Management of Shock

1. Management of Shock Managing Complications in Pregnancy and Childbirth These presentation graphics are based on the guide Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors (2000) by the World Health Organization. These presentation graphics are based on the guide Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors (2000) by the World Health Organization.

2. 2 Management of Shock Session Objectives Best practices for management of shock Evidence for replacement fluids Best practices for use of blood/blood products

3. 3 Management of Shock Definition of Shock Failure of circulatory system to maintain adequate perfusion of vital organs LIFE THREATENING REQUIRES IMMEDIATE AND INTENSIVE TREATMENT

4. 4 Management of Shock When to Expect or Anticipate Shock Bleeding: Early pregnancy (e.g., abortion, ectopic pregnancy, molar pregnancy) Late pregnancy or labor (e.g., placenta previa, abruptio placenta, ruptured uterus) After childbirth (e.g., ruptured uterus, uterine atony) Infection (e.g., unsafe or septic abortion, amnionitis, metritis) Trauma (e.g., injury to uterus or bowel during abortion, ruptured uterus) There are different kinds of shock, including hemorrhagic and septic shock. In addition, there are many situations during pregnancy that can cause shock.There are different kinds of shock, including hemorrhagic and septic shock. In addition, there are many situations during pregnancy that can cause shock.

5. 5 Management of Shock Symptoms and Signs of Shock Fast, weak pulse (110 beats/min. or more) Low blood pressure (systolic less than 90 mm Hg) Pallor (inner eyelids, palms, around mouth) Sweatiness or cold clammy skin Rapid breathing (30 breaths/min. or more) Anxiousness, confusion, unconsciousness Low urine output (less than 30 mL/hour) Shock occurs in two stages. During the early stage, the pulse becomes faster first. Then, the circulatory system stops supplying blood to some organs, such as the skin, in order to maintain the blood supply to vital organs, such as the brain, lungs and kidneys. The woman may look pale or her skin may be cool and moist. In the late stage of shock, the body is unable to supply blood to the vital organs, so the patient may have low urine output or lose consciousness.Shock occurs in two stages. During the early stage, the pulse becomes faster first. Then, the circulatory system stops supplying blood to some organs, such as the skin, in order to maintain the blood supply to vital organs, such as the brain, lungs and kidneys. The woman may look pale or her skin may be cool and moist. In the late stage of shock, the body is unable to supply blood to the vital organs, so the patient may have low urine output or lose consciousness.

6. 6 Management of Shock Immediate Management of Shock Shout for help—mobilize personnel Monitor vital signs Position woman onto her side Keep woman warm Elevate legs Collect blood for testing It is important to be prepared and have supplies ready. To manage shock successfully, the support of other personnel is necessary. Get help. It is important to be prepared and have supplies ready. To manage shock successfully, the support of other personnel is necessary. Get help.

7. 7 Management of Shock Specific Management Start IV infusion (two if possible) Infuse fluids at a rate of 1 L in 15–20 min., then give at least 2 L of fluids in first hour If shock results from bleeding, more rapid infusion is necessary If peripheral vein cannot be cannulated, perform venous cutdown Monitor vital signs Catheterize bladder Give oxygen at 6–8 L/min. Blood work: Hemoglobin, cross-match Assess clotting status with bedside clotting test Manage specific cause Start by obtaining IV access to give fluids. Increasing the intravascular volume helps increase perfusion. Aggressive hydration is warranted. There are many disagreements about the best fluid for resuscitation. Only blood replaces intravascular volume 1 mL for every 1 mL infused. Crystalloid and colloid are less effective than blood, but of course, more widely available. While giving IV fluids, also give oxygen. Plan ahead because transfusion may be needed to further increase perfusion. Continually monitor the woman.Start by obtaining IV access to give fluids. Increasing the intravascular volume helps increase perfusion. Aggressive hydration is warranted. There are many disagreements about the best fluid for resuscitation. Only blood replaces intravascular volume 1 mL for every 1 mL infused. Crystalloid and colloid are less effective than blood, but of course, more widely available. While giving IV fluids, also give oxygen. Plan ahead because transfusion may be needed to further increase perfusion. Continually monitor the woman.

8. 8 Management of Shock Manage Specific Cause: Heavy Bleeding Stop bleeding (use oxytocics, uterine massage, bimanual compression, aortic compression, surgery) Give IV fluids Transfuse as soon as possible Manage cause of bleeding: First 22 weeks of pregnancy: Abortion, ectopic or molar pregnancy After 22 weeks or during labor but before childbirth: Placenta previa, abruptio placenta or ruptured uterus After childbirth: Ruptured uterus, uterine atony, genital tract tears, retained placenta or placental fragments Reassess condition In managing hemorrhagic shock, simply replenishing IV volume alone is inadequate. The source of the bleeding must be stopped. In managing hemorrhagic shock, simply replenishing IV volume alone is inadequate. The source of the bleeding must be stopped.

9. 9 Management of Shock Transfusion Risks of transfusion of whole blood or plasma: Transfusion reaction (skin rash to anaphylactic shock) Transmission of infectious agents (HIV, hepatitis B and C, syphilis, Chagas disease) Bacterial infection if blood is improperly manufactured or stored Risks increase with increase in volume transfused

10. 10 Management of Shock Transfusion Risks To minimize risk of transfusion: Effective donor selection Screening for infectious agents Quality assurance programs High quality blood grouping, compatibility testing, component separation, storage and transport Appropriate use of blood and blood products

11. 11 Management of Shock Principles of Clinical Transfusion Transfusion is only one element of managing woman Follow national guidelines for decision to transfuse, weighing: Risks and benefits for individual patient Expected degree of improvement Indications for transfusion Alternative fluids for resuscitation Ability to monitor patient If transfusion cannot be done safely, do not do it.If transfusion cannot be done safely, do not do it.

12. 12 Management of Shock Monitoring the Transfused Woman Monitor the woman before transfusion, at onset, 15 min. after start, every hour and at 4 hour intervals after completing the transfusion Monitor: General appearance Temperature Pulse Blood pressure Respiration Fluid balance Note volume infused, unique donation numbers, adverse effects

13. 13 Management of Shock Management of Transfusion Reaction Stop infusion Continue IV fluids Minor adverse effects: Give promethazine 10 mg by mouth

14. 14 Management of Shock Managing Prophylactic Shock from Mismatched Blood Transfusion Anaphylactic shock, give: Adrenaline 1:1000 solution 0.1 mL in 10 mL normal saline IV slowly Promethazine 10 mg IV Hydrocortisone 1 g IV every 2 hours as needed Aminophylline 250 mg in 10 mL normal saline IV slowly for bronchospasm Monitor renal, pulmonary and cardiac function Transfer to referral center when stable Document and report reaction

15. 15 Management of Shock Alternatives to Transfusion Solutions with similar concentrations to plasma: Crystalloid Colloid

16. 16 Management of Shock Prevention of Hemorrhagic Shock Minimize wastage of blood: Use best anesthesia and surgical technique to minimize blood loss at surgery Autotransfuse during procedures where appropriate Active management of third stage of labor Management of postpartum hemorrhage Being prepared is very important, but prevention is just as important. Minimizing blood loss, for example at surgery and during labor, and by acting quickly when postpartum hemorrhage occurs can reduce the risk of shock. Being prepared is very important, but prevention is just as important. Minimizing blood loss, for example at surgery and during labor, and by acting quickly when postpartum hemorrhage occurs can reduce the risk of shock.

17. 17 Management of Shock Manage Specific Cause: Infection If facilities available, collect samples of blood, urine, pus for culture Give antibiotics to cover aerobic and anaerobic infections until fever-free for 48 hours (DO NOT GIVE BY MOUTH): Penicillin G 2 million units OR ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours Reassess condition

18. 18 Management of Shock Manage Specific Cause: Trauma Prepare for surgical intervention

19. 19 Management of Shock Shock: Reassessment Reassess response within 30 min. to determine improvement Stabilizing pulse (rate of 90 beats/min. or less) Increasing blood pressure (systolic 100 mm Hg or greater) Improved mental status (less confusion or anxiety) Increasing urine output (30 mL/hour or more) If improving: Adjust IV infusion rate to 1 L in 6 hours Continue management for cause of shock If not improving or stabilizing, further management required

20. 20 Management of Shock Shock: Further Management Continue IV infusion at 1 L in 6 hours and oxygen at 6–8 L/min. Monitor closely Perform lab tests for hematocrit, blood grouping, Rh typing and cross-match If facilities available, check serum electrolytes, serum creatinine and blood pH