Description
Haemodynamic instability refers to a state where a person's circulatory system is unable to maintain adequate blood flow and perfusion to vital organs, often resulting in a critical medical condition. This instability can manifest as low blood pressure, rapid heart rate, altered mental status, and organ dysfunction. Causes can range from severe infections, bleeding, heart failure, or traumatic injuries. Prompt evaluation, diagnosis, and intervention are crucial to address the underlying cause, stabilize the patient's haemodynamics, and prevent further deterioration, often involving interventions like fluid resuscitation, medications, or surgical procedures.
Summary Listen
- Hemodynamic instability is a critical care issue best understood through the concept of "shock," defined by an imbalance between oxygen supply and demand at the organ level, leading to organ dysfunction. Blood pressure readings alone are insufficient for diagnosis, as patients may present with normal or even high BP while still experiencing shock. The core of shock lies in impaired tissue perfusion.
- Various types of shock exist, including distributive (septic shock, anaphylaxis), hypovolemic (dehydration, hemorrhage), cardiogenic (heart failure), and obstructive (tension pneumothorax, pulmonary embolism). Mixed or undifferentiated shock presents diagnostic challenges. Clinicians should assess multiple "windows" into the body, including mental status, heart and respiratory rates, urine output, and skin condition.
- Diagnostic workups involve history taking, physical examination, lab tests (CBC, KFT, LFT, ABG), and radiology, including point-of-care ultrasound. Protocols like the Rapid Ultrasound in Shock (RUSH) exam help differentiate between pump, tank, and pipeline causes of shock. Monitoring techniques range from basic pulse oximetry and blood pressure to advanced invasive methods like arterial lines, CVP lines, and cardiac output monitoring.
- Fluid management in shock has evolved, now emphasizing fluid responsiveness and avoiding fluid overload. Techniques like pulse pressure variation (PPV), passive leg raising, and point-of-care ultrasound aid in determining fluid responsiveness. Resuscitation strategies include the R-O-S-E approach (Resuscitation, Optimization, Stabilization, Evacuation), aiming for a negative fluid balance in later stages.
- Specific shock types require tailored management. Cardiogenic shock management involves inotropic support, optimized fluid management, and mechanical support (IABP, ECMO). Septic shock requires early antibiotic administration within one hour of presentation, alongside fluid resuscitation and vasopressor support. Other considerations include blood product transfusion and electrolyte maintenance.
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About the Speakers
Dr. Munish Chauhan
Senior Consultant, Critical Care Medicine, Fortis Memorial Research Institute, Gurgaon
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