Presentation on theme: "Case presentations and CVS Monitoring"— Presentation transcript:
1 Case presentations and CVS Monitoring SHOCKCase presentations and CVS Monitoring
2 Case 4 Q1: What is your diagnosis? Q2: What is your management? A 29‑year‑old lady (72 kg) arrives in the resuscitation room drowsy with the following vital signs: ABG:BP 80/50 mmHg, pH 7.31pulse 130 per minute, Pa kPaRR 28 per minute, PaC kPaSa02 95% on 10 L/min O2 bicarb 12.7mmol/Lvia 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/LQ1: What is your diagnosis?Q2: What is your management?
3 Case 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.
4 Modified Early Warning Score (MEWS) –useful tool in recognition of patients with presumed infection BP SYS < >200PULSE < >130RESP. < >30TEMP < >AVPU Alert Voice Pain UnresponsiveIf Score 3 in one category or total Score 4 - Think infection!NewWeaknessNewConfusion
5 Q: Is there at least one organ failure already? 2 Signs and symptoms of infection (SSI) plus presumed infection = SepsisTwo or more of the following:Tachycardia > 90 bpmCore temperature > 38.3°C < 36°CTachypnoea > 20 bpmWCC >12,000 or <4,000 or >10% immature neutrophilsHyperglycaemia in the absence of Diabetis MellitusQ: Is there at least one organ failure already?
6 Septic shock - Acute circulatory failure unexplained by other causes. Severe sepsisInfectionSSISepsisDeathSepsis with signs of at least one acute organ dysfunction (organ failure)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)CardiovascularUnexplained metabolic acidosisCentral nervous systemRespiratoryRenalHepaticHaematologicaSevere sepsis is defined as sepsis with signs of at least one acute organ dysfunction.11Septic shock is sepsis-induced refractory hypotension that persists despite adequate fluid resuscitation, along with the presence of hypoperfusion abnormalities or organ dysfunction.11In septic shock, hypotension is defined as a systolic blood pressure of <90mmHg or a reduction of >40mmHg from baseline in the absence of other causes of hypotension.11It is important to realise that these stages do not necessarily imply an increasing severity of infection, but rather an increasingly severe systemic response to infection.3SSI - Signs and symptoms of infection
7 Case 4 Patient has Severe Sepsis according to the SSC. Fluid resuscitation using crystalloids or colloids ml/kg/hrBlood cultures and Lactate taken ASAPAntibiotics administered within 1 hourIf BP is not responsive to fluids or if serum lactate is still elevated consider CVP, Invasive Arterial line for ABG and CVS monitoringRepeated boluses of crystalloid/colloid ml every 30 min until CVP 8-12 mmHgVasopressors 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)
8 Case 5 Q1: What are the possible causes of his low BP? A 53 year old motorcyclist is brought by Air Ambulance having been involved in a high speed RTA with a truck.Blood pressure is unrecordable, pulse is not palpable, except in carotid and femoral regionsA 14G cannula has been inserted by ‘cutdown’ in the left great saphenous vein, NaCl 0.9% runningHe is intubated and ventilatedQ1: What are the possible causes of his low BP?Q2: What should the management comprise?Hypovolaemic,Obstructive (PTx)Cardiogenic (tamponade, contusion)Neurogenic8
9 Case 5 Management plan: A and B are checked and cleared ABC approach Volume resuscitationAchieve stabilityTransfer to CT scan for ‘Trauma series’Act upon findingsA and B are checked and clearedNo pneumothorax detected clinicallyCXR confirms no extrapulmonary air
10 Case 5 Q1: What might be happening? Circulation:Despite on-going IV fluid infusion, BP is difficult to record via NIBP monitorAdditional venous access obtained (14G) - bloods are taken and Hartmann’s 1000 ml given stat.Radial Arterial line inserted, showing invasive pressure of 76/42 mmHgQ1: What might be happening?Q2: What could be done to investigate?
11 Case 5 Q1: How does this help you? FAST scanSuggests some free fluid in abdomenSmall amount of fluid in pericardiumOtherwise normal but empty heart appearanceBP is very low - patient is not stable for CT scanner or theatre.Q1: How does this help you?Q2: What could be done, in view of the continuing instability?Focused Assesment using Sonography in Trauma11
12 Case 5 Q: What else could be done to save life? In view of possible intra abdominal bleeding2 units of O (I) Neg blood and 1L Colloids given,In order to support BP:Metaraminol IV boluses given every 3-5 mins,Subclavian CVC line is obtained and Noradrenaline infusion started by ITU RegistrarBut HR is now 150, BP is mmHg systolic.Patient is in PEA arrest, +/- drug induced SVT ??CPR started with Adrenaline given every 3 min.Q: What else could be done to save life?
13 Case 5 CPR: 3 minute cycles with 1 mg Adrenaline given each time BP is unresponsive to drugs, only to CPRMassive Transfusion Protocol (MTP) is activated and another 6 u-ts of O (I) Neg blood givenThoracotomy for open compressions in A&EDescending Aorta clampedBlood pressure improves somewhat (110/60)Heart is pumping well, massage stoppedPatient is more stable now, can go to CT scanner
14 Case 5 Q: Why is the blood pressure still poor? CT results Small splenic and liver injuries (both Grade 2)Undisplaced T6 spinal fracture, no brain injuryFemoral fracturesWent to Theatre for Laparotomy + OrthopaedicsSpleenectomy, but only mild blood loss in abdomenAortic clamp removed, chest drain placedEx-fix placed on femur to prevent bleedingCVP reading is low CVP (~2 mmHg)Requiring moderate dose of noradrenaline to maintain adequate blood pressureQ: Why is the blood pressure still poor?
15 Case 5In Critical CareIntubated, ventilate, positive fluid balance is almost 10.5 litres;Patient noted to be moving arms but not legs;When woken up from sedation completely, still could not move legsMRI shows cord damage at T6 levelDischarged from ITU in 2 weeks with some neurological improvementPresumably spine was displaced enough to damage cord then returned to normal anatomical position