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By. Ms. Shanta Peter

Shock

“A momentary pause in the act of

death.”John Collins Warren, 1800s

“Shock is a symptom of its cause.”

Isolated head injury does not cause shock

Categories of Shock

• HYPOVOLEMIC

• CARDIOGENIC

• DISTRIBUTIVE

• OBSTRUCTIVE

Goals of Shock

Resuscitation

• Restore blood pressure

• Normalize systemic perfusion

• Preserve organ function

Time to Trauma Death

• 50% deaths occur at scene within minutes:– CNS injury 40-50%– Hemorrhage 30-40%

• 50% after hospital arrival:– 60% die within first 4 hrs– 84% die within first 12 hrs– 90% die within first 24 hrs

• Hemorrhage accounts for 50%Deaths in the

first 24 hours

Hemorrhagic Shock Definition

Hemorrhagic Shock

–Reduction in tissue perfusion below that necessary to meet metabolic needs

Inadequate Perfusion

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Confounding Factors In Response To Hemorrhage

• Patients age

• Pre-existing disease / meds

• Severity of injury

• Access to care

• Duration of shock• Amount pre-hospital fluid-EMS

• Presence of hypothermia

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Treatment of Traumatic shock

Compensated Traumatic shock :

Easy recovery with appropriate resuscitative measures

• Decompensated Traumatic Shock :

Cellular damage – secondary to hypo-perfusion, toxic metabolic effects

Reversible but recovery period is extended

Injuries Prone to Hemorrhage

Vascular Solid Organ Bones

Aorta

Vena Cava

Spleen

Liver

Pelvis

Femur

Quickly Rule Out Blood Loss

Chest – CXR / FAST

Abdomen - FAST

Pelvis – Xray

Femur – exam / X-ray

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Classic Signs & Symptoms of Shock

• Change in mental stability

• Tachycardia

• Cool, clammy, skin

• Prolonged capillary refill

• Narrow pulse pressure

• Hypotension

• Decreased urine output

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Treating Hemorrhagic Shock- 6 Steps

• Step 1: Optimize oxygenation – Airway management

• Step 2: Identify and control immediate threats to central perfusion.

• Step 3: Identify and assess severe intracranial injuries.

• Step 4: Identify and control potentially life-threatening thoracic and abdominal injuries.

• Step 5: Identify and control potentially limb

threatening injuries.

• Step 6: Identify and treat non-critical injuries. 11

HemorrhagicShock

Assessment12

• pH• Serum Lactate• Base Deficit• Echocardiography• Arterial Wave –

Analysis (Art line)

• Mentation

• Skin Perfusion

• Pulse

• Blood Pressure

• Pulse Pressure

• Shock Index

• Urine Output

Init

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Assessment Vs. Resuscitation Endpoints

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Manual Vital Signs- its importanceGCS

Motor,

Verbal

Pulse

Character

Most Predictive for Need of Life Saving Interventions

Pulse & character together more reliable

Age dependentAffected by-

Emotion, FeverPain, Drugs Pulse pressure Narrowed pulse pressure

suggests significant blood loss

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Permissive Hypotension

• Many hypothesize that one should not raise blood pressure

to more than ¾ of pre-injury levels (~80 mmHg).

• Humerus 750 ml

• Tibia 750 ml

• Femur 1500 ml

• Pelvis > 3 L

Fracture Associated Blood Loss

Associated Soft Tissue Trauma

Release of Cytokines

• Increased permeability

• Magnify fluid loss

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Assessing for Sources of Hemorrhage

• Chest radiography: – Tension pneumothorax? Massive hemothorax?

Aortic injury?

• Pelvis radiography: Pelvic ring disruption?

• Focused Assessment with Sonographyfor Trauma (FAST):– Pneumo/hemo-thorax? Hemo-pericardium?

Hemo-peritoneum?– If positive, then emergency laparotomy.– If negative, continue resuscitation, treat other

causes. 17

Practical Diagnosis of Shock

• Perform a targeted physical examination

Diagnostic testing:-

• Chest radiography,

• Pelvis radiography, and

• Bedside ultrasound

• Objective serum makers of tissue perfusion (serum lactate or base deficit)

• Send for CBC, type/cross

• DON’T delay resuscitation for lab results

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Diagnostic Peritoneal Aspiration (DPA)

Can be done

• if - FAST in blunt abdominal trauma.

• If DPA +ve , then emergency laparotomy.

• If DPA –ve , then seek and treat other sources.

– Perform serial abdominal exams.

– Perform serial FAST exams.

– If patient stabilizes, then CT.

• Get surgery involved!

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FAST Algorithm

• Unstable patient + FAST OR.

• Stable pt + FAST abdominal CT.

• Stable pt, low mechanism of injury ,

- FAST observation, serial exams.

• CT is the “Gold Standard”.

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Hypo-perfusion --- Think wisely and explore …Patients don’t suddenly deteriorate !

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HemorrhagicShock

Lab Values

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ABG --Acidosis - Serum pH < 7.20

Indicates ---• Decreased cardiac contractility

• Decreased cardiac output

• Vasodilation and decreased BP

• Decreased hepatic and renal blood flow

Lactate Levels > 5 = ↑ mortality (N 1.0 mEq/L)

Inability to clear lactate within 12 hoursPredictive of multisystem organ failure

Base Deficit (Normal range -3 to +3)

Worsening BD: On going bleeding,

Inadequate volume replacement

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International Normalized Ratio (INR)

Value

Normal 0.8 - 1.2

Anticoagulant Use 2.0 - 3.0

Hemoglobin / HematocritIn Acute blood loss – unreliable

Baseline result to use as comparison

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Estimate the BP from Pulse ? ( Rough& Quick)

60

70

80

80

• If you can palpate this

pulse---------

you know the SBP is

roughly this number

MAP ..

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HemorrhagicShock

Treatment

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IV Access Principles in Shock• Fastest, simplest route best (antecubital)

• Large bore, short length (14-16G,2” length)

• 2 lines -minimum

Optimally

• Two people attempting simultaneously

• Two different sites (above & below diaphragm)

• Two to three sites required per major trauma

• Progression [PIV → Femoral → Subclavian]

• Consider Intraosseous (IO) early as rescue device

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Avoid IV Access--

• Injured limb

• Distal to possible

vascular wound

• Femoral access with injury below diaphragm

I.V Access in Shock Femoral, Sub Clavian JugularIntraosseous Devices (Temp)

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Fluid Resuscitation

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Crystalloids (Isotonic Solutions)

Balanced electrolyte solutions similar to ECF

Rapidly equilibrates across compartments

Only 25% remain in IVS after 17

minutes!

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Hespan /Hesteril• Plasma volume expander

• 500cc expands blood volume 800cc (Half life is 17 mins)

• Safe and effective at 500cc bolus

• Consider ……..– May cause coagulopathy in large doses (>2L dose)

– Renal tubular dysfunction concern

2-3 L LR500ml

HetastarchEquivalent

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Treatment of Hemorrhagic Shock

• Type and cross match for 6-8 units of blood -immediately.

(Massive transfusion defined as

> 10 U of PRBCs in 24 hrs)

• Consider use of PRBC to platelet to FFP ratio of 1:1:1

– May result in decreased need for blood products

(Give calcium to prevent citrate toxicity )

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Hemostatic Resuscitation

• Early diagnosis in ED

• 1:1 ratio (PRBC to FFP)

• Early frequent:

– Cryoprecipitate

– Platelets

• Minimal crystalloids

• Stop the bleeding

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Component Therapy vs. Whole Blood

1 u PRBC

335ml, Hct 55%

1u Plasma

275ml, 80% Coags

1 u Platelets

50ml, 5.5X1010

Total: 650 ml

Hct 29%

Platelest 88,000

Coag Factors 65%

Whole Blood 500 ml

Hct 38-50%

PLTs 150-400,000

Coag Factors 100%

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Complications of Transfusion

• Impaired O2 release from Hge

• Immunosuppression + infection

– leuko reduced

• Coagulopathy

• Hypothermia

• Ca, K, pH

• Transfusion-related acute lung injury

• Hemolytic transfusion reaction

Urine Output

Adult 0.5 ml / kg / hour

Child 1.0 ml / kg / hour

Toddler 1.5 ml / kg / hour

Infant 2.0 ml / kg / hour

Emergency Laparotomy Indications

• Peritonism: (symptoms of peritonitis without actual inflammation of peritoneum )

• Free air under the diaphragm

• Significant gastrointestinal hemorrhage

• Hypotension with +ve FAST scan or +ve DPA

Do NOT keep trauma patients if you

lack resources to care for them!

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Coagulopathy

Hypothermia (core temp 35 <32 = 100% mortality )

Acidosis

Trauma

Triad

Death

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Treatment Concepts