Shock managment - Fasa University of Medical Scieneces
Shock management Mahnaz Amanat .MD A 37 YO FEMALE WITH HX OF TL PRESENT WITH ABDOMINAL PAIN,SPOTTING ,AGITATION ,TACHYCARDIA,TACKYPNEA AND HYPOTENTION Is this pation in shock? Ill appearance or altered mental status
Haert rate>100 RR>20 Or Paco2<32mm Hg Arterial base deficit <-4 or lactate>4 Urine output<0.5 ml/kg/hr Hypotention> 30 continus minutes duratione
Goals of treatment ABCDE airway control work of breathing optimaize circulation
assure adequate oxygen delivery achive end point of resuscitation Airway Determine need for intubation but remember: Intubation Sedatives Positive can worsen hypotension can worsen hypotention
pressure ventilation decreased preload Resuscitation prior to intubation to avoid hemodynamic collapse 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. 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. 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 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
Persistent hypotention Assesment of equipment and monitoring Inadequate volume resuscitation Pnemothorax Cardiac tamponade
Hidden bleeding Adrenal insufficiency Medication allergy PTE,MI,. Practically speaking Keep one eye on these patient
Frequent vital sign monitoring Let your nurses know that these patient are sick 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
As indicated CXR US Chest ct,.. Hypovolemic shock ABCD
2large bore IV or Cvline Crystlloid RBCs Control any bleeding Arrang definitive traetment
What type of shock? A 81 yo F resident of nursing home present to ED with altered mental status. Febrile and hypotensive with tachycardia SEPTIC SHOCK Two or more of SIRS criteria T>38 Or <36 c HR>90 RR>20 or Paco2<32 mmHg WBC>12000 Or<4000 or band>10%
Septic shock SIRS with suspected or confirmed infection with hypotension despite adquate fluid resuscitation Ancillary Studies Cardiac monitoring Pulse oximetry CBC,
LFT, lipase ABG lactate BC*2, UA UC CXR Foley cathetr
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 Early goal directed therapy 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. Anaphylactic shock Anaphylactic shock treatment 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 Check external bleeding of GCS
AIRWAY CONTROL, VENTILATION, Supplment o2 Intubate as needed Ventilate to achieve o2 sat>94% Treat potential respiratory conditions:
Tension Pneumothorax Hemotroax Circulation IV access*2 large bore Cardiac monitoring Pulse oximetri
IV fluid Bedside US 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 ANY QUESTION ?
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