Resuscitation and Shock
LSU Medical Student Clerkship,
New Orleans, LA
Resuscitation
Goals
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Provide an introduction to the ABC’s of
resuscitation in the ED
Review available oxygen delivery devices and
airway adjuncts
Describe the pathophysiology of shock and its
major subtypes
Provide an introduction to the basics of treatment of
shock in the ED
Resuscitation
Shock

Shock is defined as circulatory insufficiency that
creates an imbalance between tissue oxygen
supply and oxygen demand. The result of shock
is global tissue hypoperfusion and is associated
with a decreased venous oxygen content and
metabolic acidosis (lactic acidosis).
Resuscitation
Pathophysiology of Shock
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Imbalance between tissue supply and demand 
Anaerobic Metabolism  Lactic Acid Production
Resuscitation
Emergency Medicine Always Starts with the ABC’s
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Compressions
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A – Airway
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B - Breathing
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C - Circulation
Resuscitation
Airway
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Remove any obstructions
Head tilt, chin lift
Jaw Thrust
Oropharyngeal and nasopharyngeal airways
Orotracheal and nasotracheal intubation
Cricothyroidotomy and Tracheotomy
Resuscitation
Jaw Thrust
Resuscitation
Head Tilt
Resuscitation
Nasopharygeal airway
Resuscitation
Orotracheal airway
Resuscitation
Supraglottic devices
Resuscitation
Orotracheal
Resuscitation
Neck airways
Resuscitation
challenges…
Resuscitation
Rapid Sequence Intubation
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Assume every ED patient has a full stomach
Combination of sedation and paralysis to facilitate
procedure
Evidence based to increase chance of success and
decrease incidence of aspiration
Not without its dangers: paralyzing a patient who
cannot be ventilated
Resuscitation
Rapid Sequence Intubation




Assume every ED patient has a full stomach
Combination of sedation and paralysis to facilitate
procedure
Evidence based to increase chance of success and
decrease incidence of aspiration
Not without its dangers: paralyzing a patient who
cannot be ventilated
Resuscitation
RSI Indications

Airway Protection

Respiratory Failure
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Expected Clinical
Course
Resuscitation
Breathing
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Hypoxic Respiratory Failure
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Hypercapnic Respiratory Failure
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Mechanical Respiratory Failure
Resuscitation
Oxygen Delivery Devices
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Nasal Cannula - up to 40% FiO2
Venturi mask - fixed 25% to 50% FiO2
Nonrebreather mask - theoretical 100% FiO2
Bag Valve Mask – 100%FiO2
Noninvasive Positive Pressure Ventilation (BiPAP
or CPAP) FiO2 up to 100% based on setting
Resuscitation
Nasal cannula/ Venturi mask
Resuscitation
Resuscitation
Positive pressure ventilation
Resuscitation
Circulation
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Restoration of a pulse is the first goal
ACLS
However having a pulse is not the end of the story
Adequate circulation requires correction of original
mismatch
Resuscitation
Types of Shock
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Hypovolemic
Cardiogenic
Distributive
Obstructive
Resuscitation
Hypovolemic Shock
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Caused by inadequate circulating volume
(decreased preload)
Hemorrhage (trauma, ruptured AAA, GI bleeding)
Fluid loss (diarrhea, vomiting, poor intake, burns,
third spacing)
Resuscitation
Cardiogenic Shock
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Caused by pump failure (decreased cardiac output)
Myopathic – systolic dysfunction, diastolic
dysfunction
Dysrrythmic – disorganized cardiac activity
Resuscitation
Distributive Shock
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Caused by maldistribution of bloodflow from
peripheral vasodilatation and decrease in SVR
(decreased afterload)
Sepsis
Neurogenic
Anaphylaxis
Toxic shock syndrome
Resuscitation
Obstructive shock
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Caused by
extracardiac
obstruction to blood
flow
Cardiac tamponade,
tension
pneumothorax,
pulmonary embolus
Resuscitation
Clinical Presentation of Shock
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Clinical presentation varies with type of shock
History and physical are key for determining underlying
cause
Hypotension is very common
Altered mental status may be most sensitive sign of illness
Lethargy, cool clammy skin, tachypnea, tachycardia, and
cyanosis are common as well
DIAGNOSE THE UNDERLYING CAUSE!!!!
Resuscitation
Treating Shock
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Early intervention is vital to reducing morbidity and
mortality
All efforts are aimed at balancing maximizing tissue
oxygen supply decreasing tissue oxygen demand
Resuscitation
Systemic inflammatory response
syndrome
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Early phase
1) temperature greater than 38°C (100.4°F)
or less than 36°C (96.8°F);
(2) heart rate faster than 90 beats/min;
(3) respiratory rate faster than 20
breaths/min;
(4) white blood cell count greater than 12.0
less than 4.0 , or with greater than 10 percent
bands
Resuscitation
Multi organ disease
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myocardial depression
adult respiratory distress syndrome,
disseminated intravascular coagulation,
hepatic failure
renal failure.
Resuscitation
Early Goal Directed Shock Therapy
Resuscitation
Treating Shock - Breathing
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Maximize oxygenation (Keep Sa02 > 93%)
Control the work of breathing. Respiratory muscles
are highly metabolic and can greatly increase
oxygen demand.
Treating Shock – Fluid Resuscitation
Resuscitation
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Most patients in shock have either an absolute or
relative volume deficit, except the patient in
cardiogenic shock with pulmonary edema
Central venous catheterization can guide help
guide via central venous pressure monitoring and
SVCO2 monitoring
A good bolus is a bold bolus!!
Massive trauma transfusion- more blood products/
crystalloids
Resuscitation
Treating Shock – Vasopressors
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Vasopressor agents are used when there has been
an inadequate response to volume resuscitation or
when a patient has contraindications to volume
infusion
Vasopressors are most effective after fluid
resuscitation but may be necessary to avoid
prolonged hypotension
Goal is generally a MAP of 65
Resuscitation
Treating Shock – Vasopressors
Resuscitation
Treating Shock – Endpoints
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No therapeutic end point is universally effective,
and only a few have been tested in prospective
trials, with mixed results.
Resuscitation
Treating Shock – Endpoints
Table 30-8 Hemodynamic Resuscitation End Points
Modality
Goals
CVP
10–12 mm Hg
PAOP
12–18 mm Hg
MAP
90–100 mm Hg
SVR = (MAP –
CVP/CO)(80)
800–1400 dyne s/cm5
CO
5.0 L/min
CI
2.5–4.5 L per min m2
SV = CO/heart rate
50–60 mL per min
Heart rate
60–100 bpm
Avoid >100 bpm; this will decrease SV
and
increase myocardial oxygen
consumption
Coronary perfusion
pressure
CPP = DBP – CVP (or
PAOP)
>60 mm Hg
Tissue oxygenation
ScvO2 or SmvO2
>70%
Serum lactate
<2mM/L
Preload
Afterload
Contractility
Resuscitation
Take Home Points
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The goal of resuscitation is to maximize survival
and minimize morbidity using objective
hemodynamic and physiologic values to guide
therapy.
The first few hours are vital.
Diagnose and treat the underlying cause!!!
Stay ahead of shock!!!!!!!