1. Sergio Zanotti MD Assistant Professor of Medicine Robert Wood Johnson Medical School Cooper University Hospital Camden, New Jersey How useful and sensitive are clinical findings in the diagnosis of shock?

2. Introduction Methods How useful? How sensitive? Conclusions

3. Introduction Shock represents the failure of the circulatory systems to maintain adequate delivery of oxygen and other nutrients to tissues.

4. Classification of Shock Distributive (septic shock) Obstructive (pulmonary embolism) Cardiogenic (myocardial infarction) Hypovolemic (hemorrhage) PAOP CO SVR

5. Methods  Medline: January 1966 to April 2006  Key Words: Shock, clinical findings, physical exam, examination, diagnosis, blood pressure, capillary refill, temperature, sensitivity, hypovolemia, sepsis, cardiogenic.  Based on review of titles and abstracts relevant articles were retrieved  Bibliographies of articles and of physical diagnosis or shock articles/textbooks

6. Are clinical findings useful in the diagnosis of Shock?

7. Clinical Findings  Hypotension  Tachycardia  Altered mental status  Delayed capillary refill  Decreased urine output  Cool skin  Cold extremities

8. Blood pressure measurements in Shock. J. Cohn. JAMA 1967; 199:972.  Patients with hypotension or clinical diagnosis of shock.  If vasopressors were started, they were discontinued and BP was allowed to stabilize.  BP measures;  Directly: Femoral or radial artery cannulation  Indirectly: By auscultation/palpation method.  CO measured by indirect dilution method.  PVR was calculated.

9. Differences between direct and indirect BP measurements  SBP 33.1 mm Hg (+169 to –20)  Direct pulse pressure 43 mm Hg  Indirect pulse pressure 19 mm Hg J. Cohn. JAMA 1967; 199:972.

10. Blood Pressure Measurement in Shock 120 100 80 60 40 20 Pressure (mm Hg) High PVR Low PVR CuffArterialCuffArterial J. Cohn. JAMA 1967; 199:972.

11. Clinical parameters for estimating severity of circulatory shock StageBPHRCR (2min) Urine ml/h Mental Status % Loss 1Normal < 2>39Normal or anxious < 15 2 Tilt +> 100> 220Anxious> 20 3> 120> 25 – 15Confused> 30 4> 140> 20 – 5Lethargic> 40 Weil, MH. Defining Hemodynamic Instability. Functional Hemodynamic Monitoring 2005 Springer.

12. Capillary Refill: What is normal? Patient Group MedianFalse / + Rate Upper Limit (95 % CI) Y Fem.0.7 sec4.0% Y Male0.8 sec4.0% A Male1.0 sec4.0% A Fem.1.2 sec13.7%2.9 sec E Male1.5 sec29.0%4.5 sec E Fem.1.8 sec29.0%4.5 sec Schriger DL. Ann Emerg Med 1998; 17:932

13. Capillary Refill – Is it a Useful Predictor of Hypovolemic States? Schriger. Ann Emerg Med 1991; 20:601  Design: prospective, nonrandomized study.  Patients:  (1) ED patients with history of hypovolemia + one:  orthostatic vital signs (n 19)  hypotension (n 13)  (2) Blood donors (n 47)  Intervention: capillary refill measurement.

14. Capillary Refill Times Mean (sec)SDRange Blood donors Before 1.90.70.6 – 3.7 After 1.10.70.9 – 4.0 Clinical pts. Orthostatic 1.90.70.8 – 3.3 Hypotension 2.81.21.1 – 5.1 Total 2.21.00.8 – 5.1 Schriger. Ann Emerg Med 1991; 20:601

15. Two-Second Sens.Spec.Sens.Spec. 450 ml blood loss 11%89%6%93% Orthostatic 47%86%26%95% Hypotension 77%86%46%95% Total59%86%34%95% Adjusted Capillary refill in hypovolemia Schriger. Ann Emerg Med 1991; 20:601

16. Probability of Hypovolemia AccuracyPPVNPV 10%89%43%93% 25%80%69%81% 50%64%87%59% 90%40%98%14% Capillary refill in hypovolemia Schriger. Ann Emerg Med 1991; 20:601

17. Toe Temperature Henning, R.J.,et al., Measurement of toe temperature for assessing the severity of acute circulatory failure. Surg Gynecol Obstet, 1979. 149(1); p. 1-7. Joly, H.R. and M.H. Weil, Temperature of the great toe as an indication of the severity of shock. Circulation, 1969. 39(1); p. 131-8. Ibsen B. Treatment of shock with vasodilators measuring skin temperature on the big toe. Dis Chest, 1967. 52:425.

18. 24 28 32 36 4 0 2 TOE TEMPERATURE °C r = 0.71 CI= - 5.24 + T toe (0.286) Cardiac Index L/min/m2 Correlation between CI and Toe Temperature Joly HR. Weil MH. Circulation 1969

19.  Cº TOE-AMBIENT Henning RJ. Et al. Surg Gynecol Obstet.1979;149:1-7 10 5 0 CºCº 5 0 CºCº 5 0 CºCº Survivors Fatalities

20. Toe temperature versus transcutaneous oxygen tension monitoring during acute circulatory failure. Vincent JL. Intensive Care Med 1988; 14:64 Cardiogenic Shock  Toe-ambient T gradient: strong correlation with CI, stroke index, oxygen transport.  Toe-ambient T gradient > P TC O 2 Septic Shock  Both techniques were poor indicators of blood flow indexes

21. Start with a subjective assessment of skin temperature to identify hypoperfusion in ICU patients. Kaplan CJ, et al. J Trauma 2001; 50:620-28 Objective: Determine whether physical examination alone or with biochemical markers can accurately dx hypoperfusion. Design: retrospective data collection (n 264) Two groups:  Cool skin temperature [CST]  Warm skin temperature [WST]

22. ValueCoolWarmp Cardiac output (L/min) 5.3 ± 2.28.2 ± 2.6 < 0.05 Cardiac index (L/min/m 2 ) 2.9 ± 1.24.3 ± 1.2 < 0.05 pH7.32 ± 0.27.39 ± 0.07 < 0.05 TCO 2 (mEq/dL)19.5 ± 3.125.1 ± 4.8 < 0.05 Svo 2 (%)60.2 ± 4.468.2 ± 7.8 < 0.05 Lactate (mmol/L)4.7 ± 1.52.2 ± 1.6 < 0.05 Kaplan CJ, et al. J Trauma 2001 Hemodynamic and Biochemical Parameters

23. Temperature All patients: Cool extremity PPV 39 % NPV 92 % CST group + HCO3 < 21 meg/dL PPV 98 % NPV 97 % Sepsis + cool extremity PPV 51.3 % NPV 88.9 % Sepsis + cool extremity + low HCO3 PPV 68 % NPV 90 % Kaplan CJ, et al. J Trauma 2001

24. Are clinical findings sensitive in the diagnosis of Shock?

25. How good are our clinical skills? Cardiac output Wedge pressure Connors (NEJM ‘83) ICU pts 44% 42% Eisenberg (CCM ‘84) ICU pts 50% 33% Bayliss (BMJ ‘83) CCU pts 71% 62%

26. Diagnostic Accuracy of SBP < 95 mm Hg for Acute Blood Loss Source, yearModerate BL Sensitivity (95 % CI) Large BL Sensitivity (95 % CI) Before BL Specificity (95 % CI) Warren, 194513…100 Shenkin, 1944…36100 Wallace, 1941…3296 Skillman, 1967…56100 Bergenwalkd, 1977…13… Summary measure ‡ 13 (0-50)33 (21-47)97 (90-100) McGee S. JAMA 1999; 281:1022

27. What can we learn from shock clinical trials? Cardiogenic Shock Septic Shock Obstructive Shock

28. Clinical Profile of Suspected Cardiogenic Shock Report from SHOCK trial registry 28% of patients with shock had no pulmonary congestion. Mortality for these patients was 70% Menon V. et al. J Am Coll Cardiol 2000; 36:1071.

29. Early Goal-Directed Therapy for Severe Sepsis and Septic Shock Severe Sepsis + ↓ ↓Blood Pressure or ↑ ↑Lactic acid Standard (n 133) Mortality 46.5% EGDT (n 130) Mortality 30.5% Rivers et al. N Engl J Med 2001;345:1368-77

30. + MAP > 100 mmHg + Lactate > 4 mmol/L Sepsis MAP ( mmHg) ScVO 2 Mortality Control (n 23) EGDT (n 25) 116 45 % 61 % 118 44 % 20 % Donnino, MW et al. CHEST 2003; 124:90S.

31. Outcomes in Pulmonary Embolism 100 % 0 % 10 % 30 % 70 % Mortality Sudden Death Cardiac Arrest Shock Severity Embolism SizeCardiopulmonary Status Wood KE. CHEST 2002

32. Clinical Outcome of Patients With Acute Pulmonary Embolism. 31% normotensive with RV dysfunction 10% developed PE related shock Higher mortality than normotensive group Grifoni S, et al. Circulation 2000;101:2817

33. Conclusions Rigorous conclusions about the value of clinical findings in the diagnosis of shock are difficult to make because there are very few studies on this matter.

34. Useful? Yes. Sensitive? No.

35. “the nose sharp, the eyes sunken, the temples fallen in, the ears cold and drawn in and their lobes distorted, the skin of the face hard, stretched, and dry, and the color of the face pale or dusky” Hippocrates, 400 BC