Shock on trauma

Tatat A. Agustian

Objectives

Define shock
Recognize the shock state
Determine the cause
Apply treatment principles
Apply principles of fluid management
Monitor patients response
Employ options for vasculer access
Recognize complications of vascular access

Key Issues : Shock Management

Recognize inadequate organ perfusion

Identify the cause
Hemorrhagic vs nonhemorrhagic
Treatment
Stop the bleeding!
Restore volume

Cardiac Physiology
CO = SV X HR

Preload

Contractility

Venous
Capacitance

Afterload

Vascular
dp / dt

Tone

Cardiac Physiology
CO = stroke volume x heart rate
Stroke volume is determined by:
Preload
Volume of venous return to the heart
Venous capacitance, volume status, difference
between mean venous systemic pressure and right
atrial pressure.
Myocardial contractility
Starlings Law
Afterload
Systemic vascular resistance

Pathophysiology

Cellular Alteration in shock

Recognition of Shock State

1. Tachycardia
2. Vasoconstriction
2. Cardiac output
Narrow pulse pressure
3. Map
3. Blood Flow
Caution : Compensatory mechanisms

Pitfalls in shock Recognition

Extremes of age
Athletes
Pregnancy
Medications
Hematocrit/hemoglobin concentration

Etiology of Shock
Hemorrhagic
Nonhermorrhagic
Most common
Tension
pneumothorax
Clinical clues
History & Physical Cardiogenic
examination
Neurogenic
Selected
Septic
diagnostic tests

Hemorrhagic Shock

Loss of circulating blood volume

Normal blood volume
Adult 7% of ideal weight
Child: 9 % of ideal weight

Classification of Hemorrhage

Class I-IV
Not absolute
Only A clinical guide
Subsequent treatment determined by
patient response

Class I Hemorrhage
750 mL BVL

Class II Hemorrhage
750 1500 ml BVL

Class III Hemorrhage

1500 2000 ml BVL

Class IV Hemorrhage : 2000 ml

2000 ML BVL

Fluid Shifts : Soft tissue Injury

Blood loss into
injury site

Tissue
edema

Compounds
intravascular loss.

Assessment and Management

Recognize shock
Stop the bleeding !
Replenish intravascular volume
Restore organ perfusion

Assessment and Management

Airway and Breathing

Oxygenate and ventilate
Pao > 80 mm hg (10,6 kpa)
Circulation
Assess
Control
Treat

Assessment and Management

Disability cerebral perfusion

Exposure/Environment
Associated injuries
Prevent hypothermia
Gastric and bladder decompression
Urinary output

Management : Vascular Access

2 large caliber, peripheral IV s

Central access
Femoral
Jugular
Subclavian
Intraosseous
Obtain blood for croossmatch

Management : Fluid Therapy

Warmed crystalloid solution

Rapid fluid bolus ringer,s lactate
Adult: 2 Liters, Ringers Lactate
Child :20 ml /kg Ringers lactate
Monitor response to initial therapy

Reevaluate Organ perfusion

Monitor
Vital signs
CNS status
Skin perfusion
Urinary output
Pulse oximetry

Resuscitation Evaluation
Hourly Urinary Output
Inadequate output suggests
inadequate resuscitation

Acid Base Abnormalities

Monitor with ABGs

Usual etiology
Adult : Acidosis due to inadequate
perfusion
Child : Acidosis due to inadequate
ventilation

Acid Base Abnormalities

Treatment
Oxygenate and ventilate
Stop the bleeding !
Consider inadequate volume restoration
Bicarbonate rarely indicated

Therapeutic Decisions
Patient response determines
subsequent therapy
Hemodynamically normal vs
hemodynamically stable
Recognize need to resuscitate in
operating room

Therapeutic Decisions
Rapid Response
<20 % blood loss
Responds to fluid replacement
Surgical consultation evaluation
Continue to monitor

Therapeutic Decisions
Transient Response
20% -40% blood loss
Deteriorates after initial fluids
Surgical consultation evaluation
Continued fluid plus blood
Continued hemorrhage : Operation

Therapeutic Decisions
Minimal to No Response
> 40% Blood loss
No Response to fluid resuscitation
Immediate surgical consultation
Exclude nonhemorrhagic Shock
Immediate operation

Volume Replacement
Warmed fluids
Crossmatched PRBCs
Type specific
Type O, Rh negative
Autotransfusion
Coagulopathy

Pitfalls
Equating Bp with
cardiac output
Extremes of age
Hypothermia

Athletes
Pregnancy
Medications
Pacemaker

Avoiding Complications
Continued hemorrhage
Fluid overload
Invasive monitoring (ICU)
CVP
Pulmonary artery catheter
Other problems

Keys to Successful Treatment

Early control of hemorrhage

Euvolemia
Continuous reevaluation

Questions

Summary

Restore organ perfusion

Early recognition of the shock state
Oxygenate and ventilate
Stop the bleeding
Restore volume
Continuous monitoring of response
Anticipate pitfalls