Initial Assessment and Management

Committee on Trauma Presents

Shock

Case Scenario

● 28-year-old female in MVC

● Pulse: 126; BP: 96/70; RR: 28

● Confused and anxious

How would you manage this patient?

Is this patient in shock? If so, what type?

Objectives

● Define shock.

● Recognize the shock state.

● Determine the cause of shock.

● Discuss treatment principles.

● Recognize the importance of early identification and control of hemorrhage.

What is shock?

Cell death

Inadequate oxygen delivery

Catecholamines and other responses

Anaerobic metabolism

Cellular dysfunction

Generalized State of Hypoperfusion

Shock

●Alteration in level of consciousness, anxiety

●Cold, diaphoretic skin

●Tachycardia

●Tachypnea, shallow respirations

●Hypotension

●Decreased urinary output

Is the patient in shock?

Shock

●Scene information / mechanism of injury

●AMPLE history

Inadequate perfusion

Organ dysfunction

How do I recognize shock?

Shock

What is the cause of the shock state?

●Blood loss

●Fluid loss

●Tension pneumothorax

●Cardiac tamponade

●Cardiogenic

●Septic

●Neurogenic

Hypovolemic

Nonhemorrhagic

vs

Shock

How do I locate the bleeding?

Shock

●Physical examination

●Diagnostic adjuncts to primary survey

● Chest X-ray

● Pelvic X-ray

● FAST / DPL

How do I locate the bleeding?

What is the cause of the shock state?

In the vast majority of trauma patients, shock is due to blood loss.

Shock

Interventions

Direct pressure / tourniquet STOP

thebleeding!

Reduce pelvic volume

Angio-embolization

Splint fractures

Operation

What can I do about it?

Interventions

●Fluid resuscitation

● Vascular access?

● Type?

● Volume?

●Monitor response

●Prevent hypothermia!

What can I do about it?

Patient Response

●Skin: warm, capillary refill

●Renal: increased urinary output

●Vital signs

●CNS: improved level of consciousness

Identify improved organ function

How do I evaluate the patient’s response?

Patient Response

What is the patient’s response?

Patient Response

●Rapid responder

●Transient responder

●Nonresponder

Related to volume or persistence of hemorrhage

Operation

What is the patient’s response?

Class I Hemorrhage

●Slightly anxious

●Normal blood pressure

●Heart rate < 100 / min

●Respirations 14-20 / min

●Urinary output 30 mL / hour

750 mL BVL (15%)

Crystalloid

Class II Hemorrhage

●Anxious

●Normal blood pressure

●Heart rate > 100 / min

●Decreased pulse pressure

●Respirations 20-30 / min

●Urinary output 20-30 mL / hour

750-1500 mL BVL (15-30%)

Crystalloid,? blood

Class III Hemorrhage

●Confused, anxious

●Decreased blood pressure

●Heart rate > 120 / min

●Decreased pulse pressure

●Respirations 30-40 / min

●Urinary output 5-15 mL / hour

1500-2000 mL BVL (30-40%)

Crystalloid, blood

components, operation

Class IV Hemorrhage

●Confused, lethargic

●Hypotension

●Heart rate > 140 / min

●Decreased pulse pressure

●Respirations >35 / min

●Urinary output negligible

>2000 mL BVL (>40%)

Definitive control, blood components

Pitfalls

●Age extremes

●Athletes

●Pregnancy

●Medications

●Pacemaker

Complications of Shock – Patient Factors

Pitfalls

●Hypothermia

●Early coagulopathy

Pitfalls

Pitfalls

Complications of Shock and Shock Management

●Equating BP with cardiac output

●Misleading hemoglobin and hematocrit levels

Pitfalls

Pitfalls

Complications of Shock

Summary

●Shock is inadequate organ perfusion and tissue oxygenation.

●Hypovolemia is the cause of shock in most trauma patients.

●Patients may present with mild to severe shock.

Summary

●Conduct a rapid initial assessment and resuscitation.

●Determine cause of shock.

●Stop the bleeding.

●Reevaluate.