Resuscitation and Shock

LSU Medical Student Clerkship,

New Orleans, LA
 Resuscitation

Goals

Provide an introduction to the ABCs of resuscitation

in the ED
Review available oxygen delivery devices and

airway adjuncts
Describe the pathophysiology of shock and its

major subtypes
Provide an introduction to the basics of treatment of

shock in the ED
 Resuscitation

Shock

Shock is defined as circulatory insufficiency that

creates an imbalance between tissue oxygen
supply and oxygen demand. The result of shock
is global tissue hypoperfusion and is associated
with a decreased venous oxygen content and
metabolic acidosis (lactic acidosis).
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Pathophysiology of Shock

Imbalance between tissue supply and demand

Anaerobic Metabolism Lactic Acid Production
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Emergency Medicine Always Starts with the ABCs

Compressions

A Airway

B - Breathing

C - Circulation
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Airway

Remove any obstructions

Head tilt, chin lift

Jaw Thrust

Oropharyngeal and nasopharyngeal airways

Orotracheal and nasotracheal intubation

Cricothyroidotomy and Tracheotomy

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Jaw Thrust
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Head Tilt
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Nasopharygeal airway
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Orotracheal airway
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Supraglottic devices
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Orotracheal
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Neck airways
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challenges
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Rapid Sequence Intubation

Assume every ED patient has a full stomach

Combination of sedation and paralysis to facilitate
procedure
Evidence based to increase chance of success and
decrease incidence of aspiration
Not without its dangers: paralyzing a patient who
cannot be ventilated
 Resuscitation

Rapid Sequence Intubation

Assume every ED patient has a full stomach

Combination of sedation and paralysis to facilitate
procedure
Evidence based to increase chance of success and
decrease incidence of aspiration
Not without its dangers: paralyzing a patient who
cannot be ventilated
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RSI Indications

Airway Protection

Respiratory Failure

Expected Clinical
Course
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Breathing

Hypoxic Respiratory Failure

Hypercapnic Respiratory Failure

Mechanical Respiratory Failure

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Oxygen Delivery Devices

Nasal Cannula - up to 40% FiO2

Venturi mask - fixed 25% to 50% FiO2

Nonrebreather mask - theoretical 100% FiO2

Bag Valve Mask 100%FiO2

Noninvasive Positive Pressure Ventilation (BiPAP

or CPAP) FiO2 up to 100% based on setting
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Nasal cannula/ Venturi mask
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Positive pressure ventilation
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Circulation

Restoration of a pulse is the first goal

ACLS

However having a pulse is not the end of the story

Adequate circulation requires correction of original

mismatch
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Types of Shock

Hypovolemic

Cardiogenic

Distributive

Obstructive
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Hypovolemic Shock

Caused by inadequate circulating volume

(decreased preload)
Hemorrhage (trauma, ruptured AAA, GI bleeding)

Fluid loss (diarrhea, vomiting, poor intake, burns,

third spacing)
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Cardiogenic Shock

Caused by pump failure (decreased cardiac output)

Myopathic systolic dysfunction, diastolic
dysfunction
Dysrrythmic disorganized cardiac activity
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Distributive Shock

Caused by maldistribution of bloodflow from

peripheral vasodilatation and decrease in SVR
(decreased afterload)
Sepsis

Neurogenic

Anaphylaxis

Toxic shock syndrome

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Obstructive shock

Caused by
extracardiac
obstruction to blood
flow
Cardiac tamponade,

tension pneumothorax,
pulmonary embolus
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Clinical Presentation of Shock

Clinical presentation varies with type of shock

History and physical are key for determining underlying
cause
Hypotension is very common
Altered mental status may be most sensitive sign of illness
Lethargy, cool clammy skin, tachypnea, tachycardia, and
cyanosis are common as well
DIAGNOSE THE UNDERLYING CAUSE!!!!
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Treating Shock

Early intervention is vital to reducing morbidity and

mortality
All efforts are aimed at balancing maximizing tissue
oxygen supply decreasing tissue oxygen demand
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Systemic inflammatory response syndrome

Early phase
1) temperature greater than 38C (100.4F) or

less than 36C (96.8F);

(2) heart rate faster than 90 beats/min;

(3) respiratory rate faster than 20 breaths/min;

(4) white blood cell count greater than 12.0

less than 4.0 , or with greater than 10 percent

bands
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Multi organ disease

myocardial depression
adult respiratory distress syndrome,

disseminated intravascular coagulation,

hepatic failure

renal failure.
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Early Goal Directed Shock Therapy
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Treating Shock - Breathing

Maximize oxygenation (Keep Sa02 > 93%)

Control the work of breathing. Respiratory muscles
are highly metabolic and can greatly increase
oxygen demand.
 Treating Shock Fluid Resuscitation
Resuscitation

Most patients in shock have either an absolute or

relative volume deficit, except the patient in
cardiogenic shock with pulmonary edema
Central venous catheterization can guide help
guide via central venous pressure monitoring and
SVCO2 monitoring
A good bolus is a bold bolus!!

Massive trauma transfusion- more blood products/

crystalloids
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Treating Shock Vasopressors

Vasopressor agents are used when there has been
an inadequate response to volume resuscitation or
when a patient has contraindications to volume
infusion
Vasopressors are most effective after fluid
resuscitation but may be necessary to avoid
prolonged hypotension
Goal is generally a MAP of 65
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Treating Shock Vasopressors

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Treating Shock Endpoints

No therapeutic end point is universally effective,

and only a few have been tested in prospective
trials, with mixed results.
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Treating Shock Endpoints

Table 30-8 Hemodynamic Resuscitation End Points

Modality Goals
Preload CVP 1012 mm Hg

PAOP 1218 mm Hg

Afterload MAP 90100 mm Hg

SVR = (MAP 8001400 dyne s/cm5

CVP/CO)(80)

Contractility CO 5.0 L/min

CI 2.54.5 L per min m2

SV = CO/heart rate 5060 mL per min

Heart rate 60100 bpm Avoid >100 bpm; this will decrease SV
and
increase myocardial oxygen
consumption

Coronary perfusion CPP = DBP CVP (or >60 mm Hg

pressure PAOP)

Tissue oxygenation ScvO2 or SmvO2 >70%

Serum lactate <2mM/L

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Take Home Points

The goal of resuscitation is to maximize survival

and minimize morbidity using objective
hemodynamic and physiologic values to guide
therapy.
The first few hours are vital.

Diagnose and treat the underlying cause!!!

Stay ahead of shock!!!!!!!