1. Case presentations and CVS Monitoring
SHOCK
Case 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 7.31
pulse 130 per minute, Pa kPa
RR 28 per minute, PaC kPa
Sa02 95% on 10 L/min O2 bicarb 12.7mmol/L
via 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/L
Q1: 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 < >200
PULSE < >130
RESP. < >30
TEMP < >
AVPU Alert Voice Pain Unrespon
sive
If Score 3 in one category or total Score 4 - Think infection!
New
Weakness
New
Confusion

5. Q: Is there at least one organ failure already?
2 Signs and symptoms of infection (SSI) plus presumed infection = Sepsis
Two or more of the following:
Tachycardia > 90 bpm
Core temperature > 38.3°C < 36°C
Tachypnoea > 20 bpm
WCC >12,000 or <4,000 or >10% immature neutrophils
Hyperglycaemia in the absence of Diabetis Mellitus
Q: Is there at least one organ failure already?

6. Septic shock - Acute circulatory failure unexplained by other causes.
Severe sepsis
Infection
SSI
Sepsis
Death
Sepsis 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)
Cardiovascular
Unexplained metabolic acidosis
Central nervous system
Respiratory
Renal
Hepatic
Haematologica
Severe sepsis is defined as sepsis with signs of at least one acute organ dysfunction.11
Septic shock is sepsis-induced refractory hypotension that persists despite adequate fluid resuscitation, along with the presence of hypoperfusion abnormalities or organ dysfunction.11
In 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.11
It 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.3
SSI - Signs and symptoms of infection

7. Case 4 Patient has Severe Sepsis according to the SSC.
Fluid resuscitation using crystalloids or colloids ml/kg/hr
Blood cultures and Lactate taken ASAP
Antibiotics administered within 1 hour
If BP is not responsive to fluids or if serum lactate is still elevated consider CVP, Invasive Arterial line for ABG and CVS monitoring
Repeated boluses of crystalloid/colloid ml every 30 min until CVP 8-12 mmHg
Vasopressors 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 regions
A 14G cannula has been inserted by ‘cutdown’ in the left great saphenous vein, NaCl 0.9% running
He is intubated and ventilated
Q1: What are the possible causes of his low BP?
Q2: What should the management comprise?
Hypovolaemic,
Obstructive (PTx)
Cardiogenic (tamponade, contusion)
Neurogenic 8

9. Case 5 Management plan: A and B are checked and cleared ABC approach
Volume resuscitation
Achieve stability
Transfer to CT scan for ‘Trauma series’
Act upon findings
A and B are checked and cleared
No pneumothorax detected clinically
CXR 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 monitor
Additional venous access obtained (14G) - bloods are taken and Hartmann’s 1000 ml given stat.
Radial Arterial line inserted, showing invasive pressure of 76/42 mmHg
Q1: What might be happening?
Q2: What could be done to investigate?

11. Case 5 Q1: How does this help you?
FAST scan
Suggests some free fluid in abdomen
Small amount of fluid in pericardium
Otherwise normal but empty heart appearance
BP 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 Trauma 11

12. Case 5 Q: What else could be done to save life?
In view of possible intra abdominal bleeding
2 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 Registrar
But 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 CPR
Massive Transfusion Protocol (MTP) is activated and another 6 u-ts of O (I) Neg blood given
Thoracotomy for open compressions in A&E
Descending Aorta clamped
Blood pressure improves somewhat (110/60)
Heart is pumping well, massage stopped
Patient 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 injury
Femoral fractures
Went to Theatre for Laparotomy + Orthopaedics
Spleenectomy, but only mild blood loss in abdomen
Aortic clamp removed, chest drain placed
Ex-fix placed on femur to prevent bleeding
CVP reading is low CVP (~2 mmHg)
Requiring moderate dose of noradrenaline to maintain adequate blood pressure
Q: Why is the blood pressure still poor?

15. Case 5
In Critical Care
Intubated, 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 legs
MRI shows cord damage at T6 level
Discharged from ITU in 2 weeks with some neurological improvement
Presumably spine was displaced enough to damage cord then returned to normal anatomical position

16. Questions 16