How useful and sensitive are clinical
findings in the diagnosis of shock?
Sergio Zanotti MD
Assistant Professor of Medicine
Robert Wood Johnson Medical School
Cooper University Hospital
Camden, New Jersey
How useful and sensitive are clinical
findings in the diagnosis of shock?
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Introduction
Methods
How useful?
How sensitive?
Conclusions
Introduction
Shock represents the failure of the
circulatory systems to maintain adequate
delivery of oxygen and other nutrients to
tissues.
Classification of Shock
Hypovolemic Cardiogenic
SVR
CO
PAOP
(hemorrhage)
(myocardial
infarction)
Obstructive
Distributive
(pulmonary
embolism)
(septic shock)
Methods
 Medline: January 1966 to April 2006
 Key Words: Shock, clinical findings, physical
exam, examination, diagnosis, blood
pressure, capillary refill, temperature,
sensitivity, hypovolemia, sepsis, cardiogenic.
 Based on review of titles and abstracts
relevant articles were retrieved
 Bibliographies of articles and of physical
diagnosis or shock articles/textbooks
Are clinical findings
useful in the diagnosis of
Shock?
Clinical Findings







Hypotension
Tachycardia
Altered mental status
Delayed capillary refill
Decreased urine output
Cool skin
Cold extremities
Blood pressure measurements in Shock.
J. Cohn. JAMA 1967; 199:972.
 Patients with hypotension or clinical diagnosis
of shock.
 If vasopressors were started, they were
discontinued and BP was allowed to stabilize.
 BP measures;
 Directly: Femoral or radial artery cannulation
 Indirectly: By auscultation/palpation method.
 CO measured by indirect dilution method.
 PVR was calculated.
Differences between direct and
indirect BP measurements
 SBP 33.1 mm Hg (+169 to –20)
 Direct pulse pressure 43 mm Hg
 Indirect pulse pressure 19 mm Hg
J. Cohn. JAMA 1967; 199:972.
Blood Pressure Measurement in Shock
Pressure
(mm Hg)
High
PVR
Cuff
Low
PVR
Arterial
Cuff
Arterial
120
100
80
60
40
20
J. Cohn. JAMA 1967; 199:972.
Clinical parameters for estimating
severity of circulatory shock
Stage
BP
HR
CR
(2min)
Urine
ml/h
Mental
Status
%
Loss
1
Normal
Normal
<2
>39
Normal or
anxious
< 15
2
Tilt +
> 100
>2
20
Anxious
> 20
3
> 120
>2
5 – 15
Confused
> 30
4
> 140
>2
0–5
Lethargic
> 40
Weil, MH . Defining Hemodynamic Instability.
Functional Hemodynamic Monitoring 2005 Springer.
Capillary Refill: What is normal?
Patient
Group
Median
False / +
Rate
Upper Limit
(95 % CI)
Y Fem.
0.7 sec
4.0%
Y Male
0.8 sec
4.0%
A Male
1.0 sec
4.0%
A Fem.
1.2 sec
13.7%
2.9 sec
E Male
1.5 sec
29.0%
4.5 sec
E Fem.
1.8 sec
29.0%
4.5 sec
Schriger DL. Ann Emerg Med 1998; 17:932
Capillary Refill – Is it a Useful Predictor of
Hypovolemic States?
Schriger. Ann Emerg Med 1991; 20:601
 Design: prospective, nonrandomized study.
 Patients:
 (1) ED patients with history of hypovolemia + one:
 orthostatic vital signs (n 19)
 hypotension (n 13)
 (2) Blood donors (n 47)
 Intervention: capillary refill measurement.
Capillary Refill Times
Mean (sec)
SD
Range
Before
1.9
0.7
0.6 – 3.7
After
1.1
0.7
0.9 – 4.0
Orthostatic
1.9
0.7
0.8 – 3.3
Hypotension
2.8
1.2
1.1 – 5.1
Total
2.2
1.0
0.8 – 5.1
Blood donors
Clinical pts.
Schriger. Ann Emerg Med 1991; 20:601
Capillary refill in hypovolemia
Two-Second
Adjusted
Sens.
Spec.
Sens.
Spec.
450 ml blood
loss
11%
89%
6%
93%
Orthostatic
47%
86%
26%
95%
Hypotension
77%
86%
46%
95%
Total
59%
86%
34%
95%
Schriger. Ann Emerg Med 1991; 20:601
Capillary refill in hypovolemia
Probability of
Hypovolemia
10%
Accuracy
PPV
NPV
89%
43%
93%
25%
80%
69%
81%
50%
64%
87%
59%
90%
40%
98%
14%
Schriger. Ann Emerg Med 1991; 20:601
Toe Temperature
Ibsen B. Treatment of shock with vasodilators measuring skin
temperature on the big toe. Dis Chest, 1967. 52:425.
Joly, H.R. and M.H. Weil, Temperature of the great toe as an
indication of the severity of shock. Circulation, 1969. 39(1); p. 131-8.
Henning, R.J.,et al., Measurement of toe temperature for assessing
the severity of acute circulatory failure. Surg Gynecol Obstet, 1979.
149(1); p. 1-7.
Correlation between CI and
Toe Temperature
4
L/min/m2
Cardiac Index
r = 0.71
2
CI= - 5.24 + T toe (0.286)
0
24
28
32
36
TOE TEMPERATURE °C
Joly HR. Weil MH. Circulation 1969
Cº TOE-AMBIENT
AMI
Bacteremia
10
10
Cº 5
Cº 5
0
0
Adm.
Max.
Pre-DC
Adm.
Max.
Pre-DC
Hypovolemia
10
Survivors
Cº 5
Fatalities
0
Adm.
Max.
Pre-DC
Henning RJ. Et al. Surg Gynecol Obstet.1979;149:1-7
Toe temperature versus transcutaneous
oxygen tension monitoring during acute
circulatory failure.
Vincent JL. Intensive Care Med 1988; 14:64
• Cardiogenic Shock
 Toe-ambient T gradient: strong correlation
with CI, stroke index, oxygen transport.
 Toe-ambient T gradient > PTCO2
• Septic Shock
 Both techniques were poor indicators of
blood flow indexes
Start with a subjective assessment of skin
temperature to identify hypoperfusion in ICU
patients. Kaplan CJ, et al. J Trauma 2001; 50:620-28
• Objective: Determine whether physical
examination alone or with biochemical
markers can accurately dx hypoperfusion.
• Design: retrospective data collection (n 264)
• Two groups:
 Cool skin temperature [CST]
 Warm skin temperature [WST]
Hemodynamic and Biochemical Parameters
Value
Cardiac output
(L/min)
Cardiac index
(L/min/m2)
pH
Cool
Warm
p
5.3 ± 2.2
8.2 ± 2.6
< 0.05
2.9 ± 1.2
4.3 ± 1.2
< 0.05
7.32 ± 0.2
7.39 ± 0.07 < 0.05
TCO2 (mEq/dL)
19.5 ± 3.1
25.1 ± 4.8 < 0.05
Svo2 (%)
60.2 ± 4.4
68.2 ± 7.8 < 0.05
Lactate (mmol/L)
4.7 ± 1.5
2.2 ± 1.6
< 0.05
Kaplan CJ, et al. J Trauma 2001
Temperature
• All patients: Cool extremity
PPV 39 %
NPV 92 %
• CST group + HCO3 < 21 meg/dL
PPV 98 %
NPV 97 %
• Sepsis + cool extremity
PPV 51.3 % NPV 88.9 %
• Sepsis + cool extremity + low HCO3
PPV 68 %
NPV 90 %
Kaplan CJ, et al. J Trauma 2001
Are clinical findings
sensitive in the diagnosis of
Shock?
How good are our clinical skills?
Connors
Eisenberg
Bayliss
(NEJM ‘83)
(CCM ‘84)
(BMJ ‘83)
ICU pts
ICU pts
CCU pts
Cardiac output
44%
50%
71%
Wedge pressure
42%
33%
62%
Diagnostic Accuracy of SBP < 95 mm Hg
for Acute Blood Loss
Source, year
Moderate BL
Large BL
Before BL
Sensitivity
(95 % CI)
Sensitivity
(95 % CI)
Specificity
(95 % CI)
Warren, 1945
13
…
100
Shenkin, 1944
…
36
100
Wallace, 1941
…
32
96
Skillman, 1967
…
56
100
Bergenwalkd, 1977
…
13
…
Summary measure ‡
13 (0-50)
33 (21-47)
97 (90-100)
McGee S. JAMA 1999; 281:1022
What can we learn from shock
clinical trials?
• Cardiogenic Shock
• Septic Shock
• Obstructive Shock
Clinical Profile of Suspected
Cardiogenic Shock
• Report from SHOCK trial registry
• 28% of patients with shock had no
pulmonary congestion.
• Mortality for these patients was 70%
Menon V. et al. J Am Coll Cardiol 2000; 36:1071.
Early Goal-Directed Therapy for
Severe Sepsis and Septic Shock
Rivers et al. N Engl J Med 2001;345:1368-77
Severe Sepsis +
↓Blood Pressure or
↑Lactic acid
Standard (n 133)
EGDT (n 130)
Mortality 46.5%
Mortality 30.5%
Sepsis
+ MAP > 100 mmHg
+ Lactate > 4 mmol/L
Control
EGDT
(n 23)
(n 25)
MAP (mmHg)
116
118
ScVO2
45 %
44 %
Mortality
61 %
20 %
Donnino, MW et al. CHEST 2003; 124:90S.
Outcomes in Pulmonary Embolism
100 %
Sudden Death
70 %
Cardiac Arrest
Mortality
Shock
30 %
10 %
0%
Severity
Embolism Size
Wood KE. CHEST 2002
Cardiopulmonary
Status
Clinical Outcome of Patients With
Acute Pulmonary Embolism.
• 31% normotensive with RV dysfunction
10% developed PE related shock
Higher mortality than normotensive group
Grifoni S, et al. Circulation 2000;101:2817
Conclusions
• Rigorous conclusions about the value
of clinical findings in the diagnosis of
shock are difficult to make because
there are very few studies on this
matter.
Useful?
Yes.
Sensitive?
No.
“the nose sharp, the eyes
sunken, the temples fallen in,
the ears cold and drawn in and
their lobes distorted, the skin of
the face hard, stretched, and
dry, and the color of the face
pale or dusky”
Hippocrates, 400 BC