Post on 31-May-2015
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Initial ResuscitationIn
Surgical Emergency By
Dr. SUTHEE INTHARACHAT
Emergency Physician
Surgical Conditions
• Trauma conditions
-Airways
-Breathing
-Circulation
-Disability
-Environments/Exposure
• Non-Trauma conditions-ABCDE
Combat Casualty Care
• Care under fire
-CAB
• Tactical field care
-ABCDE
• Tactical evacuation
-ABCDE
Open Airway Methods
Jaw thrust
Head tilt chin lift
Airway equipments
Non Definitive Airways Definitve Airways
Laryngeal Tube
Needle &Surgical Cricothyroidotomy
Life threatening condition • Tension pneumothorax
• Opened pneumothrax
• Pneumohemothorax
Needle Chest Decompression
Equipments
Open pneumothorax
Bolin Chest Seal
Asherman Chest Seal
Massive Hemothorax
PARADOXICAL RESPIRATIONS
Shock
• 1937 : Henri Francis LC Dran “ Choc”
• 1734 : Clarke “ Shock ”
Classified Shock
-Obstructive shock
-Hypovolemic shock
-Inflamatory shock
-Neurogenic shock
-Cardiogenic shock
Historical Background
Claude Bernard, 1879
• Milieu interieur
Historical Background
Walter B. Cannon, 1918
• World War I
• “Toxic factor”
• “ Restoration of blood pressure prior to control of active bleeding may result in loss of blood that is sorely needed.”
Historical Background
Alfred Blalock, 1934
• Reduce cardiac output due to volume loss, not a “toxic factor”
Categories of shock
• Hypovolemic shock
• Vasogenic shock
• Neurogenic shock
• Cardiogenic shock
Hemorrhagic Shock Model
Carl J. Wiggers
1. Cardiovascular response
2. Hormonal response
3. Microcirculatory response
Pathophysiology in Hemorrhagic Shock
Pathophysiology: Cardiovascular/Hormonal
Baroreceptor reflex JGA
Renin-angiotensin system
Aldosterone
ECF osmolarity
AVP/ADH
End organ perfusion
NE/E
Osmoreceptor
Hypotension
Na reabsorption+inotropism
+chronotropism
Water reabsorption
Pathophysiology: OverviewSympatico-Adrenergic Reaction Central Venous Pressure
Vascular System
Vasoconstriction Hypotension
TISSUE PERFUSION
DO2 VO2
Anaerobic metabolism Tissue acidosis
Oxygen Free Radicals NO
Capillary Leakage
Heart
Contractility Tachycardia
Cardiac VO2
Pump Failure
Coagulopathy
Coagulation Factor
Platelets
Consumption Loss
DIC Fribinolysis
MULTIPLE ORGAN DYSFUNCTION SYNDROME
Immune System
Innate immunity
Adaptive immunity
Hyperinflammation
Immunosupression BloodyVicious cycle
HYPOTHERMIA
Major Torso Trauma
Iatrogenicfactor
Cellularshock
Tissueinjury
Pre-existingdiseases
Clotting factordeficiencies
Contact activation
Active hemorrhage
Metabolicacidosis
Progressivecoagulopathy
Corehypothermia
Massivetransfusion
Pathophysiology: Microcirculation
• Decreased capillary hydrostatic pressure
• Extracellular fluid shift
G. Tom Shires
Pathophysiology: Microcirculation
• ATP depletion
• Down regulation of membrane Na+-K+ ATPase
• Na+ in
• K+ out
• Water in
• Intracellular Ca++
• Cell death
Pathophysiology: Microcirculation
No-reflow
Cellular Effects: Anaerobic Glycolysis
Cellular Effects: Apoptosis
• Ischemic-reperfusion injury
• Intestinal mucosal cell– Bacterial translocation
• Lymphocyte apoptosis– Immunosuppression
Inflammatory Response
การประเมินความรุนแรงการเสียเลอืดผู้ป่วยอุบัติเหตุ
Class I Class II Class III Class IV
ปริมาณเลือดท่ีเสีย <750 750-1,500 1,500-2,000 >2,000
ปริมาณเลือดท่ีเสีย (%)
<15% 15% – 30% 30% - 40% >40%
ชีพจร <100 > 100 >120 >140
ความดันโลหิต ปกติ ปกติ ลดลง ลดลงPulse pressure ปกติ ลดลง ลดลง ลดลง
อัตราการหายใจ 14-20 20-30 30-40 >35
ปัสสาวะ(ml/hr) >30 20-30 5-15 เล็กน้อย
CNS กระสับกระส่ายน้อยมาก
กระสับกระส่ายเล็กนอ้ย กระสับกระส่าย/ สับสน สับสน / ซึม
ATLS
Symptom/SignMild Dehydration
< 5%
Moderate
5-10%
Severe Dehydration
>10%
LOC Alert Lethargic Obtunded
Capillary refill* 2 Seconds 2-4 Seconds > 4 seconds, cool limbs
Mucous Normal Dry Parched, cracked
Heart rate Normal Increased Very increased
Blood pressure NormalNormal, but
orthostasisDecreased
Pulse Normal Thready Faint or impalpable
Skin turgor Normal Slow Tenting
Eyes Normal Sunken Very sunken
Urine output Normal Oliguria Oliguria/anuria
Axillary sweat Normal Decrease Absent
Urine spec. </= 1.020 >/=1.030 >/=1.035
BUN Normal Elevated Markedly elevated
Arterial pH. 7.30-7.40 7.10-7.30 <7.10
Clinical Findings of Dehydration in Adult
Rosen ed6.
Symptom/Sign Mild DehydrationModerate
DehydrationSevere Dehydration
Level of
consciousness*Alert Lethargic Obtunded
Capillary refill* 2 Seconds 2-4 SecondsGreater than 4 seconds,
cool limbs
Mucous Normal Dry Parched, cracked
Tears* Normal Decreased Absent
Skin turgor Normal Slow Tenting
Fontanel Normal Depressed Sunken
Eyes Normal Sunken Very sunken
Urine output Decreased Oliguria Oliguria/anuria
Heart rate Slight increase Increased Very increased
Respiratory rate Normal IncreasedIncreased and
hyperpnea
Blood pressure NormalNormal, but
orthostasisDecreased
Pulse Normal Thready Faint or impalpable
Clinical Findings of Dehydration in Pediatric
SeverityInfants (weight <10
kg)
Children (weight
>10 kg)
Mild dehydration 5% or 50 mL/kg 3% or 30 mL/kg
Moderate
dehydration10% or 100 mL/kg 6% or 60 mL/kg
Severe dehydration 15% or 150 mL/kg 9% or 90 mL/kg
Estimated Fluid Deficit in Pediatrics
Rosen ed.6
STOP BLEEDING
1. ชนิด และ ขนาด
Flow dynamics
• Poiseuille law :
¶ x R x pressure gradient Rate of flow =
8 x dynamic fluid viscosity
4
Temperature
Catheter length
Needle size Diameter
(mm)
Flow rate (ml/min)
16 1.70 210
18 1.30 100
20 1.10 65
22 0.9 38
24 0.70 24
ต าแหน่ง
1.Peripheral
Intraosseous
Evolution of Fluid Resuscitation
1831: 1st Cholera pandemic •William Brooke O’Shaughnessy•Injection of high oxygenated salt into the venous system
•0.5-1% NaCl: Indifferent solution
Evolution of Fluid Resuscitation
1892 Spencer “normal saline”
1896 Hartog Jakob Hamburger
• 0.92% saline was normal
• Isotonic to human serum
1883 Sydney Ringer•0.75%saline in pipe water for frog heart
Evolution of Fluid Resuscitation
1932 Alexis Hartmann
• Add sodium lactate to Ringer’s solution
• Hartmann’s solution
• Lactated Ringer’s solution
Ideal Resuscitation Fluid
The ideal resuscitation fluid would have to have the properties of an elixir of life: a small-volume cocktail that among its virtues improves perfusion, enhances oxygen (O2) delivery and diffusion, provides adequate metabolic substrates, neutralizes toxic molecules released as a result of tissue injury, provides antimicrobial activity, renders the recipient globally less vulnerable to the effects of hemorrhagic shock, and has prolonged beneficial effects. The solution should further be stable for lengthy periods at a variety of temperatures, be easy to prepare and administer, and, if not inexpensive, be at least affordable
Characteristic of Resuscitation Fluids
Characteristic of Resuscitation Fluids
Crystalloids: 0.9% Saline
• 9 g sodium chloride in 1 L water
• Osmolarity 308 mOsm/L
• pH 5
• Na 154 mEq/L, Cl 154 mEq/l
“Abnormal saline”
• Fluid retention
• Hyperchloremic metabolic acidosis
• Activation of neutrophils
Crystalloids: Lactated Ringer’s Solution
• 6 g sodium chloride + 3.22 g sodium lactate (racemic: D- and L-lactate) + 400 mg potassium chloride + 270 mg calcium chloride in 1 L water
• Osmolarity 275 mOsm/L• pH 6.5• Vietnam conflicts: DaNang lung, shock lung,
Traumatic wet lung…ARDS• Neutrophils activation• Increase ICAM-1• Increase expression of Bax
Crystalloids: Hypertonic Saline
• De Felippe et al.1980; Velasco et al.,1980
• 7.5% sodium chloride
• Osmolarity 2567
• Small volume: Infusion of 250 mL, plasma volume expansion 1000 mL
• Protect microcirculation
• Immunologic protection
• Kramer 1986: 7.5% saline with 6% Dextran 70 (Hypertonic saline-dextran, HSD)
Resuscitation Outcome Consortium (ROC)
• Sponsored by NIH and USDD
• HSD: HTS: NSS Resuscitation in
1. Survival in blunt/penetrating trauma
2. Long term neurologic status after STBI
Crystalloids: Hypertonic Saline
Colloids: Conclusion
• Cochrane Injuries Group Albumin Reviewers, CIGAR 1998: RR of death with albumin was 1.68
• CIGAR 2004: Fail to show benefit of colloid over crystalloid
• Cochrane 2008: no evidence that one crystalloid was safer than another, and because no reduction in risk for death was evident in critically ill patients, continued use of these agents in these patients could not be justified outside the setting of RCT
Martin K Angele et al, Critical Care 2008;12(4)
Ideal Resuscitation Fluid
The ideal resuscitation fluid would have to have the properties of an elixir of life: a small-volume cocktail that among its virtues improves perfusion, enhances oxygen (O2) delivery and diffusion, provides adequate metabolic substrates, neutralizes toxic molecules released as a result of tissue injury, provides antimicrobial activity, renders the recipient globally less vulnerable to the effects of hemorrhagic shock, and has prolonged beneficial effects. The solution should further be stable for lengthy periods at a variety of temperatures, be easy to prepare and administer, and, if not inexpensive, be at least affordable
Still on there way
Crystalloid Colloid
intravascular compartment
สั้น นาน
ปริมาณทีใ่ช้ มากกว่า 3 เท่า น้อย
การเกิดเนื้อเยื่อบวมน้ า มาก น้อย
ราคา ถูก แพง
การหามาใช้ ง่าย ต้องจดัหา
ผลข้างเคียง น้อย มากกว่า เช่น รบกวนการแข็งตัวของเลือด , RF
Oxygen carrying resuscitation fluids
• Hemoglobin-based oxygen carriers
• Flurocarbon-based oxygen carriers
Blood transfusion
• Fully crossmathed –> 1 hr or more
• Type specific –> 10-15 min
• Type O low titer Rh +/-
Stored blood ไม่ดีเท่า fresh blood เพราะ: reduced oxygen carrying capacity (2,3-DPG): platelets are inactive: clotting factors may be degraded
• Autotransfusion:
: directly anticoagulated and reinfused into the patients using a macroaggregate filter.
: use of a cell-saver and provision of washed RBCs.
• Massive transfusion:
: Transfusion of at least one blood volume or 10 units of blood in a 24 hr
Whole blood:
• ประกอบด้วย colloids (plasma proteins), clotting factors including platelets, red blood cells for oxygen carrying capacity
• Indications: acute blood loss, concurrent anemia and hypoproteinemia, clotting defects
• Dose 5 – 15 ml/kg/hr and 40-60 ml/kg/hr ( life-threatening emergency. )
Packed red blood cells:
• 1 U Hct 3% ให้ใน 2-3 ชั่วโมง
• เด็ก 10-15 ml/kg
• Indication : 1. Anemia Hb < 7 g/dl
2. O2 carrying capacity
• Leukoreduction, • ข้อดี Alloimmunization and febrile
transfusion reactions.
• CMV transmission.
• Indication :– Chronically transfused patients
– Potential transplant recipients
– Patients with previous febrile nonhemolytic transfusion reactions
– CMV seronegative at-risk patients
Irradiation. • ข้อดี Graft- versus-host
• Indication :
– ผู้ป่วยภูมิคุ้มกันบกพร่อง ( hereditary immune deficiencies, Chemotherapy ,Transplantation, AIDs (controversial).
– Patients receiving blood transfusions from relatives in directed-donation programs
Washed PRC : กรณีแพ้ plasma เช่น IgA deficiency
Fresh Frozen Plasma:
• ประกอบด้วย colloids, active platelets, and
clotting factors ( 1U = 3-5% cofactor)
• เด็ก 10-15 ml/kg
• Indication :
– bleeding ร่วมกับขาด Coagulation factor
– แก้ coagulation defects
– Massive transfusion
– hypoproteinemia and maintaining normal colloidal osmotic pressure
Platelet
• Platelet conc. 6 U / Single donor 1U
เพิ่ม Platelet 50,000 /ml
• Indication : Therapeutic / Prophylaxis
< 10,000 Asymtomatic
< 15,000 Cogulation disorder / bleeding
< 20,000 Major bleed
< 50,000 Invasive procedure/ massive transfusion
<100,00 Neurologic / cardiac surgery
Cryoprecipitate
• Dose : 1U/5 kg เพิ่ม Fibrinogen 75 mg/dl
ให้ 10 U
: 1U/kg เพิ่ม 2% factor VIII activity
• Indication :– Bleeding with fibrinogen < 100mg/dl เช่น DIC
– Von Willenbrand disease
– Hemophelia A
Complications การให้สารน้ า
• Infection : local: swelling, redness, and fever , septicemia
• Phlebitis : irritation(foreign body (the IV catheter)) or the fluids or medication
Symptoms : swelling, pain, and redness
Mx. warmth, elevation of the affected limb, or
a change flow rate
• Fluid overload : hypertension, heart failure, and pulmonary edema
• Electrolyte imbalance
• Embolism
• A blood clot or other solid mass, or an air bubble,
• Air bubbles < 30 mL dissolve into the circulation harmlessly.
• Extremely large (3-8 mL/kg), Arrest
• Extravasation
Febrile non-hemolytic transfusion reaction
• most common ,benign
• fever and dyspnea 1 to 6 hours
Complication การรับผลิตภัณฑ์เลือด
Acute hemolytic reaction. •Medical Emergency•Hemolysis ของ donor RBC โดย host antibody. •The most common “wrong unit to wrong patient”•อาการ ไข้ หนาวสั่น ปวดหลัง ปัสสาวะสีชมพูแดง เหนื่อย หัวใจเต้นเร็ว ช็อก DIC , Renal failure
Management
• หยุดการให้เลอืดทันที
• IV hydration ให้ปัสสาวะออกดี
• Oxygen
• ส่งเลือดในถุง และเลือดผู้ป่วยกลับไปตรวจซ้้า
• Hemolytic work up : Direct / Indirect coombs test , CBC, Creatinine ,Coagulogram ,LDH ,Indirect bilirubin , Urine for hemoglobin
• Paracetamol
• Meperidine (pethidine)
• Antihistamine ถ้ามีผื่นคัน หรือคัน
• Viral infection. : HBV( 1 in 250,000 units ) HIV or HCV ( at 1 per 2 million units ).
• Bacterial infection. The risk is highest with
platelet transfusion (1 in 50,000 platelet transfusions), and 1 in 500,000 red blood cell transfusions
• Volume overload.
• Anaphylactic reaction.
• Transfusion-associated acute lung injury (TRALI).
• อาการ ไข้ , non-cardiogenic pulmonary edema , and hypotension.
• Self limited within 96 hours,
• Iron overload. .
• Transfusion-associated graft-vs-host disease (GVHD).
Large Volume Crystalloid Resuscitation
• World War II: Blood for resuscitation lead to post-traumatic ARF
• Vietnam: Large volume of crystalloid resuscitation decreased incidence of ARF
• ATLS® protocol: 2L of crystalloid bolus and check for response, if non-responder, call for blood
• Crystalloid: short term hemodynamic benefit, adverse consequences of hemostasis– Dilutional coagulopathy– Secondary clot disruption
Increase blood flowIncrease perfusion pressureDecrease blood viscosity
Immediate versus Delayed Fluid Resuscitation for
Hypotensive Patients with Penetrating Torso Injuries
William H. Bickell, Matthew J. Wall, Paul E. Pepe, R. Russell Martin,
Victoria F. Ginger, Mary K. Allen, and Kenneth L. Mattox
Among the 289 patients who received delayed fluid resuscitation, 203 (70 percent) survived and were discharged from the hospital, as compared with 193 of the 309 patients (62 percent) who received immediate fluid resuscitation (P = 0.04). The mean estimated intraoperative blood loss was similar in the two groups. Among the 238 patients in the delayed-resuscitation group who survived to the postoperative period, 55 (23 percent) had one or more complications (adult respiratory distress syndrome, sepsis syndrome, acute renal failure, coagulopathy, wound infection, and pneumonia), as compared with 69 of the 227 patients (30 percent) in the immediate-resuscitation group (P = 0.08). The duration of hospitalization was shorter in the delayed-resuscitation group.
Disabilities and Immobilization
• Rapid neurogic evaluation
– GCS, conciousness, pupillary size and reaction, localizing signs
Pathophysiology: Microcirculation
LRS and Neutrophils Activation