Acute Trauma Care:

Shock
 Definition
Shock

Inadequate organ perfusion and

tissue oxygenation
CARDIAC PHYSIOLOGY:
CO = SV x HR

CO = Cardiac Output.
SV = Stroke Volume.
HR = Heart Rate.

SV is determined by:
1. Preload
2. Contractility
3. Afterload
CARDIAC PHYSIOLOGY:
Preload depends on:
1. Venous capacitance
2. Volume status
3. Mean venous systemic pressure

70% of blood volume is in venous circuit

Blood Loss:
Pathophysiology:
Hemorrhage

Early circulatory response

Vasoconstriction Tachycardia
Blood Loss:
Release of Catecholamines,
Cytokines & Hormones

Vasoconstriction

Diastolic BP

Low Pulse Pressure

IMPORTANT To Restore Volume !

At Cellular Level:
Inadequate perfusion & oxygenation
Anaerobic Metabolism

Loss of Cell Membrane gradient

Damage to Organelle

Cell Dyfunction & Death

Isotonic Electrolyte Solutions administration counter this

 How do I recognize Shock ?

Tachycardia

Cold, diaphorectic skin

Hypotension
Hematocrit unreliable – Tachypnea
slow response, pre-existing anemia Shallow respirations
How do I recognize Shock ?

Anxiety
 Urinary Output Alteration in Level
of Consciousness (LOC)
What are other clues?
 Scene Information / Mechanism of Injury

Inadequate  Organ
Perfusion Dysfunction
Initial Managment
 Recognize signs of inadequate perfusion
 Identify cause
 Restore perfusion by restoring circulating blood
volume
 Re-evaluate patient response
 Early Surgical Intervention

Vasoconstrictors are Contraindicated

 Shock – Recognition
 Inadequate perfusion of skin, kidneys, CNS
 Systolic blood pressure produces delayed
recognition
 Early Signs:
 Pulse rate
 Respiratory rate
 Pulse pressure
Tachycardia:
AGE Heart Rate
Infant > 160

Preschool > 140

School going > 120

Adult > 100

Any trauma patient who is
cool and tachycardic is in
shock until proven otherwise
SHOCK:
 Identify probable cause

 Areas of focus:
 Hemorrhagic (hypovolemic)
 Cardiogenic
 Neurogenic
 Septic shock (unusual)

 Identification & treatment go side by side

 Hemorrhagic shock

 Most common
 Initiate treatment simultaneously with diagnosis:
Key Points:
 Stop bleeding

 Restore volume

 Hemorrhagic versus non-hemorrhagic:

 History
 Physical
 Select diagnostic Tests: FAST, DPL, CXR, AP pelvis xray
Causes
 Severe burns
 Gastro-enteritis
 Intestinal obstruction
 Multiple/severe fractures
 Severe bleeding
 Non-hemorrhagic shock
 Cardiogenic
- Myocardial Infarction
- Cardiac failure
- Pulmonary Embolism
- Pericardial effusion
 Non-hemorrhagic shock - cont’d
 Tension pneumothorax
 Mimics cardiac tamponade
 Surgical emergency
 Needle decompression
 Non-hemorrhagic shock – cont’d
 Neurogenic shock

 Isolated head injuries do not cause shock

 Loss of sympathetic tone
 Decreased BP without increase HR
 Volume restoration
 CVP monitor
 Non-hemorrhagic shock – cont’d
 Septic shock
 Warm skin – “Warm shock”
 Wide pulse pressure
 Contaminated, penetrating abdominal injury
(late)
First…..treat for hemorrhagic
shock
 Hemorrhage
 Acute loss of circulating blood
 Normal blood volume:
 Adult 7% of ideal body weight
 Child 8-9% of ideal body weight

Cellular response
 Restored produces survival
 Not restored produces death
 Class I Class II Class III Class IV
Blood Loss <750ml 750-1500 1500-2000 >2000
%Tot Vol Loss <15% 15-30% 30-40% >40%

Pulse Rate <100 >100 >120 >140

BP Normal Normal  
Pulse Normal   
Pressure or 
Resp Rate 14-20 20-30 30-40 >40
Urine Output >30 20-30 5-15 Negligible
CNS Status Slightly Mildly Anxious, Confused
anxious anxious confused
Fluid Crystalloid Crystalloid Crystalloid Crystalloid
Replacement and Blood and Blood
 Hemorrhage

 Initiate aggressive fluid resuscitation

 Direct treatment of patient’s response
initially
Hemorrhagic Shock:
Initial management:

 Physical exam.
 ABCDE.
 Vitals, Conscious level.

Baseline Vitals as reference

Hemorrhagic Shock :
Airway & Breathing:
 O2 Sp 02 >95 %

Circulation:
 Control hemorrhage
 IV access
 Repeat Assessments for tissue perfusion
 Surgical management
Hemorrhagic Shock:
Disability:
Brief neurological exam
 Assess cerebral perfusion

Exposure :
 Head-to-toe exam
 Associated Injuries
 Soft tissue hemorrhage

 Fractured tibia may loose 750ml

 Fractured femur 1500ml
 Fractured pelvis 3-5 liters
Hemorrhagic Shock:
Gastric and Bladder Decompression:
Urinary catheter:
Assessment of:
 Renal perfusion – urine output

Contraindication for urethral catheter :

1. Blood at meatus
2. High riding, mobile, non-palpable prostate
Hemorrhagic Shock:
Vascular access lines:
 Prompt
 2 large-bore, short (> 16 G), peripheral.
 Flow α radius4 / length.
 Site:
1. Forearm, antecubital.
2. Central vein.
3. Venous cut-down.
4. Intraosseus needle.
 Blood samples – Type and cross-match if available.
Hemorrhagic Shock:
Initial Fluid Therapy:
1. Warm.
2. Isotonic electrolyte solutions.
3. Rapid initial bolus of 2 L or 20 ml / kg

Reassess
If fluid requirements exceeds estimations and is
ongoing, look for:
1. Unrecognized injuries
2. Other causes of shock
Evaluation:
Fluid resuscitation & Organ perfusion:

General.
 Vitals.
 CNS.
 Skin perfusion.
 Urinary Output.
 CVP / PAC
Evaluation:
Urinary output:
1. Adults : 0.5 ml / Kg/ hr >30 ml/hr
2. Pediatrics: 1 ml / Kg/ hr
3. Infants: 2 ml / Kg/ hr

Inadequate urine output THINK

 inadequate resuscitation
Evaluation:
Acid- Base balance:

Metabolic acidosis
 Severity reflects:
duration of shock
volume of blood loss

 Trend is more important than absolute value

 Prognostic for survival
 Caveats: Alcohol intoxication; Renal Failure

Routine use of Na HCO3 is not recommended

Patient’s response to fluid determines subsequent
therapy

Remember
Use of term “hemodynamically stable”

 Pregnancy
 Extremes of Age
 Athletes
 Medications
 Pacemaker
 Hypothermia
 Therapeutic decisions
 Rapid response
 Less than 20% blood loss

 Stable response to fluid replacement

 Continue to monitor

 Type and Screen

 Maintenance Fluid

 Surgical evaluation
 Therapeutic decisions
 Unstable – deteriorates after initial fluids
 20-40% blood loss

 Continue fluids plus blood

 Surgical evaluation

 If continued need for blood to maintain

vital signs then THINK ongoing

hemorrhage, needs operation
 Therapeutic decisions
 Minimal to no response
 Greater than 40% blood loss

 No response to fluid resuscitation

 No response to IV fluids

 Exclude non-hemorrhagic shock

 Cardiac Tamponade
 Myocardial Contusion/Blunt Cardiac Injury

 Immediate operation
 Therapeutic decisions
 Blood replacement
 Crossmatch packed red blood cells
 Type specific
 Type O RH negative
 Warmed fluids
 Heat fluids to 39°C
1. Warmer
2. Microwave oven (not for blood)

Auto transfusion:
 In patients with major hemothorax
Blood Replacement:
Coagulopathy:
 Up to 25 % have abnormal PT or PTT on arrival

Can result from:

1. Massive transfusion
2. Hypothermia
3. Acidosis
4. ?Innate to patient - genotype

Baseline coagulation tests esp. if:

1. H/O coagulopathy.
2. On anticoagulants.
3. History not available

Start to think about Fresh Frozen Plasma (FFP) EARLY if available

and have started transfusion
 Diagnosis & treatment – Pitfalls and
Complications
 Avoid complications
 Continued hemorrhage – surgery

 Fluid overload – monitor patient, CVP

 Re-evaluate, high index of suspicion

Remember that,
Blood pressure is NOT equal to cardiac
output
 CVP monitoring

 Right hearts ability to accept fluid

 CVP versus actual blood volume
 Low/declining – replace fluids
 Elevated CVP – adequate or
hypervolaemia
 Shock - Summary

 Goal – restore profusion, tissue oxygenation

 Differential diagnosis
 Management
 Oxygenate/ventilate
 Hemorrhage control

 Fluids

 Monitor patient response

….end