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Bedside clinical and ultrasound-based approaches to the management of hemodynamic instability - Part I: focus on the clinical approach: Continuing Professional Development

  • André Denault
  • Annette Vegas
  • Colin Royse
Continuing Professional Development

Abstract

Shock is defined as a situation where oxygen transport is inadequate to meet the body’s oxygen demand. An understanding of the mechanism(s) of reduced cardiac output, a determinant of oxygen transport, is crucial in order to initiate appropriate therapy to manage shock. Combining the concept of venous return with the ventricular pressure-volume relationship is a useful method to appreciate the complex circulatory physiology of shock. Clues from the patient’s history, physical examination, and key laboratory tests, along with the careful inspection of hemodynamic, electrocardiographic and respiratory waveforms can help with the identification of the etiology and mechanism(s) of shock. Following verification of the arterial pressure, general resuscitation can begin, and more specific treatment can be undertaken to manage shock. If the patient is unresponsive to these measures, bedside ultrasound can then be performed to ascertain more detail regarding the mechanism(s) and etiology of shock.

Purpose

To develop an approach to the management of the hemodynamically unstable patient.

Principal finding

Not applicable.

Conclusion

Not applicable.

Approches cliniques et échographiques au chevet du patient pour la gestion de l’instabilité hémodynamique - Partie 1: L’approche clinique

Résumé

Le choc est défini comme étant une situation où le transport de l’oxygène est insuffisant pour répondre aux besoins en oxygène de l’organisme. La compréhension des mécanismes entraînant la baisse du débit cardiaque, un déterminant du transport de l’oxygène, est essentielle pour initier une thérapie adaptée à la gestion du choc. La combinaison du concept de retour veineux avec le rapport pression-volume ventriculaire est une méthode utile pour apprécier la physiologie circulatoire complexe au cours du choc. Des indices fournis par les antécédents du patient, l’examen physique et des tests de laboratoire essentiels, ainsi que par l’inspection soigneuse des tracés hémodynamiques, électrocardiographiques et respiratoires, peuvent aider à identifier l’étiologie et le ou les mécanismes du choc. Une réanimation générale peut commencer après avoir vérifié la pression artérielle à plus d’un site, puis un traitement plus spécifique peut être entrepris pour gérer le choc. Si le patient ne répond pas à ces mesures, un examen échographique peut alors être réalisé pour déterminer plus précisément le ou les mécanismes et l’étiologie du choc.

Objectif

Développer une méthode d’approche pour la gestion d’un patient hémodynamiquement instable.

Notes

Acknowledgements

The authors sincerely thank France Thériault and Denis Babin for their help in the completion of the manuscript.

Funding sources

Montreal Heart Institute Foundation.

Remerciements

L’auteur remercie sincèrement France Thériault et Denis Babin pour leur contribution à l’achèvement du manuscrit.

Sources de financement

Fondation de l’Institut de cardiologie de Montréal.

Conflits d’intérêts

Aucun déclaré.

Supplementary material

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Note that references 35 to 42 are cited in the Clinical Case Question and Answers section of the CPD module that is available to CJA subscribers at http://www.cas.ca/Members/CPDOnline.

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Copyright information

© Canadian Anesthesiologists' Society 2014

Authors and Affiliations

  1. 1.Department of Anesthesiology, Critical Care Division, Montreal Heart InstituteUniversité de MontréalMontrealCanada
  2. 2.Department of Anesthesiology, Toronto General HospitalUniversity of TorontoTorontoCanada
  3. 3.Department of SurgeryThe University of MelbourneParkvilleAustralia
  4. 4.Critical Care Division, Department of MedicineCentre Hospitalier de l’Université de MontréalMontrealCanada

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