Presentation on theme: "Sergio Zanotti MD Assistant Professor of Medicine Robert Wood Johnson Medical School Cooper University Hospital Camden, New Jersey How useful and sensitive."— Presentation transcript:
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?
Introduction Methods How useful? How sensitive? Conclusions
Introduction Shock represents the failure of the circulatory systems to maintain adequate delivery of oxygen and other nutrients to tissues.
Classification of Shock Distributive (septic shock) Obstructive (pulmonary embolism) Cardiogenic (myocardial infarction) Hypovolemic (hemorrhage) PAOP CO SVR
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
Are clinical findings useful in the diagnosis of Shock?
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.
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.
Blood Pressure Measurement in Shock Pressure (mm Hg) High PVR Low PVR CuffArterialCuffArterial J. Cohn. JAMA 1967; 199:972.
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
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.
Capillary Refill Times Mean (sec)SDRange Blood donors Before – 3.7 After – 4.0 Clinical pts. Orthostatic – 3.3 Hypotension – 5.1 Total – 5.1 Schriger. Ann Emerg Med 1991; 20:601
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
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
Toe Temperature Henning, R.J.,et al., Measurement of toe temperature for assessing the severity of acute circulatory failure. Surg Gynecol Obstet, (1); p Joly, H.R. and M.H. Weil, Temperature of the great toe as an indication of the severity of shock. Circulation, (1); p Ibsen B. Treatment of shock with vasodilators measuring skin temperature on the big toe. Dis Chest, :425.
TOE TEMPERATURE °C r = 0.71 CI= T toe (0.286) Cardiac Index L/min/m2 Correlation between CI and Toe Temperature Joly HR. Weil MH. Circulation 1969
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
Start with a subjective assessment of skin temperature to identify hypoperfusion in ICU patients. Kaplan CJ, et al. J Trauma 2001; 50: 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]
Are clinical findings sensitive in the diagnosis of Shock?
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%
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, …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
What can we learn from shock clinical trials? Cardiogenic Shock Septic Shock Obstructive Shock
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.
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:
Outcomes in Pulmonary Embolism 100 % 0 % 10 % 30 % 70 % Mortality Sudden Death Cardiac Arrest Shock Severity Embolism SizeCardiopulmonary Status Wood KE. CHEST 2002
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
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.
Useful? Yes. Sensitive? No.
“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