Obstructive Shock, from Diagnosis to Treatment

Shock is a life threatening pathological condition characterized by inadequate tissue oxygen supply. Four different subgroups of shock have been proposed according to the mechanism causing the shock. Of these, obstructive shock is characterized by reduction in cardiac output due to noncardiac diseases. The most recognized causes include pulmonary embolism, tension pneumothorax, pericardial tamponade and aortic dissection. Since obstructive shock typically cannot be stabilized unless cause for shock is resolved, diagnosis of the underlying disease is eminent. In this review, we therefore focus on diagnosis of obstructive shock and suggest a structured approach in three steps including clinical examination, ultrasound examination using the rapid ultrasound in shock (RUSH) protocol and radiological imaging if needed.

European Resuscitation Council Guidelines 2021: First aid

The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.

Fluid Response Evaluation in Sepsis Hypotension and Shock: A Randomized Clinical Trial

BACKGROUND

Fluid and vasopressor management in septic shock remains controversial. In this randomized controlled trial, we evaluated the efficacy of dynamic measures (stroke volume change during passive leg raise) to guide resuscitation and improve patient outcome.

RESEARCH QUESTION

Will resuscitation that is guided by dynamic assessments of fluid responsiveness in patients with septic shock improve patient outcomes?

STUDY DESIGN AND METHODS

We conducted a prospective, multicenter, randomized clinical trial at 13 hospitals in the United States and United Kingdom. Patients presented to EDs with sepsis that was associated hypotension and anticipated ICU admission. Intervention arm patients were assessed for fluid responsiveness before clinically driven fluid bolus or increase in vasopressors occurred. The protocol included reassessment and therapy as indicated by the passive leg raise result. The control arm received usual care. The primary clinical outcome was positive fluid balance at 72 hours or ICU discharge, whichever occurred first.

RESULTS

In modified intent-to-treat analysis that included 83 intervention and 41 usual care eligible patients, fluid balance at 72 hours or ICU discharge was significantly lower (-1.37 L favoring the intervention arm; 0.65 ± 2.85 L intervention arm vs 2.02 ± 3.44 L usual care arm; P = .021. Fewer patients required renal replacement therapy (5.1% vs 17.5%; P = .04) or mechanical ventilation (17.7% vs 34.1%; P = .04) in the intervention arm compared with usual care. In the all-randomized intent-to-treat population (102 intervention, 48 usual care), there were no significant differences in safety signals.

INTERPRETATION

Physiologically informed fluid and vasopressor resuscitation with the use of the passive leg raise-induced stroke volume change to guide management of septic shock is safe and demonstrated lower net fluid balance and reductions in the risk of renal and respiratory failure. Dynamic assessments to guide fluid administration may improve outcomes for patients with septic shock compared with usual care.

CLINICAL TRIAL REGISTRATION

NCT02837731.