SHOCKSHOCK

Case presentations and CVS Case presentations and CVS MonitoringMonitoring

Case 4Case 4A 29‑year‑old lady (72 kg) arrives in the resuscitation room drowsy with the following vital signs:

ABG:• BP 80/50 mmHg, pH 7.31• pulse 130 per minute, Pa02 35.5 kPa • RR 28 per minute, PaC02 3.5 kPa• Sa02 95% on 10 L/min O2 bicarb 12.7mmol/L

via a reservoir bag mask, BE‑10. • temperature 38.5°C.

She has a petechial rash on her trunk. She responds to voice and there is no neck stiffness.Her bedside glucose measurement is 6.2 mmol/L

Q1: What is your diagnosis?Q2: What is your management?

Case 4Case 4 “A” - ensure a patent and protected airway, give a high

concentration of oxygen (for example, 15 L/minute via a reservoir bag mask),

“B” - assess and treat any breathing problems, “C” - assess and treat any circulation problems, “D” - assess conscious level and check for Temp & UO. The petechial rash is a clue to the possible cause of

sepsis – think meningococcal and/or staphylococcal infections.

A full examination and appropriate investigations (including CT/MRI, CSF and other cultures) should follow.

Modified Early Warning Score (MEWS) –useful tool in recognition of patients with presumed infection

Score 3 2 1 0 1 2 3

BP SYS < 80 80-89 90-109 110-160 161-180 181-200 >200

PULSE < 40 - 40-50 51-100 101-110 111-129 >130

RESP. < 8 - - 8-20 21-25 26-30 >30

TEMP. - <35 - 35.1-37.9 38.0-38.4 >38.5 -

AVPU Alert Voice Pain Unrespon

sive

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If Score 3 in one category or total Score 4 - Think infection!

New

Weakness New

Confusion

2 Signs and symptoms of infection (SSI)plus presumed infection = Sepsis

Two or more of the following:• Tachycardia > 90 bpm• Core temperature > 38.3°C < 36°C• Tachypnoea > 20 bpm • WCC >12,000 or <4,000 or >10% immature

neutrophils • Hyperglycaemia in the absence of Diabetis Mellitus

Q: Is there at least one organ failure already?

Septic shock - Acute circulatory failure unexplained by other causes.

SepsisSSIInfection SevereSeveresepsissepsis

Death

Sepsis with signs of at least one acute organ dysfunction (organ failure) Cardiovascular Unexplained metabolic acidosis Central nervous system Respiratory Renal Hepatic Haematologica

Septic shock – is defined as Severe sepsis with hypotension refractory to adequate volume resuscitation, Hypotension is defined as a systolic blood pressure of <90mmHg or a reduction of >40mmHg from baseline)

SSI - Signs and symptoms of infectionSSI - Signs and symptoms of infection

Case 4Case 4

Patient has Severe Sepsis according to the SSC. Fluid resuscitation using crystalloids or colloids 20-40 ml/kg/hr Blood cultures and Lactate taken ASAP Antibiotics administered within 1 hour If BP is not responsive to fluids or if serum lactate is still elevated

consider CVP, Invasive Arterial line for ABG and CVS monitoring Repeated boluses of crystalloid/colloid 250-500 ml every 30 min until

CVP 8-12 mmHg Vasopressors via central line if MAP < 65 mm Hg during and after

adequate fluid resuscitation - Noradrenaline (4 mg in 50 ml of 5% Dextrose - start at 0.05 mcg/kg/min) or Metaraminol infusion.

If Scv O2 < 70 % after adequate fluid replacement and Noradrenaline running, start Isotopes (Dobutamine at 2.5 mcg/kg/min or Adrenaline infusion via central line) and/or give RBC’s (to keep Ht above 30)

Case 5Case 5 A 53 year old motorcyclist is brought by Air A 53 year old motorcyclist is brought by Air

Ambulance having been involved in a high speed RTA Ambulance having been involved in a high speed RTA with a truck.with a truck.

Blood pressure is unrecordable, pulse is not palpable, Blood pressure is unrecordable, pulse is not palpable, except in carotid and femoral regionsexcept in carotid and femoral regions

A 14G cannula has been inserted by A 14G cannula has been inserted by ‘‘cutdowncutdown’’ in the in the left great saphenous vein, NaCl 0.9% runningleft great saphenous vein, NaCl 0.9% running

He is intubated and ventilatedHe is intubated and ventilated

Q1: What are the possible causes of his low BP?Q1: What are the possible causes of his low BP?

Q2: What should the management comprise?Q2: What should the management comprise?

Case 5Case 5 Management planManagement plan::

• ABC approachABC approach• Volume resuscitationVolume resuscitation• Achieve stabilityAchieve stability• Transfer to CT scan for Transfer to CT scan for ‘‘Trauma seriesTrauma series’’• Act upon findingsAct upon findings

A and B are checked and clearedA and B are checked and cleared• No pneumothorax detected clinicallyNo pneumothorax detected clinically• CXR confirms no extrapulmonary airCXR confirms no extrapulmonary air

Case 5Case 5 Circulation:Circulation:

• Despite on-going IV fluid infusion, BP is difficult to Despite on-going IV fluid infusion, BP is difficult to record via NIBP monitor record via NIBP monitor

• Additional venous access obtained (14G) - bloods are Additional venous access obtained (14G) - bloods are taken and Hartmann’s 1000 ml given stat.taken and Hartmann’s 1000 ml given stat.

• Radial Arterial line inserted, showing invasive Radial Arterial line inserted, showing invasive pressure of 76/42 mmHgpressure of 76/42 mmHg

Q1: What might be happening?Q1: What might be happening?

Q2: What could be done to investigate?Q2: What could be done to investigate?

Case 5Case 5 FAST scanFAST scan

• Suggests some free fluid in abdomenSuggests some free fluid in abdomen• Small amount of fluid in pericardiumSmall amount of fluid in pericardium• Otherwise normal but empty heart appearanceOtherwise normal but empty heart appearance• BP is very low - patient is not stable for CT scanner BP is very low - patient is not stable for CT scanner

or theatre.or theatre.

Q1: How does this help you?Q1: How does this help you?

Q2: What could be done, in view of the Q2: What could be done, in view of the continuing instability?continuing instability?

Case 5Case 5 In view of possible intra abdominal bleeding In view of possible intra abdominal bleeding

2 units of O (I) Neg blood and 1L Colloids given,2 units of O (I) Neg blood and 1L Colloids given, In order to support BP:In order to support BP:

• Metaraminol IV boluses given every 3-5 mins,Metaraminol IV boluses given every 3-5 mins,• SubclavianSubclavian CVC line is obtained and Noradrenaline CVC line is obtained and Noradrenaline

infusion started by ITU Registrarinfusion started by ITU Registrar• But HR is now 150, BP is 46-51 mmHg systolic.But HR is now 150, BP is 46-51 mmHg systolic.• Patient is in PEA arrest, +/- drug induced SVT ??Patient is in PEA arrest, +/- drug induced SVT ??

CPR started with Adrenaline given every 3 min.CPR started with Adrenaline given every 3 min.

Q: What else could be done to save life?Q: What else could be done to save life?

Case 5Case 5 CPR:CPR:

• 3 minute cycles with 1 mg Adrenaline given each 3 minute cycles with 1 mg Adrenaline given each timetime

• BP is unresponsive to drugs, only to CPR BP is unresponsive to drugs, only to CPR • Massive Transfusion Protocol (MTP) is activated and Massive Transfusion Protocol (MTP) is activated and

another 6 u-ts of O (I) Neg blood given another 6 u-ts of O (I) Neg blood given Thoracotomy for open compressions in A&EThoracotomy for open compressions in A&E

• Descending Aorta clampedDescending Aorta clamped• Blood pressure improves somewhat (110/60)Blood pressure improves somewhat (110/60)• Heart is pumping well, massage stoppedHeart is pumping well, massage stopped• Patient is more stable now, can go to CT scannerPatient is more stable now, can go to CT scanner

Case 5Case 5 CT resultsCT results

• Small splenic and liver injuries (both Grade 2)Small splenic and liver injuries (both Grade 2)• Undisplaced T6 spinal fracture, no brain injuryUndisplaced T6 spinal fracture, no brain injury• Femoral fracturesFemoral fractures

Went to Theatre for Laparotomy + OrthopaedicsWent to Theatre for Laparotomy + Orthopaedics• Spleenectomy, but only mild blood loss in abdomenSpleenectomy, but only mild blood loss in abdomen• Aortic clamp removed, chest drain placedAortic clamp removed, chest drain placed• Ex-fix placed on femur to prevent bleedingEx-fix placed on femur to prevent bleeding• CVP reading is low CVP (~2 mmHg)CVP reading is low CVP (~2 mmHg)• Requiring moderate dose of noradrenaline to maintain Requiring moderate dose of noradrenaline to maintain

adequate blood pressureadequate blood pressure

Q: Why is the blood pressure still poor?Q: Why is the blood pressure still poor?

Case 5Case 5 In Critical CareIn Critical Care

• Intubated, ventilate, positive fluid balance is almost 10.5 Intubated, ventilate, positive fluid balance is almost 10.5 litres; litres;

• Patient noted to be moving arms but not legs;Patient noted to be moving arms but not legs;• When woken up from sedation completely, still could not When woken up from sedation completely, still could not

move legsmove legs• MRI shows cord damage at T6 levelMRI shows cord damage at T6 level• Discharged from ITU in 2 weeks with some neurological Discharged from ITU in 2 weeks with some neurological

improvementimprovement

Presumably spine was displaced enough to damage cord Presumably spine was displaced enough to damage cord then returned to normal anatomical positionthen returned to normal anatomical position

QuestionsQuestions