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