K. John Hartman MD FACS

Trauma Services Medical Director Genesis Davenport

Objectives1. Discuss tourniquet indications

2. Review Tourniquet application

3. Review Fluid resuscitation

4. Assessing Shock

5. Providing Care for Shock

4/15/2013

“Past tourniquet bad experiences are now explicable because prior science, device designs, training, doctrine and evacuation were inadequate”.

-Kragh, Use of Tourniquets and Their Effects on Limb Function…

Foot Ankle Clin N Am 15 (2010) 23-40

Purpose: stop blood flow through an extremity’s

arteries

Main Use Scenario: stop

bleeding from an injured limb

Arterial and venous blood flow in the limb is stopped.

To stop bleeding so you can do something else (direct pressure “inconvenient”)

Return enemy fire (military/tactical care)Solve an airway problemAttend to other injuries

Attend to another casualtyExtricate from current location (crushed vehicle, machinery entanglement, unsafe

location)Transport to definitive care

Kragh et al. J Spec Oper Med 2011;11:30-38

Reasons to use arterial tourniquetsATo stop bleeding not amenable to direct pressure

Open fracturesAmputationsVascular woundsSevere soft tissue woundsExpanding hematoma Impaled objectImpaled object

20 of 90 IA EMTs with no military experience had used a tourniquet on a limb injury (6 more than once).

Injury Sources: motor vehicle accidents (9), farm equipment (6), manufacturing equipment (4), falls through glass (2), gunshots (2),

chainsaws (2), and stab (1)

Tourniquet Indications: severe hemorrhage, extrication/transport time, injury access, other injuries

Tourniquets Used: blood pressure cuffs (9, only 6 indicated as stopping the bleeding), other improvised (10, only 4 listed as

stopping the bleeding)

Tourniquets have civilian injury relevance.

90% survival applied pre-shock (429/476)

18% survival applied after shock onset (4/22)

89% survival applied pre-hospital (374/422)

78% survival applied in hospital (59/76)

0% survival not applied for severe limb trauma (0/10)

For life threatening bleeding, don’t wait stop

the bleeding!

Kragh et al. J Emerg Med 2011;4:590-597

Between the heart and the injury

The presence of two long bones in the forearm and lower leg does not decrease tourniquet effectiveness for

stopping arterial blood flow as compared to the single long bone in the upper arm and thigh.

Tourniquet placement on a smaller circumference limb location allows easier pressure application to the

underlying arteries.

Place tourniquet(s) just proximal to the injury.

Tourniquet Placement on the Limb

Need to stop arterial blood flow (importance of mechanical advantage)

Are most life saving used before shock

Should be wider than 2.5cm (wider is better so long as stop arterial blood flow, side by side is good)

Should be placed close to the injury (forearm and lower leg are good tourniquet locations)

Need reassessment

Hartford Consensus The American College of Surgeons brought together

senior leaders from medical, law enforcement, fire/rescue and EMS communities to create a strategy to improve survival of the victims of mass casualty shooting events in April, 2013.

Hartford Consensus Threat Suppression

Hemorrhage control

Rapid Extrication to safety

Assessment by medical providers

Transport to definitive care

“Life threatening bleeding from the extremities is best controlled by

early placement of a tourniquet.”

“Life threatening bleeding from penetrating wounds to the chest and

trunk are best addressed through rapid transport to a hospital setting.”

“Improving survival from active shooter events: The Hartford Consensus.”

Journal of Trauma and Acute Care Surgery, June 2013-Volume 74-Issue6-p1399-1400

ShockInadequate oxygen delivery to meet

metabolic demands.

3 factors determine:

1. oxygen content

2. oxygen delivery

3. distribution

Causes/Types of Shock Hypovolemic/Hemorrhagic

Septic

Cardiogenic

Neurogenic

Anaphylactic

Obstructive

Shock

60

80

70

90

• If you palpate a pulse, you know SBP is at least this number

Hypovolemic Shock• Non-hemorrhagic

• Vomiting• Diarrhea• Bowel obstruction, pancreatitis• Burns • Neglect, environmental (dehydration)

• Hemorrhagic • GI bleed• Trauma• Massive hemoptysis• AAA rupture• Ectopic pregnancy, post-partum bleeding

Possible Locations of the Blood Abdomen

Retroperitoneum

Pelvis

Thigh

Chest

Pavement

•It is possible to

exsanguinate from a

scalp laceration.

•Take note and report any

saturated clothing, towels,

etc.

Hypovolemic Shock• ABCs

• Establish 2 large bore IVs

• Crystalloids• Normal Saline or Lactate Ringers

• Up to 3 liters

• PRBCs• O negative or cross matched

• Control any bleeding

Controlling bleeding1. Direct pressure

2. If unsuccessful, and location is on extremity, apply a tourniquet.

Tachycardic, cold/cool extremities, widened pulse pressure.

Sepsis• Two or more of SIRS criteria

• Temp > 38 or < 36 C

• HR > 90

• RR > 20

• WBC > 12,000 or < 4,000

• Plus the presumed existence of infection

• Blood pressure can be normal!

Septic Shock• Clinical signs:

• Hyperthermia or hypothermia

• Tachycardia

• Wide pulse pressure

• Low blood pressure (SBP<90)

• Mental status changes

• Beware of compensated shock!• Blood pressure may be “normal”

Warm, vasodilated, tachycardic

Cardiogenic Shock• Signs:

• Cool, mottled skin

• Tachypnea

• Hypotension

• Altered mental status

• Narrowed pulse pressure

• Rales, murmur

• Defined as:

• SBP < 90 mmHg

• CI < 2.2 L/m/m2

• PCWP > 18 mmHg

Etiologies • What are some causes of cardiogenic shock?

• AMI

• Sepsis

• Myocarditis

• Myocardial contusion

• Aortic or mitral stenosis, HCM

• Acute aortic insufficiency

Pathophysiology of Cardiogenic Shock

• Often after ischemia, loss of LV function

• CO reduction = lactic acidosis, hypoxia

• Stroke volume is reduced

• Tachycardia develops as compensation

• Ischemia and infarction worsens

Treatment of Cardiogenic Shock

• Goals- Airway stability and improving myocardial pump function

• Cardiac monitor, pulse oximetry

• Supplemental oxygen, IV access

• Intubation will decrease preload and result in hypotension • Be prepared to give fluid bolus

Treatment of Cardiogenic Shock• AMI

• Aspirin, beta blocker, morphine, heparin• Dopamine – will ↑ HR and thus cardiac work• Dobutamine – May drop blood pressure• Combination therapy may be more effective

• PCI or thrombolytics

Cold extremities, tachycardic, narrow pulse pressure

Anaphylactic Shock• Anaphylaxis – a severe systemic

hypersensitivity reaction characterized by multisystem involvement

• IgE mediated

• Anaphylactoid reaction – clinically indistinguishable from anaphylaxis, do not require a sensitizing exposure

• Not IgE mediated

Anaphylactic Shock• What are some symptoms of anaphylaxis?

• First- Pruritus, flushing, urticaria appear

•Next- Throat fullness, anxiety, chest tightness, shortness of breath and lightheadedness

•Finally- Altered mental status, respiratory distress and circulatory collapse

Anaphylactic Shock• Risk factors for fatal anaphylaxis

• Poorly controlled asthma

• Previous anaphylaxis

• Reoccurrence rates• 40-60% for insect stings

• 20-40% for radiocontrast agents

• 10-20% for penicillin

• Most common causes• Antibiotics

• Insects

• Food

Anaphylactic Shock• Mild, localized urticaria can progress to full anaphylaxis

• Symptoms usually begin within 60 minutes of exposure

• Faster the onset of symptoms = more severe reaction

• Biphasic phenomenon occurs in up to 20% of patients• Symptoms return 3-4 hours after initial reaction has cleared

• A “lump in my throat” and “hoarseness” heralds life-threatening laryngeal edema

Anaphylactic Shock- Diagnosis• Clinical diagnosis

• Defined by airway compromise, hypotension, or involvement of cutaneous, respiratory, or GI systems

• Look for exposure to drug, food, or insect

Anaphylactic Shock- Treatment• ABC’s

• Angioedema and respiratory compromise require immediate intubation

• IV, cardiac monitor, pulse oximetry

• IVFs, oxygen

• Epinephrine

• Second line• Corticosteriods

• H1 and H2 blockers

Anaphylactic Shock- Treatment

• Epinephrine• 0.3 mg IM of 1:1000 (epi-pen)

• Repeat every 5-10 min as needed

• Caution with patients taking beta blockers- can cause severe hypertension due to unopposed alpha stimulation

• For CV collapse, 1 mg IV of 1:10,000

• If refractory, start IV drip

Anaphylactic Shock - Treatment• Corticosteroids

• Methylprednisolone 125 mg IV • Prednisone 60 mg PO

• Antihistamines• H1 blocker- Diphenhydramine 25-50 mg IV• H2 blocker- Ranitidine 50 mg IV

• Bronchodilators• Albuterol nebulizer• Atrovent nebulizer• Magnesium sulfate 2 g IV over 20 minutes

• Glucagon• For patients taking beta blockers and with refractory hypotension• 1 mg IV q5 minutes until hypotension resolves

Neurogenic Shock • Occurs after acute spinal cord injury

• Sympathetic outflow is disrupted leaving unopposed vagal tone

• Results in hypotension and bradycardia

• Spinal shock- temporary loss of spinal reflex activity below a total or near total spinal cord injury (not the same as neurogenic shock, the terms are not interchangeable)

Neurogenic Shock • Loss of sympathetic tone results in warm and dry skin

• Shock usually lasts from 1 to 3 weeks

• Any injury above T1 can disrupt the entire sympathetic system

• Higher injuries = worse paralysis

Neurogenic Shock- Treatment• A,B,Cs

• Remember c-spine precautions

• Fluid resuscitation• Keep MAP at 85-90 mm Hg for first 7 days• Thought to minimize secondary cord injury• If crystalloid is insufficient use vasopressors

• Search for other causes of hypotension• For bradycardia

• Atropine• Pacemaker

Warm and dry extremities, bradycardic, usually with a mechanism of injury.

Obstructive Shock• Tension pneumothorax

• Air trapped in pleural space with 1 way valve, air/pressure builds up

• Mediastinum shifted impeding venous return

• Chest pain, SOB, decreased breath sounds

Rx: Needle decompression, chest tube

Obstructive Shock• Cardiac tamponade

• Blood in pericardial sac prevents venous return to and contraction of heart

• Related to trauma, pericarditis, MI

• Beck’s triad: hypotension, muffled heart sounds, JVD

• Diagnosis: large heart CXR, echo

• Rx: Pericardiocentisis

Obstructive Shock• Pulmonary embolism

• Virscow triad: hypercoaguable, venous injury, venostasis

• Signs: Tachypnea, tachycardia, hypoxia

• Low risk: D-dimer

• Higher risk: CT chest or VQ scan

• Rx: Heparin, consider thrombolytics

The Golden HourWhat should we be doing?

Rapid assessment

Resuscitation and stabilization

Definitive management/Transfer

ATLS

The Golden HourRapid Resuscitation

restores circulating volume

improves oxygen delivery

prevents cellular ischemia and tissue necrosis

prevents onset of secondary cellular injury

prevents onset of MODS

The Golden HourShock Pathophysiology

prolonged hypoperfusion creates a vicious cycle of ischemia and shock

2 most important steps in managing shock:

1. recognition

2. treatment

Goals of Treatment

• ABCDE

• Airway

• control work of Breathing

• optimize Circulation

• assure adequate oxygen Delivery

• achieve End points of resuscitation