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SHOCK AND

RESUSCITATION
Hugh M. Foy, MD
Harborview Medical Center
University of Washington

Shock and Resuscitation

Goal: understand the pathophysiology of shock


and its treatment

Objectives:

Be able to categorize types of shock


Understand mechanisms of adapting to
volume loss of blood loss
Demonstrate shock treatment:
lines, sites, types of fluid
End points of resuscitation
Complications of treatment

SHOCK: Definition
Commonly misused

psychogenic
Webster: 12 different definitions

4: the state of profound depression of the vital processes


associated with reduced blood volume and pressure and
caused usually by severe esp. crushing injuries,
hemorrhage, or burns.

The rude unhinging of the machinery of life Gross 1872

Types of Shock
Classic

Blalock 1937

Hematogenic
Neurogenic
Vasogenic
Cardiogenic

Classification of Shock

Low Cardiac Output states


Hypovolemic shock
volume loss
Internal volume loss
Cardiac shock
Impaired inflow
Primary pump
dysfunction
Impaired outflow
Low peripheral resistance
states
Neurogenic shock
Loss of sympathetic
tone
Vasogenic Shock
Septic
Anaphylactic

Carrico:ACSEarlyCareoftheInjuredPatient4thEd.

The Circulatory System


Components:

Heart (pump)
Blood Vessels
Blood

Circulation and
Electricity
Circulation

The flow of blood

Electricity

The flow of electrons

Ohms law: V= IR

(Voltage = Current x
Resistance)
BP = CO x SVR

(Cardiac Output x System


Vascular Resistance)

Circulation Schematic
The Pump (heart)
2 sided

Anatomically looks
parallel, BUT:
Physiologically and
in Actuality
Supplies 2
systems
connected in

series

The Heart:

2-Sided Pump
Right Side

Compliant, flexible
Low pressure,
variable volume

Left Side

Stiff, strong
High pressure,
fixed volume
Like the colon?

The Circulatory System


Multiple Parallel
Circuits
Organized
teleologically:

Prioritized supply

Closest circuits get


supplied first and
foremost
Coronaries,
Brain, Kidneys
Distal circuits get
shut down when
volume low
Gut/Muscle,
Skin

Circulatory Control
Mechanisms

Closest, fastest

Carotid Bodies (Baroreceptors)

Mid-level

Kidneys- Juxtaglomerular
Apparatus

Stimulate Sympathetic Nervous


System

Sense low flow and stimulate


Renin resulting in
vasoconstriction (splancnic)

Down-line

Adrenal Cortex

Senses need for more Sodium


and Fluid Re-absorbtion to deal
with upright posture volume
needs

SHOCK

Acute Volume Loss


Shock - Classes:
I
0-15% blood loss
II 15-30%
blood loss
III 30-40%
blood loss
IV >40% blood loss

Response to Volume Loss


Type % blood loss

HR BP

Postural

Cap Ref

I
0-15%
nl nl
maybe
nl
II 15-30% + maybe
yes
nl
III 30-40% +++
decr
moot incr
IV
>40% ++++ <60Sys

incr

Shock Resuscitation Study


Shires, et al

Bled dogs 40% blood


volume
100% mortality
untreated

Bled, then gave back


blood
80% mortality
Autopsy study

Swollen muscle cells


despite total volume
loss
Tagged RBCs, Na+,
K+, Alb., and repeated
the experiment

Shires Shock Study

Results
Na+ leaked into cells
K+ leaked out of
cells
Albumin leaked into
interstitial space
Water followed Na+
Translocated fluid 3
times the shed blood
Measured
composition of
transloc. fluid

Shires Shock Study

Conclusions
Translocated Fluid composition is LR
Inadequate O2 delivery shuts down Na+/K+
pumps, making cells leaky
Repeated the Experiment:

Gave Shed Blood plus 3 times volume of LR


Mortality decreased from 80 to 30%

Treatment of Shock
Recognize Type of
Shock

If definite pump failure


and cardiogenic shock
institute cardiac
protocols

Otherwise: 2 large bore,


upper extremity
lines
and:
Volume
Volume
Volume
When in doubt, try a little
more volume

Treatment of Shock
Goal: Restore
perfusion
Method: Depends on
type of Shock
Basically 2 kinds:

Hypovolemic
(hemorrhagic, septic,
neurogen.)
Cardiogenic
(Impedence or primary
Cardiac Failure)

Treatment:
Cardiogenic Shock
Oxygen by nasal cannula
IV access
Pain medication
Nitrates prn-

may need unloading only


after volume status
addressed

Treat arrythmias
CPR as needed

Treatment of Shock
Prioritized approach
Must address and treat sequentially:
PRELOAD
AFTERLOAD
PUMP

QUESTIONs:

What type of fluid


How Much
End Point of Resuscitation

Resuscitation Fluids

Blood
Lactated Ringers
Normal Saline
Colloids
Hypertonic Saline
Blood Substitutes

Treatment: Hemorrhagic
Shock
Large bore access

2 upper extremity IVs


16 gauge or larger

Bolus therapy

20 cc/kg
Adults- 2 liters

Monitor Effect
Repeat if necessary
After 2nd bolus: need
blood txn
10cc/kg

End Points of Resuscitation:


Restoration of normal vital signs
Adequate Urine output
0.5 - 1.0 cc/kg/hr

Tissue Oxygenation measurement


Adequate Cardiac Index
Normalization of Oxygen delivery DO2I
Normal Serum Lactate levels

none proven helpful, some deleterious


Englehart; Curr Op Crit Care; Vol 12(6), Dec 06, p 579-574

Evolution in Treatment
Strategies
Auto transfusion (Cell Saver)
Hyperdynamic Supranormal
Resuscitation (Shoemaker)
Less is More - Mattox
Trauma Vaccine - Vedder, et al.
Hypertonic Saline
Glue Grant-

standardization, endpoints, genetics

Alternatives to Transfusion:
Autotransfusion

Safe, warm, better 2-3


DPG levels
Coagulation factors
present
2 methods

Passive collection and


anti-coagulant (chest
tubes)
Cell Saver- washes
Red Cells
Contamination and
Time issues in
trauma

Expensive, fussy, too slow in trauma,


Okay in elective, clean cases

Hyperdynamic
Supranormal Resuscitation
Swan Ganz Catheter
Measure ratio of O2 delivery
and consumption
Push fluid resuscitation until
no longer flow dependent
Massive Edema can be lethal
(DaNang Lung, ARDS, MSOF, SIRS,
Abdominal Comp. Syn.

Multiplesynergisticfactors:someinfluencedbyventilatorstrategy

Mattox in Houston
Q: Is less fluid better?
Randomized pts. QOD

LR vs 250 cc. Hypertonic Saline/Dextran


3% increase in survival in HSD (not significant)
Trend in increase survival in penetrating trauma
victims only
Prospective trial showed only a trend in
improvement, with low n of 48 pts
May be beneficial with head injuries only

Ann Surg 1991;213:482-491


Am J Surg 1989;157:528-34

Well see

Trauma Vaccine Trials


ShockIschemia-Reperfusion Injury
* WBCs up-regulated
adhere to endothelium
* Damaged endothelium leaky
Create massive edema
Blocking adherence -mAb 60.3
-neutropenia protective against ARDS
- WBC surface adhesion molecules when blocked
decreases the edema and injury
- animal data encouraging

HYPERTONIC SALINE WITH


DEXTRAN (HSD)
7.5%saline with 6% dextran-70

Less volume and


weight to carry
May reduce mortality
Limits secondary
brain injury
Less activation of
inflammatory cells

Harborview Study
Double blind, randomized study
N = 209
Endpoint: ARDS free survival

250 ml 7.5% HTS/ 6% Dextran70 vs LR

Findings:

No difference in population overall


Improvement in sickest patients (19%)
> 10 units PCs required

Bulger et al: Arch Surg. 2008; 143(2); 139-148

Shock-Treatment Algorithm

scutaneous O2 Sat Monitoring

Tissue Oxygenation Measurements

*StO2 <75 severe shock


78% MODS
91% Dead
StO2 <75% in 1st hr.
* StO2 >75
88%
MODS free survival
Similar to Base Deficit
measurement

Cohn SM, Nathens AB, Moore FA, Rhee P, Puyana JC, Moore EE, Beilman GJ.

J Trauma. 2007 Jan;62(1):44-54; discussion 54-5.

Blood Transfusion
Blood Banks safer
Some risk
unavoidable
New viruses are
inevitable
False negative
screening tests

Independent risk
factor for MSOD
Time for cross-match
delays Rx
The Search for
Alternatives continues

Alternatives to Transfusion:
Blood Substitutes:

Immediately available, storage easier, no need


for compatibility testing, disease free
Polymerized, Stroma-free Hemoglobin

50 gm in 500 ml
No adverse effects up to 6 units
Slight increase in Bilirubin
Studies small, more needed

Gould:J Am Coll Surg 1998: 187:113-122

Shock and Resuscitation:

SUMMARY

The Circulation is a Circuit


Volume is most often the answer
Lactated Ringers still the standard
More is better than less, maybe
New techniques:
Hypertonic Saline-

okay in Head Injury


Less immunosuppression
Helpful in the sickest patients

Better Indicators & Endpoints of Resuscitation