Hypovolemic Shock

Issues with Multiple Tansfusions

1) Severe allergic reactions 2) Development of antibodies to WBC, Platelets 3)Transfusion- related acute lung injury (Trail) - Pulm. Edema 4)Graft v host disease- in immune compromised pt— can be prevented by irradiation of all blood components

3 factors of Fluid management in Shock

1) identify and treat etiology 2) tx electrolyte and acid-base disturbances 3) assess volume deficit

6 things to monitor following fluid resuscitation response:

1) prevent/monitor for irreversible shock 2) prevent over resuscitation 3) Monitor for peripheral edema 4) Labs within 6 hours 5) Urinary Na within 24 hours of replacement 6) UO: 0.5-1 cc/kg/hr minimum

The need for Diuresis if a patient is suspected of being over resuscitated is dependent upon three things

1) the Need for supplemental oxygen 2) the presence of respiratory failure 3) lower extremity discomfort from edema

You suspect your patient is in hypovolemic shock when she exhibits what symptoms?

1)Cold, Clammy, sweaty, pale skin 2) Tachypnea, tachycardia 3) oliguria/anuria 4) weakness, anxiety, altered MS

Major classes of replacement fluids

1)Crystalloid solutions- *1st line TX for Non hemorrhagic shock* 2)Colloid solutions 3) Blood Products

Mass Transfusion Indicators- JTTS Guidelines 2020

1)SBP 90- but >110 2) HR > 105 3) Hct <32 4) pH <7.25 **if 3/4 conditions- consider fresh whole blood (FWB)**

6 Symptoms of Hemorrhagic Shock

1)T-Tachycardic 2)U-Unresponsive to IVF 3)U-Urine ouput < 50 ml/hr 4)T- Tachypnea 5)C-Cold and modeled Ext. 6)H- Hypotension **SBP 90 or less**

Evaluation of Hemorrhagic Shock

1)follow ATLS protocol 2) Radiological exams- Focused assessment with sonography for trauma (FAST), Ultrasound

Treatment goals for hypovolemia

1) Restore intravascular volume 2) Prevent organ Hypoperfusion 3) ID and TX underlying cause

What is the best measurement for estimating blood volume?

"There is no magic bullet for estimating blood volume"

Treatment of Hemorrhagic shock

**Use of blood products of crystalloids results in better outcomes -Balanced transfusions: 1:1:1/2 FFP: Plates: PRBCs -Anti-fibrinolytic administration for pts w/in 3 hours of traumatic injury (Amicar)

Whole Blood Considerations

- When possible type a patient before giving O or it may be impossible to establish blood type after transfusion begins. -Must be stored very cold (1-6 deg c) -8 hours at room temp -has 21 day shelf life

What is the Universal Plasma Donor Blood Type?

-**TYPE AB IS UNVERSAL DONOR** - In absence of type AB you can use Type A b/c it has low anti-b antigens

Classification of Hemorrhage: Stage 3:

-30-40% blood volume loss -Changes in perfusion to brain->Mental status changes -Considered severe hemorrhage

Total body fluid components

-60% weight for men, 50% women -75% of ECF is Interstitial -25% of ECF is Intravascular

Desmopressin (DDAVP)

-Causes the release of von willebrands antigen —> carries Vactor VIII—>initiates clotting cascade -Given for hemophelia A or Von Willebrand's Disease

factor eight inhibitor bypassing activity (FEIBA) MOA/Se

-Controls bleeding by inducing thrombin -Se: Stroke, PE, tachycardia

Hypovolemia

-Decreased hydrostatic Pressure r/t decreased Blood Volume —> Less capillary filtration -"Autotransfusion" from interstitium -> Increased Pc due to dehydration = Fluid Reabsorption

Vasopressin (Synthetic ADH)

-Decreases bleeding by reducing blood flow to the injured areas; has not demonstrated survival value

Aminocaproic Acid (Amicar)

-For acute bleeding; inhibits fibrin degradation

Iron Therapy

-For anemia esp. for military females -SE: Severe constipation

Classification of Hemorrhage: Stage 4:

-Greater than 40% blood loss -Hypotension -Narrow Pulse Pressure -Few survive

Colloids

-Include Albumin Solutions -considered after resus. With cyrstalloid -for Patients with Non-hemorrhagic shock = as good as colloids

Hypervolemia

-Increased Hydrostatic Pressure —> increased volume - Fluid exits vasculature, lymph system increases absorption -Net result: tissue Edema

Classification of Hemorrhage: Stage 1

-Less than 15% blood loss -No Change in BP -True Symptom: Anxiety*

**Tranexamic Acid (TXA)

-Mainstay of deployed care - Give SLOW IV Push b/c it can cause dramatic hypotension -1gm over 10 minutes

Octreocide: MoA, SE

-Mimics somatostatin reducing blood flow to portal system -Bradycardia, Hypotension, LONG QT interval

Vitamin K (phytonadione)

-Most common agent for use to counteract Coumadin (warfarin) SE: Flushing, hypotension, diaphoresis

Euvolemia

-Net flux of IVF @ arteriole->pushes fluid out -Negative Pc @ Venule -> fluid resabsorption -Net result= near equilibrium

Kcentra- MOA, Dosing

-Provides increased levels of vitamin K dependent coag factors -Reversal for Warfarin -Dose based on INR

Erythropoeitin

-Stimulates RBC production -Used weeks in advance for planned surgery

Goal in Tx of Hemorrhagic shock

-Stop the bleed** -Fresh whole blood or PRBC

Classification of Hemorrhage: Stage 2:

-Up to 1500 ml Blood Loss -Cold and clammy

Fluid resusicitation/repletion rate for hypovolemic shock

-individualized -model sepsis/septic shock -30 ml/kg IVF w/in 1 hour and completed in first 3 hours

Volume depletion (loss of Na and H2O) occurs from where?

1) Gi Loss- 100-200 ml in stool 2) Renal- avg. UO 1-2L /day 3) Skin - 1-2L/day in a hot, dry climate 4) 3rd Space Sequestration- loss of interstitial and intravascular fluid = Edema

Signs and symptoms of irreversible shock

1) HR/BP unstable 2)UO decreased 3) Poor Skin turgor, mucus membrane integrity 4) Mental status changes

Two factors that protect against development of hypovolemia

1) Na+ & H2O intake > needs 2) min. urinary loss by Renal resabsorption of Na and H2O

Fluid Maintenance Therapy

Administer: 100ml/kg for 1st 10kg 50ml/kg for next 10-20kg 20ml/kg for every kg greater than 20 OR: 20-40 ml/kg/day

Cause of Hemorrhagic Hypovolemic shock

Blood loss- trauma, surgical, ruptured etopic, hemorrhage etc

Indication for vasopressors in hypovolemia

Hypotension not reversed by fluid resuscitation Hypotension accompanied by cardiac dysfunction

When is a patient considered to be in Hypovolemic Shock?

Hypovolemia —> Inadequate tissue perfusion —> Organ dysfunction

Fluid loss reduces _____ volume and can lead to _______

ECF, Hypovolemia

Causes of Non-hemorrhagic Hypovolemic Shock

Excessive fluid losses from GI, Skin, Renal, 3rd spacing

Medications to stop bleeding and avoid blood transfusions

F-Factor 7, 8 A- Amicar T-TXA P-Prothrombin Complex O-Octreocide/Somatostatin D-DDAV V-Vasopressin K- Vitamin K

Hydrostatic pressure v Oncotic Pressure

In normal state, Hydrostatic pressure pushes fluid out, Oncotic pressure pulls it back in

A false increase in Hematocrit is the result of

Loss of free fluid—> intravascular space collapes, HCT is a ratio of RBC:Volume

LR: Na, Cl-, Osmolarity

Na: 130 Cl: 109 Osmol: 273 *LR is metabolized to BICARB*

Plasma: Na, Cl- and Osmolarity

Na: 135-145 Cl- 3.5-5.0 Osmol: 275-295

PlasmaLyte: Na, Cl, Osmolarity

Na: 140 Cl: 98 Osmol: 294. *Plasma lyte is closest to plasma concentrations = best

Normal Saline: Na, Cl- Osmolarity

Na: 154 Cl: 154 Osmol: 308 *contains more Cl than blood

Recommendations for hypotensive resuscitation in trauma

Recommended for hemorrhagic shock pt WITHOUT head trauma

Hypovolemic shock is the result of ______

Reduced intravascular volume

Over-resuscitation can cause...

Respiratory distress, Pulmonary Edema, CHF

3 types of crystalloid solutions

Saline LR (Buffered) Harmann's solution (Plasymolyte)

Delayed fluid resuscitation can lead to:

ischemic injury and irreversible shock with multi-organ-system failure

Most sensitive indicator of hypovolemia

Thirst! = 5% or more blood volume loss