MDSO - SHOCK STATES

Question 1

Push Epi

Mix, Dose, Patch

Answer 1

5-20 mcg q 2-5 min PRN

1 mL of Cardiac Epi + 9 mL of NS = 10mcg/mL
- 1:10 000 = 1g in 10 000 mL = 1000 000 mcg / 10 000 mL = 100mcg/mL - - > take 1 mL + 9 NS = 10 mcg/mL

Or 1 mg (1mg/1mL - 1:1000)in 100 mL = 10 mcg/mL
- 1mg/100mL —-> 1000mcg/100mL—->10mcg/mL

Question 2

HYPOVOLEMIC SHOCK

Fluids, Drugs, Conditions, PATCH

Answer 2

1) NS - 20mL/kg - MAX 1 L - IP - Target > 65…can repeat to target
- at 50 kg x 20 = 1000mL - - - so easy enough to say, drop a 1 L, then reassess.

2) NE 0 - 0.5 mcg/kg/min

IF HEMORRHAGIC….

3) If blood loss consider 1:1:1 (PRBC: FFP : Platelets) first (if possible) ,but can do 20cc/kg. - MP FOR BKLOOD, TARGET HG 70

**also consider TXA 1g> 10 min in hemorrhagic shock
**if hemorrhagic - consider reversal - - ie Octaplex if on WarfaRIN AND INR> 1.5, OR OTHER MEDS THAT NEED REVERSAL.
** be careful of not too much crystalloid to not dilute IF concerned about bleed.

Question 3

MDSO: Clinical Guidelines: SEPSIS:

Criteria for Dx Sepsis:
Criteria for Dx of Septic Shock:

Answer 3

SEPSIS “Suspected or Documented Infection with SOFA >2”

SEPTIC SHOCK: “ persistent hypotension requiring vasopressor to maintain MAP > 65 and Lactate > 2; despite adequate volume resuscitation”

Question 4

Surviving Sepsis Guidelines:

Key Features:

Answer 4

Document Lactate, if not available, ETCO2 (will be lower because of lower HCO3, compensation for Lactate/Lactic Metabolic Acidosis - - this assumes Resp drive is not suppressed…..)

Try to get Blood Cultures before giving ABX

Give broad spectrum ABX

Give AT LEAST 30cc/kg if hypotension and/or Lactate > 4
- - can use NS or RL, but large volumes of NS - - risk of Hyperchloremic Metabolic Acidosis
— Hypotension = SBP < 90 or MAP < 65 ….or drop of > 40 SBP from baseline if normally Hypertensive.
- put in fluids fast - use pressure bags, pumps limited to less than 1200 mL/hr not fast enough
—Min 2 large bore IV, consider IO if needed.

Add Vasopressor - NE 1st, EPI if high NE not enough… or when Poor Cardiac Contractility (RV or LV) is suspected.

Then Consider Vasopressin

Can consider Dopamine as 2nd or 3rd Vasopressor , particularly if Bradycardic

Ideally have a CVL will be added

Failure to increase BP after all this….add the following:
- Ca++ if TCa <2.2 or iCa < 1.0
-Corticosteroids (w suspected adrenal insufficiency , chronic steroids, hypotension refractory to fluids and vasopressors)
-If Hg < 70, consider transfusion to increase O2 delivery
-Add potentially an Inotrope : DOBUtamine (or EPI or DOPAMINE)

Treat other potential causes of Hypotension:
- ie cardiogenic, hemorrhagic, obstructive (tamponade . PE. Tension Pneumo)

Reassess Lactate q 1-2 hrs - document - looking for > 10% decrease

Question 5

MDSO: Septic Shock

Meds, Conditions, Targets, Doses, Patch

Answer 5

1) NS/ RL @ 30 mL/kg - target MAP> 65 - no patch

2) NE 0-0.5 mcg/kg/min - target MAP > 65 - IP

3) VASOPRESSIN. 0 - 0.04 u/min (2.4 u/hr) - target MAP> 65 - MP

4) EPI 0-0.5 mcg/kg/min - target MAP > 65 - MP

5) Hydrocortisone - 100 mg IV/IO - MP (or if not available 125 mg Methylprednisoline IV.IO)

** 1 g CaCl in 100 NS > 1 hr if Ca < 1 or Ca < 2.0
**if pre-arrest - patch for EPI PUSH and NE min at 0.3 mcg/kg/min

Question 6

MDSO: Septic Shock: Flowchart - extras

Answer 6

• Early ABX
• Consider ETT if needed BUT resuscitation first, prefer Ketamine and Fent - on vent ? ARDS ? - use ARDS setting

Question 7

MDSO Extravasation

For which drugs ? What do we use ? Dose ? Patch? Timeline?

Answer 7

Used for extravasation of : NE, EPI, DOPAMINE, DOBUTAMINE, VASOPRESSIN or PHENYLEPHRINE

Tx: Phentolamine
When: within 12 hrs of extravasation
Dose: 0.1 mg/kg to max 10 mg in 9 ml NS
How - half through the IV line in question over 60 sec.
- half Sub Q around area using 25g or 30 g needle at tissue that is discoloured or swelling
RISK: may cause hypotension