopamine n If MAP < 60mmHg
+/-
 CVL / PAC
Dobutamine
Hypotension sympathomimeti
OT if c drugs
E / NE required
Cardiogenic Shock
Management
• Avoid excessive fluid resuscitation
• Insertion of intra –aortic balloon pump
• Cardiogenic shock with right ventricular failure may respond better to fluid
resuscitation – IV 500 ml boluses
• Further definitive management will depend on underlying pathology
Management of Septic Shock - Investigations
• To establish the definitive diagnosis
• Blood Culture and sensitivity (2 sets)
• For IV line sepsis:1 set from suspected IV line, another
from peripheral vein
• Urine C&S
• Stool culture
• Sputum culture
• UFEME
• Blood Investigation
• FBC
• ABG
• Coagulation profile with DIVC screen
• BUSE with creatinine
• LFT
• Radiological
• CXR
• USG abdomen (if indicated)
• CT(if indicated)
• LP (if indicated)
Management of Septic Shock

Management

Hemodynamic Instability Infection

Management of Infection
• C&S before empirical antibiotic
• Intravenous broad-spectrum antimicrobials should be
initiated immediately (preferably <30 minutes)
following the clinical diagnosis
• At dosing at the high end of the therapeutic range
• Duration of therapy: 7-10 days
• Empiric antimicrobial therapy should be adjusted to a
narrower regimen within 48 to 72 hours if a plausible
pathogen is identified or patient stabilizes clinically
Where possible, early source control should be
implemented
Anaphylactic Shock
 Anaphylactic shock

Normotensive Hypotensive patient

0.01ml/kg 0.1 mg of a 1: 10000 solution

1: 1000 solution by deep IM given by slow IV OVER 5
inj MINUTES

IV infusion 1-4
microgram /min
Administer histamine
antagonists

• block vasodilation, capillary leak, and shock

• H1 blockade, 25 mg of IM/IV
diphenhydramine

• h2 blockade, cimetidine (TAGAMET) 200-

400mg IV bolus 25-50 mg of ranitidine
diluted in 20 ml d5 % iv infusion over 5
minutes
Others
• Nebulizer Bronchodilator
• Short acting beta2 agonist every 15-
30minutes
• For persistent bronchospasm
• Consider Corticosteroid
• 200-300mg IV hydrocortisone, repeated 6
hourly
• Reduce protracted anaphylaxis
• Effects are not immediate
• Consider glucagon administration
• Used when adrenaline relatively contraindicated
• IHD ,severe hpt, pregnancy, or no response to adrenaline
• 1–5 mg IV over 1 minute, then 1–5 mg/hour in a continuous
infusion
Neurogenic Shock
• Clinical features:
• Bradycardia,
• hypotension
• warm peripheral extremities
Neurogenic shock
• Mx:
• Aggressive fluid resuscitation : to restore preload due to vasodilation
• Vasopressors: iv dopamine 5-20 microgram /kg/minV .Add iv noradrenaline 0.5-
30microgram/min if necessary

• Urgent orthopedic or neurological consult

Thanks you