project: document title: shock - open.michigan...document title: shock author(s): patrick carter...
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Project: Ghana Emergency Medicine Collaborative Document Title: Shock Author(s): Patrick Carter (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
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CLASS I II III IV
BVL < 15% 15 - 30% 30 - 40% > 40%
AMOUNT 750 cc 750 - 1500 cc 1500 - 2000 cc > 2000 cc
PULSE <100 > 100 >120 >140
BP No change Narrowed pulse pressure
Consistent decrease in SBP
Decreased SBP and narrowed pulse pressure or no DBP
RESP No change 20-30 30-40 >35
CNS No change Anxiety Anxious, confused Confused. lethargic
Urine >30cc per hr 20-30cc per hr 5-15cc per hr negligible
TX Replace fluid loss
2L NS IV 2 L NS IV, usually requires blood transfusion
Rapid transfusion of blood and NS, requires immediate intervention to stop hemorrhage
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Rapid Response Transient Response
No Response
Vitals Return to normal Transient improvement with return to previous
Remain Abnormal
Estimated Blood loss
10-20% 20-40% with ongoing likely
Severe >40%
Need for more Fluid
Low High High
Need for Blood Type and cross Type specific O neg Need for surgery Possible Likely Highly likely
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B >.2<5.8"756"<5'7<'D"I3<-"+<72D75D"(75'"72D"7D63_'D"<."C>j"
B ?5'7<6'2<"756"@.88.I'D"=5.<.(.8"32"V0"@.5"S"-.F5+"72D"<-'2"7D63_'D"<."C>j"
B d32D32;+f$F<(.6'"B ?5'7<6'2<";5.F="5'('3*'D"6.5'"\F3D+"(.6=75'D"<."(.2<5.8";5.F="WP"i"*+l"AlP"iX"
B AlU"D7:+"8'++"32"-.+=3<78"@.5"<5'7<6'2<";5.F="B #"@.8D"8'++"(75D3.=F86.275:"(.6=83(7).2+"@.5"<5'7<6'2<";5.F="
B D&).2?&'#&8*12$0',0'+$#".),"7'$/'EFGFH'AP"
V758:"[.78"035'(<'D"?-'57=:"
H3*'5+"V"'<"78l"V758:";.78YD35'(<'D"<-'57=:"32"<-'"<5'7<6'2<".@"+'*'5'"+'=+3+"72D"
+'=)("+-.(/"4"V2;8"h"^'Dl"#cc!bAJPb!ASUY!ATTl"
"
AS"
e27=-:87()(",-.(/"
B e27=-:87G3+"B ,'*'5'"+:+<'63("
-:='5+'2+3)*3<:"5'7().2"
B >-757(<'53g'D"%:"6F8)+:+<'6"32*.8*'6'2<""
B C;V"6'D37<'D"
B e27=-:87(<.3D"5'7().2"B >8323(788:"32D3+)2;F3+-7%8'"@5.6"727=-:87G3+"
B 0.'+"2.<"5'EF35'"7"+'2+3)g32;"'G=.+F5'"
B 4.<"C;V"6'D37<'D"
Justin Beck, Flickr
AT"
e27=-:87()(",-.(/"O">8323(78"
^723@'+<7).2+"
• >8323(78",='(<5F6"– d35+<",:6=<.6+b""
• 95F53<F+"• d8F+-32;"• j5)(7537"
– 95.;5'++3.2b""• ?-5.7<"@F882'++"• e2G3'<:"• >-'+<");-<2'++"• ,-.5<2'++".@"%5'7<-"• i3;-<-'7D'D2'++"
– ,'*'5'",:6=<.6+b"""• e8<'5'D"6'2<78"+<7<F+"
• H'+=357<.5:"D3+<5'++"• >35(F87<.5:"(.887=+'"
• H3+/"@7(<.5+"@.5"@7<78"727=-:87G3+""– 9..58:"(.2<5.88'D"7+<-67"""
– 95'*3.F+"727=-:87G3+"""
• H'.((F55'2('"57<'+"– JcYScp"@.5"32+'(<"+)2;+"– #cYJcp"@.5"57D3.(.2<57+<"7;'2<+"
– !cY#cp"@.5"='23(38832""
• ^.+<"(.66.2"(7F+'+"– e2)%3.)(+"– C2+'(<+"– d..D""
AU"
e27=-:87()(",-.(/"Y"037;2.+3+"
• >8323(78"D37;2.+3+"– 0'12'D"%:"735I7:"(.6=5.63+'R"-:=.<'2+3.2R".5"
32*.8*'6'2<".@"(F<72'.F+R"5'+=357<.5:R".5"[C"+:+<'6+"
B ^38DR"8.(783g'D"F5)(7537"(72"=5.;5'++"<."@F88"727=-:87G3+"
B ,:6=<.6+"F+F788:"%';32"I3<-32"Sc"632F<'+".@"'G=.+F5'"
B d7+<'5".2+'<".@"+:6=<.6+"L"6.5'"+'*'5'"5'7().2"
B K3=-7+3("=5'+'2<7).2".((F5+"32"F="<."#cp".@"=7)'2<+"B ,:6=<.6+"I388"5'<F52"AYJ"-.F5+"7n'5"323)78"5'7().2"-7+"(8'75'D"
• i../"@.5"'G=.+F5'"<."D5F;R"@..DR".5"32+'(<"• i7%+"-7*'"2."5.8'"
A]"
e27=-:87()(",-.(/"Y"?5'7<6'2<"
• eK>q+"– H'+=357<.5:"(.6=5.63+'"5'EF35'"366'D37<'"
32<F%7).2"
• CNR">75D37("^.23<.5R"9F8+'"$G36'<5:"
• CNdq+R"$G:;'2"• V=32'=-532'"@.5"e27=-:87G3+f,-.(/"• ,'(.2D"832'"?-'57=3'+"
– >.5)(.+<'5.3D+"– Q!"72D"Q#"%8.(/'5+"
Jc"
e27=-:87()(",-.(/"Y"?5'7<6'2<"
• V=32'=-532'"– clA"6;"C^".5",>".@"!b!ccc"D38F).2"@.5"727=-:87G3+""
– H'='7<"'*'5:"PY!c"632"7+"2''D'D"
– >7F).2"3@"=7)'2<".2"%'<7"%8.(/'5+"DF'"<."F2.==.+'D"78=-7"+)6F87).2"72D"5'+F8<72<"+'*'5'"
-:='5<'2+3.2"
– d.5">N"(.887=+'"W3l'l"(75D37("755'+<XR"!"6;"CN".@"
!b!cRccc"W+76'"7+"e>i,"0.+'X"
– C@"5'@57(<.5:"-:=.<'2+3.2"72D"+-.(/R"+<75<"CN"D53="
J!"
e27=-:87()(",-.(/"Y"?5'7<6'2<"
• >.5)(.+<'5.3D+"– ^'<-:8=5'D23+.8.2'"!#P"6;"CN""
– 95'D23+.2'"Sc"6;"9$"
• e2)-3+<7632'+"
– Q!"%8.(/'5Y"03=-'2-:D57632'"#PYPc"6;"CN"
– Q#"%8.(/'5Y"H723)D32'"Pc"6;"CN"
• K5.2(-.D387<.5+"– e8%F<'5.8"2'%F83g'5"– e<5.*'2<"2'%F83g'5"– ^7;2'+3F6"+F8@7<'"#";"CN".*'5"#c"632F<'+""
"
J#"
>75D3.;'23(",-.(/"
B ^.5<783<:"=53.5"<."5'='5@F+3.2"
<-'57=:"L"PcYUcp"
B ,3;2+b"B >..8R"6._8'D"+/32"
B ?7(-:=2'7"B 9F86.275:"*7+(F875"(.2;'+).2""
B Q:=.<'2+3.2"B e8<'5'D"6'2<78"+<7<F+"
B 4755.I'D"=F8+'"=5'++F5'"B H78'+R"6F56F5"
B 0'12'D"7+b"B ,K9"m"]c"66Q;"
B >75D37("C2D'G"m"#l#"if6f6#"
B 9F86.275:">7=38875:"Z'D;'"
95'++F5'"W9>Z9X"o"!U"
66Q;"
Patrick J. Lynch, Wikimedia Commons JA"
>75D3.;'23(",-.(/""
• >75D3.;'23(",-.(/"V).8.;:"– e(F<'"^:.(75D378"C2@75().2"We^CX"
– ,'=+3+"– ^:.(75D3)+"
– ^:.(75D378">.2<F+3.2"
– e(F<'"e.5)("C2+F`(3'2(:"
– e.5)(".@"^3<578",<'2.+3+"
– Q:='5<5.=-3(">75D3.6:.=7<-:"
JJ"
>75D3.;'23(",-.(/"
• $n'2"5'+F8<+"@5.6"6:.(75D378"3+(-'637"
I3<-"8.++".@"8'n"*'2<53(F875"WiNX"@F2().2"
– >8323(78"+-.(/"'2+F'+"7n'5"8.++".@"Jcp"iN"• H'+F8)2;"(75D37(".F<=F<"5'DF().2"8'7D+"<."87()("7(3D.+3+"72D"-:=.G37"
• ,<5./'"*.8F6'"3+"5'DF('D""
– ?7(-:(75D37"D'*'8.=+"7+"(.6='2+7).2"@.5"
D'(5'7+'D",N"<."6732<732"(75D37(".F<=F<""
– C+(-'637"72D"32@75().2"I.5+'2+"(5'7)2;"
D.I2I75D"+=3578"
JP"
>75D3.;'23(",-.(/"Y"037;2.+3+"
• Vt["• >MH"• i7%.57<.5:b""
– >.6=8'<'"K8..D">.F2<"
– >-'63+<5:"972'8"WV8'(<5.8:<'+R"Kj4f>HX"
– >75D37("'2g:6'+"W^:.;8.%32R">tR">tY^KR"?5.=.232X"
– >.7;F87).2"+<FD3'+"• V(-.(75D3.;576"
JS"
>75D3.;'23(",-.(/"Y"?5'7<6'2<"
• ?5'7<6'2<"[.78+"
– e35I7:"(.2<5.8"W3@"2'('++75:X"– C6=5.*32;"6:.(75D378"=F6="@F2().2"
– H'='5@F+3.2"W3@"7*7387%8'X"– 95'*'2)2;"@F5<-'5"6:.(75D378"D767;'"
• ^.23<.532;""
– >75D37("6.23<.5"
– 9F8+'"$G36'<5:"
• ,F==8'6'2<78".G:;'2R"CN"7(('++"
• C2<F%7).2"D'(5'7+'+"=5'8.7D"72D"(7F+'+"-:=.<'2+3.2"""
– ^7:"2''D"<.";3*'"\F3D"%.8F+"<."(.6='2+7<'"3@"32<F%7)2;"
JT"
>75D3.;'23(",-.(/"Y"?5'7<6'2<"
• e^C"
– e+=3532R"K'<7Y%8.(/'5R"^.5=-32'R"Q'=7532"
– 43<5.;8:('532"@.5"=732"(.2<5.8"W7*.3D"32"32@'53.5"^CX"
– C@"2."=F86.275:"'D'67R"67:"<5:"CN"\F3D"@.5"K9"+F==.5<"
– C@"=F86.275:"'D'67"
• 0.=7632'"O"I388"x"QH"72D"<-F+"(75D37("I.5/"
• 0.%F<7632'"O"^7:"D5.="%8..D"=5'++F5'"DF'"<."='53=-'578"
*7+.D387<7).2"
• >.6%327).2"<-'57=:"67:"%'"6.5'"'a'()*'"
– H'='5@F+3.2"?-'57=:"W3@",?V^C"72D"7*7387%8'"32"<-'"(8323(78"
+'y2;X"
• >75D37("(7<-'<'53g7).2"I3<-"32<'5*'2).2""• ?-5.6%.8:)(+"
"JU"
4'F5.;'23(",-.(/"
• H'+F8<+"@5.6"+=3278"(.5D"32&F5:"I3<-"+-.(/"
87+)2;"@5.6"!YA"I''/+"
• i.++".@"+:6=7<-')("<.2'"72D"5'+F8<72<"
F2.==.+'D"*7;78"<.2'"
• 0'(5'7+'D"*7+.6.<.5"<.2'""
• H'+F8<+"32"-:=.<'2+3.2"72D"%57D:(75D37"
• 97)'2<+"67:"5'6732"78'5<R"I756R"72D"D5:"
D'+=3<'"<-'"-:=.<'2+3.2"
• ,=3278"+-.(/"
– ?'6=.575:"8.++".@"+=3278"5'\'G"7()*3<:"
%'8.I"7"<.<78".5"2'75"<.<78"+=3278"(.5D"
32&F5:"
– 4.<"<-'"+76'"7+"2'F5.;'23("+-.(/R"<-'"
<'56+"75'"2.<"32<'5(-72;'7%8'"
gunkyboy, Wikimedia Commons
J]"
4'F5.;'23(",-.(/Y"?5'7<6'2<"
• eRKR>+"– H'6'6%'5">Y+=32'"=5'(7F).2+"
– Q3;-">Y+=32'"32&F53'+"5'EF35'"6'(-723(78"*'2)87).2""
• >AY>JY>P"O"9-5'23("4'5*'"322'5*7).2"• d8F3D"5'+F+(3<7).2"
– t''="^e9"7<"UPY]c"66"Q;"@.5"15+<"T"D7:+"
– ^32363g'"+'(.2D75:"(.5D"32&F5:"
– C@"(5:+<788.3D"3+"32+F`(3'2<"F+'"*7+.=5'++.5+"
• ,'75(-"@.5".<-'5"(7F+'+".@"-:=.<'2+3.2"– $n'2R",>C"5'+F8<+"@5.6"<57F67"L"5f."Q'6.55-7;3(",-.(/"
• d.5"%57D:(75D37"– e<5.=32'"– 97('67/'5""
Pc"
$%+<5F()*'",-.(/"
• ?'2+3.2"92'F6.<-.57G"
• >75D37("?76=.27D'"
• 9F86.275:"V6%.83+6"
• ,'*'5'"e.5)(",<'2.+3+"
P!"
$%+<5F()*'",-.(/"
B ?'2+3.2"=2'F6.<-.57G"
B e35"<57=='D"32"=8'F578"+=7('"I3<-"!"I7:"*78*'R"735f=5'++F5'"%F38D+"F="
B ^'D37+)2F6"+-3n'D"36='D32;"
*'2.F+"5'<F52"
B >-'+<"=732R",$KR"D'(5'7+'D"%5'7<-"+.F2D+"
B 4."<'+<+"2''D'Df(8323(78"D37;2.+3+"B ?5'7<6'2<b"4''D8'"D'(.6=5'++3.2"
@.88.I'D"%:"(-'+<"<F%'"Source: www.meddean.luc.edu/lumenMedEd/medicine/pulmonar/cxr/pneumo1.htm
Delldot, Wikimedia Commons
P#"
$%+<5F()*'",-.(/"
B >75D37("<76=.27D'"
B K8..D"32"='53(75D378"+7("=5'*'2<+"*'2.F+"5'<F52"<."72D"(.2<57().2".@"
-'75<"
B V).8.;:b""?57F67R"9'53(75D3)+R"^C"
B K'(/q+"<537Db""B Q:=.<'2+3.2R"6Fz'D"-'75<"+.F2D+R"hN0"
B 037;2.+3+b"i75;'"-'75<">MHR"'(-."B ?5'7<6'2<b"9'53(75D3.('2<'+3+"
K8..D"
9'53(75D3F6"
V=3(75D3F6"
Aceofhearts1968, Wikimedia Commons
PA"
$%+<5F()*'",-.(/"
• 9F86.275:"'6%.83+6"
– N35(-.I"<537Db""• Q:='5(.7;F87%8'"• N'2.F+"32&F5:"• N'2.+<7+3+"
– ,3;2+b""• ?7(-:=2'7""• ?7(-:(75D37"• Q:=.G37"
– i.I"53+/b"0YD36'5"
– Q3;-'5"53+/b">?"(-'+<".5"Nk"+(72"
– ?5'7<6'2<b""Q'=7532"
• >.2+3D'5"<-5.6%.8:)(+"3@"+-.(/"
@5.6"9V"
Hellerhoff, Wikimedia Commons
PJ"
$%+<5F()*'",-.(/"
B e.5)("+<'2.+3+"B H'+3+<72('"<."+:+<.83("'&'().2"(7F+'+"D'(5'7+'D"(75D37("@F2().2"
B >-'+<"=732"I3<-"+:2(.='"B ,:+<.83("'&'().2"6F56F5"
B 0'123)*'"D37;2.+3+"I3<-"'(-."B N7+.D387<.5+"W4?[X"I388"D5.="=5'++F5'"B ?5'7<6'2<b"e.5)("*78*'"+F5;'5:"
PP"
Z-3(-"=5'++.5"+-.F8D"C"(-..+'r"
! Q:=.*.8'63("+-.(/"
– Fluids and Blood
! >75D3.;'23("+-.(/"– Dobutamine - !1 agonist
! Increases squeeze and heart rate
! 4'F5.;'23("+-.(/"– Fluids, phenylephrine, Levophed,
look for another type of shock if it is persistent
! e27=-:87()("+-.(/"– Fluids and epinephrine
! ,'=)("+-.(/"– Neosynephrine - alpha agonist
! Increases SVR by arteriolar constriction
– Norepinephrine/Levophed - alpha and beta agonists
! 0.=7632'"
– Low Dose - increases renal blood supply
– Medium Dose - beta effects (increases heart rate and squeeze)
– High Dose - alpha effects (arteriolar constriction)
PS"
kF'+).2+r"
Dkscully, Flickr PT"