Shock... Now What?
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Transcript of Shock... Now What?
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MY PATIENT IS IN SHOCK…NOW WHAT?
Chris Nickson FACEM FCICM Intensivist, The Alfred ICU
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Financial Conflicts of Interest NO !
http://litfl.org/CONCEPTOS
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OVE
RVIE
W
ResuscitationSeek & treat the cause!Fluid therapyVasoactive agents!Hemodynamic targetsRefractory Shock!
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RESUSCITATION
(NOW WHAT?)
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Shock is a state of !circulatory failure – !
tissue perfusion is inadequate !to meet the needs of the body!
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Early recognition is vital!
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Shock is not a diagnosis – !seek and treat the !underlying cause !
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Requires a coordinated !team-based approach !
with simultaneous !assessment and management!
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SEEK & TREAT THE CAUSE
(NOW WHAT?)
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SHO
CK
C
AU
SES Pump
Rate / rhythmObstructiveVolumeEndocrineDistributive? (is there an error?)
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Focused Assessment!
History!Examination!
Investigations!
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Ultrasoundis!
Awesome!!
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Courtesy of @emresus (Sam Ghali)!
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SHO
CK
C
AU
SES Pump
Rate / rhythmObstructiveVolumeEndocrineDistributive? (is there an error?)
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FLUID THERAPY
(NOW WHAT?)
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“You can resuscitate a patient with
sterile dog piss if you want – just give the right amount of it!”!
Sir Malcolm Fisher!
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Use crystalloids and !do not give “too much”!
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Bolus and reassess…!usually up to about !
mL/kg20mL/kg!
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Levitov and Marik (2012) PMC3171766!
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Fluid responsiveness does not mean you should give fluid !
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Give blood !if bleeding or significantly
anaemic
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VASOACTIVE AGENTS
(NOW WHAT?)
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Start early using !peripheral IV access!
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Norepinephrine is first line vasoactive agent for
undifferentiated shock!(usually)!
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HAEMODYNAMIC TARGETS
(NOW WHAT?)
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MAP (mmHg)
65
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Individualise targets according to !
the patient, the context!and the phase of illness!
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Frequent assessment !of the whole patient is !more important than an!
invasive monitor
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Other targets are !important too!!
!SaO2 PaCO2 pH glucose!
Lactate ScvO2!
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REFRACTORY SHOCK
(NOW WHAT?)
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Reassess frequently !and consider the !
underlying cause(s) !(PROVED?)!
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Use Occam’s Razor but remember!
Hickam’s Dictum!!!!
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“Let no one die without a !trial of steroids”!
!Hydrocortisone 50mg q6h!
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Add vasoactive agents !and consider !
circulatory assist devices
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SUM
MA
RY
ResuscitationSeek & treat the cause!Fluid therapyVasoactive agents!Hemodynamic targetsRefractory shock!
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http://litfl.org/CONCEPTOS