Acute Trauma Care:: Shock
Acute Trauma Care:: Shock
Acute Trauma Care:: Shock
Shock
Definition
Shock
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
Vasoconstriction Tachycardia
Blood Loss:
Release of Catecholamines,
Cytokines & Hormones
Vasoconstriction
Diastolic BP
Damage to Organelle
Tachycardia
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
Areas of focus:
Hemorrhagic (hypovolemic)
Cardiogenic
Neurogenic
Septic shock (unusual)
Most common
Initiate treatment simultaneously with diagnosis:
Key Points:
Stop bleeding
Restore volume
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%
Physical exam.
ABCDE.
Vitals, Conscious level.
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
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
Metabolic acidosis
Severity reflects:
duration of shock
volume of blood loss
Remember
Use of term “hemodynamically stable”
Pregnancy
Extremes of Age
Athletes
Medications
Pacemaker
Hypothermia
Therapeutic decisions
Rapid response
Less than 20% blood loss
Continue to monitor
Surgical evaluation
Therapeutic decisions
Unstable – deteriorates after initial fluids
20-40% blood loss
Surgical evaluation
No response to IV fluids
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
Remember that,
Blood pressure is NOT equal to cardiac
output
CVP monitoring
Fluids