SHOCK. Dr. David Carr February 23 rd 2014

Transcription

1 SHOCK Dr. David Carr February 23 rd 2014

2 Moore et al: Acad Emerg Med 2002 According to the above study, How often did ED physicians correctly identify the etiology of the patients shock A) 25% B) 45% C) 65% D) 85%

3 Moore et al: Acad Emerg Med 2002 According to the above study, How often did ED physicians correctly identify the etiology of the patients shock A) 25% B) 45% C) 65% D) 85%

4 SHOCK- The way I was taught Septic/Spinal Hypovolemic/Hemorrhagic Obstructive Cardiogenic AnaphylactiK

5 Objectives How to survive sepsis Review SHOCK in the new millennium Get equipped to rapidly diagnose and treat shock with US A couple of cases

6 SHOCK Shock: A momentary pause in the act of death Dr. John Collins Warren 1895

7 THE SHIFT 1 DOC 38 y.o female working in the ER Unwell x 1/52 with a cough/cold Did not want to call in the on call doc PMHX- nil Meds - nil

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9 Text from the ER DOC Temp 37.5 Lactate 2.8 Wbc 4 Cr 120 CXR RLL pneumonia My response It s just sepsis, who cares Return text: Its me

10 Dellinger et al: Surviving Sepsis Campaign: Critical care med 2013 Feb; 41(2)

11 Sepsis Nomenclature SIRS: > or = 2/4: Ask are they infected? A) T >38 or < 36 B) HR> 90 C) RR>20 or PaC02 >32 D) WBC >12 or <4 or 10% bands Sepsis =SIRS + Infection: Is it shock or severe? Septic shock: sepsis + hypotension after 2L Severe sepsis: sepsis + poor organ perfusion Transition point for aggressive therapy hypotension after 2L or lactate >4

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13 30 Mortality risk relative to lactate level Lactate Lactate Lactate >4 Shapiro et Al: Ann emerg med 2005(45) 524-8

14 Higher and higher lactate Patients with lactate > 4 without hypotensive septic shock Mortality 26.5% Independent predictor of 28 day mortality RESPECT YOUR LACTATE: CALL THE UNIT Howell et al: Intensive Care Medicine 2007

15 Shock is not ruled out by a normal BP. It s about the perfusion not the pressure Dr. Scott Weingart

16 BP is overrated! Hypotension is not defined by the physician but rather the patient No specific number at which MAP is too low Perfusion problem Organ dysfunction: cardiac/renal/cns Tissue ischemia: lactate production

17 Management RESUSCITATION GOAL is to restore tissue perfusion and oxygenation HOW? Break it down into: First 3 hours First 6 hours Thereafter.

18 Surviving Sepsis Bundles: Keep it simple

19 Resuscitation Options 1. Fluids 2. Antibiotics/Source Control 3. Vasopressors 4. Inotropes 5. Panic

20 Access: 2 tries or 2 min or! IO

21 What is the evidence? ER study comparing PIV s (57 patients), CVC (5), PHIO (29) PHIO faster than PIV and CVC (1.5min vs 3.6 min and 15.6 min) Pain scores higher in PHIO patients No differences in major complications Increase minor complications in PHIO group Journal of trauma vol 67, September 2009

22 What is the evidence?

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24 Fluids: Which one? Surviving Sepsis Campaign (2012) Crystalloids remain fluid of choice for initial resuscitationà 30 ml/kg bolus over min Colloids: Transfusion trigger for < 70 and target of Hb Albumin can be used after ~4-6L of crystalloids

25 Protein Shake: Albumin Expensive SAFE study (2004): No difference when compared with saline EXCEPT: increased mortality at 2 years for TBI BUT: decreased mortality in Severe Sepsis No definitive evidence BUT consider it for Severe sepsis

26 How much fluid?

27 ICU approach: How much fluid How do I know that I have optimized my preload? MAP 65 mm Hg Urine output 0.5 ml/kg/hr CVP - Target 8-12 mmhg Converts to cmh2o OR JVP of 6 11! SvO2 - Target 70% Lactate Normalization US markers?

28 Antibiotics and Source Control Administer EFFECTIVE antimicrobials within the FIRST hour of RECOGNITION: RECOGNITION = The first time sepsis crosses your mind

29 Antibiotics Broad spectrum >1 agent active against the most likely bugs and capable of penetrating the source 7-15% mortality reduction if started in the ER in the 1st hour in severe sepsis or shock DON T WAIT FOR IV S TO FINISH EACH ABX Critical Care Medicine, 2010,38(4): Critical Care Medicine, 2006,34(6):

30 Respiratory pathogen treatment for septic shock Use a big gun Antipneumococcal/antipseudomonal: Ø Imipenem g iv q6-8h or Ø Piperacillin-tazobactam 4.5 g iv q8h or Ø Cefepime 2 g iv q8-12h Plus add a second agent(s) Ø Levofloxacin 750 mg iv q24h or Ø Aminoglycoside + azithromycin *Add Vancomycin 2 g iv if MRSA suspected or coexisting central line or medical device IDSA 2007 Guidelines

31 Have you ever been experienced?

32 Treatment of suspected abdominal infections in septic shock Ø ampicillin + gentamycin + metronidazole Ø ampicillin + ceftriaxone + metronidazole Ø piperacillin-tazobactam or levofloxacin or imipenem, plus metronidazole Ø ceftriaxone plus metronidazole Ø moxifloxacin plus metronidazole *Avoid clindamycin: 75% resistance to B. frag and 40% to Group A strep

33 Empiric treatment of septic shock without known infection source Vancomycin plus Imipenem or Piperacillin-tazobactam or Cefepime

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36 Intubate Early Septic patients get diffuse alveolar damge ALIà ARDS Mechanical ventilation eliminates work and metabolic demands of breathing Accounts for 30% of total metabolic demand Low TV 6ml/kg + PEPP + Plateau pressure <30

37 Surviving Sepsis Bundles:

38 Resuscitation Options 1. Fluids 2. Antibiotics/Source Control 3. Vasopressors 4. Inotropes 5. Panic

39 Vasopressors Purpose: Help restore MAP Reverse the vasodilation Restore tissue perfusion without using fluids CAVEATS: Do not use until pt receives adequate fluid challenge All CAN be infused peripherally! BUT need a central line

40 Push dose pressors Temporizing measure Post intubation hypotension Awaiting central line Phenylephrine is the likely drug of choice Run peripherally as no extravasation concerns Take 1 ml (10mg/ml) vial add to 100 ml mini bag Give 1 ml = 100 mcg give q2-5mins

41 DOPAMINE IS DEAD

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43 Vasopressors Dopamine is just as unsafe as NE if given peripherally First line is Norepinephrine: 5-20 ug/min If adding a second agentà NE should be maxed If not getting better on NE.Ask yourself, what am I missing?

44 What am I missing checklist? Fluids, fluids and more fluids Correct calcium if low Give blood if bleeding Toxicologic issue: Intralipid Endocrine issue: hydrocortisone, thyroxine Allergic: Epinephrine Thrombosis: t-pa If nothing apparent! add 2 nd vasopressor

45 Vasopressors If they need a second vasopressor Is the heart contracting well? YES and HR highà Vasopressin: fixed dose 0.03 U/min No and HR low à Epinephrine: potent inotrope 1-10U/min Inotropic support Dobutamine if ongoing hypoperfusion (increasing lactate and no u/o) with reasonable MAP Start 2.5U/kg/min

46 Evidence for steroids

47 Steroids Corticosteroids (CORTICUS) Role has been de-emphasized IV hydrocortisone 200mg /day for vasopressin resistant shock (grade 2C) NO PRESSORS = NO ROIDS

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49 Back to our ER DOC After 5 L lactate rises from After about 15 hours U/O re-established and lactates start to fall WBC goes from 4à 26 in 24 hours Given cetriaxone+azithro+vanco w/i 30 mins Back to work in a monthà great outcome

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51 Critical Care US Critical tool in ED assessment Guides Resuscitation Diagnostics Therapeutics Procedures Early recognition and correct treatment of shock à decreases mortality

52 Emerg Med Clinic N Am:

53 RUSH: HI MAP Heart: Effusion/Tamponade/R heart strain/ LVF IVC: Fluid Status Morrison s pouch/fast: Free fluid Aorta: AAA Pneumothorax Weingart et al 2006

54 RUSH Protocol Steps

55 RUSH Protocol Summary

56 PUMP Problems Pericardial effusion RV strain

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58 TANK PROBLEMS: Sniff test IVC< 2cm with Inspiratory collapse > 50%! CVP <10 (~3) IVC > 2cm with Inspiratory collapse < 50%! CVP >10 (15) Lower CVP Higher CVP Before sniff After sniff Before sniff After sniff

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60 Tank Problems: Leaking POSITIVE FAST PLEURAL EFFUSION

61 TANK Problems: Compromised Pneumothorax Pulmonary edema

62 PIPE Problems AAA Aortic dissection

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64 /51 R 58/34 L

65 Case 3: Sudden Onset of CP 63 yo male, sudden onset 10/10 epigastric/ RSCPà back No hx similar PMHX HTN, DMII, Hep C, PUD, ETOH MEDS: Metformin, ASA, amitriptyline, pantoloc Thoughts?

66 Case 3: Sudden Onset of CP Gen: Obvious distress, screaming, swearing Vitals /51 R and 58/34 L 18 98% Chest: Clear, trachea ml CVS: NHS no es/m/rubs/edema JVP flat Abdo: diffuse tenderness FOB EKG and portable CXR normal Management ABC s

67 Case 3: Sudden Onset of CP Septic/Spinal: Maybe no fever & source/injury Hypovolemic/hemorrhagic: Maybe FOB Obstructive: PE? Tamponade?- Unlikely Cardiogenic: Dissection? MI (EKG N)- Maybe Anaphylactic: Unlikely What about US?

68 RUSH Protocol Steps CXR NORMAL

69 Case 3: Sudden Onset of CP Labs Wbc 9 Hb 127 Plt 443 Lactate 6.1 Lytes and extended lytes N ETOH- 53 AST 71 ALT 66 BR 14 Amylase 76 INR 1.0 Trop VBG: 7.35/40/37/22 Additional Tests?

70 Case 3: Sudden Onset of CP US guides treatment and workup Responded to fluids Lactate fell from 6.1 à 4.6 after 3L BP normalized CT Chest/Abdo/Pelvis No dissection Peripancreatic inflammatory changes and pseudocyst Distributive Shock secondary to pancreatitis

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74 Case 4: SOB after breakfast 72 yo female woke up N Sudden onset of SOB at kitchen table Driven by son to ER O2 Sat 68% at triage PMHX: Pancreatic cancer dx 3/52 ago Meds: none

75 Case 4: SOB after breakfast What do you want to do? Portable CXR normal Bloods? Wnl except trop 1 RUSH the US

76 Check the pump 1. No effusion 2. Contractility of LV N 3. LARGE RV Now what?

77 RUSH Protocol Steps

78 Case 4: SOB after breakfast Presumed diagnosis: sub-massive PE Given 70 mg enoxaparin Anti-coagulate high risk PE prior to testing 2012 Chest guidelines TPA indications: Does she fit? Hemodynamic instability Cardiogenic shock Limb compromise Does anyone want to give t-pa?

79 MOPPET TRIAL Prospective non blinded RCT safe low dose TPA for sub-massive PE Dose 10mg bolus then 40 mg over 2 hours Primary endpoint: pulmonary HTN and recurrent PE Secondary endpoint: Mortality, LOS 121 patients with 28 months follow up Sharifi M: Amer Jour Cardiology 2013 Jan 15: 111(2): 273-7

80 MOPPET TRIAL 41% ARR in pulmonary HTN No increased bleeding risk No mortality benefit This improves QoL not mortality How do you define a sub massive PE? EKG? Echo? Trop?

81 Case 4: SOB after breakfast Patient becomes drowsy BP 70/40 T-PA called for.. Push dose phenyl 100mcg given pre-intubation PEA arrest 50 mg TPA pushed ROSC in one minute Pt walked out of the hospital

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83 Conclusions Treat perfusion not the pressure Watch the lactate If you think they may need an abx à GIVE IT Fluids, fluids and more fluids Get comfy with norepinephrine Have a what am I missing checklist Develop an US based approach to work it out

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