Emergency medicine hemorrhagic shock.pptx

Emergency medicine hemorrhagic shock

1. Hemorrhagic shock

2. Objective of course Define shock. Describe the likely causes of shock in trauma patients. Describe the clinical signs of shock and relate them to the degree of blood loss. Explain the importance of rapidly identifying and controlling the source of hemorrhage in trauma patients . Describe the proper initial management of hemorrhagic shock in trauma patients. Describe the rationale for ongoing evaluation of fluid resuscitation, organ perfusion, and tissue oxygenation in trauma patients. Explain the role of blood replacement in managing shock

3. The first step in managing shock in trauma patients is to recognize its presence. The definition of shock—an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation— also guides the trauma team in the diagnosis and treatment . Diagnosing shock in a trauma patient relies on a synthesis of clinical findings and laboratory tests .

4. The second step in managing shock is to identify the probable cause of shock and adjust treatment accordingly . In trauma patients, this process is related to the mechanism of injury. Most injured patients in shock have hypovolemia, but they may suffer from cardiogenic , obstructive, neurogenic, and/or, rarely, septic shock.

5. CLASS OF HEMORRHAGIC SHOCK Class I hemorrhage involves a blood volume loss of up to 15 percent. The heart rate is minimally elevated or normal, and no change in blood pressure, pulse pressure, or respiratory rate. Class II hemorrhage occurs when there is a 15 to 30 percent blood volume loss and is manifested clinically as tachycardia (heart rate of 100 to 120), tachypnea (respiratory rate of 20 to 24), and a decreased pulse pressure, systolic blood pressure changes minimally if at all. The skin may be cool and clammy, and capillary refill may be delayed.

6. Class III hemorrhage involves a 30 to 40 percent blood volume loss, a significant drop in blood pressure and changes in mental status. Heart rate (≥120 and thready ) and respiratory rate are markedly elevated, while urine output is diminished. Capillary refill is delayed. Class IV hemorrhage involves more than 40 percent blood volume loss significant depression in blood pressure and mental status. systolic blood pressure less than 90 mmHg. Pulse pressure is narrowed (≤25 mmHg), and tachycardia is marked (>120). Urine output is minimal or absent. The skin is cold and pale, and capillary refill is delayed.

7. ----------- immediately detectable manifestations of the shock state include: Tachycardia Hypotension Cool extremities Weak peripheral pulses Prolonged capillary refill (>2 seconds) Narrowing of the pulse pressure (<25 mmHg) Altered mental status not due to head injury

8. I. Low CVP A. Hypovolemia 1. Hemorrhage a. External (compressible) i. Lacerations ii. Contusions iii. Fractures (partly compressible) b. Internal (noncompressible) i. Intrathoracic ii. Intraperitoneal iii. Retroperitoneal (partly compressible) c. Fractures (partly compressible) 2. Third spacing (eg, burns) B. Neurogenic (high cervical cord injury) II. High CVP A. Pericardial tamponade B. Tension pneumothorax C. Myocardial contusion III. Other diagnoses to consider A. Pharmacologic or toxicologic agents B. Myocardial infarction (severe) C. Diaphragmatic rupture with herniation D. Fat or air embolism

9. INITIAL HOSPITAL MANAGEMENT Basic approach and initial interventions — Initial management of the adult trauma patient in shock is focused on the following: ●Recognizing and reversing life-threatening injuries ( eg , tension pneumothorax, cardiac tamponade) immediately. ●Restoring intravascular volume if necessary. ●Maintaining adequate oxygen delivery to vital organs. ●Preventing or limiting ongoing blood loss.

10. performing the following immediate interventions listed in order of priority: ●Establish a patent and protected airway while protecting the cervical spine. ●Maximize oxygenation. ●Gain intravenous (IV) access and initiate fluid resuscitation or blood transfusion as indicated. ●Control hemorrhage. ●Identify and reverse immediate threats to life ( eg , pericardial tamponade, tension pneumothorax). ●Obtain blood for laboratory and blood bank testing.

11. Bleeding control methods Direct pressure is the primary and preferred means for controlling external hemorrhage. blind clamping should  NOT  be performed . Scalp lacerations can be managed by placing clips ( eg , Raney clips or by closing the wound with running ( ie , noninterrupted ) or running locked stitches using heavy suture. Use of a tourniquet is acceptable to stop hemorrhage in cases of amputation or severe extremity injury when other measures have not successfully controlled bleeding.

12. Guiding principles for resuscitation  —  key principles guide the management of hemorrhage due to trauma: Resuscitation using intravenous (IV) fluids should be used only for hypotensive patients, and then only until blood is available. Blood products should be given as soon as the need for transfusion is recognized. Blood products ( ie , red blood cells, plasma [clotting factors], and platelets) should be given in equivalent amounts – in other words, in a 1:1:1 ratio. Thromboelastography , or comparable rapid point-of-care assessment of coagulation, should be used to guide trauma resuscitation whenever available

13. Massive transfusion protocol massive transfusion was considered 10 units of PRBCs or more transfused over a 24-hour period, but many experts now advocate a revised definition of 10 units or more transfused over 6 hours

14. The ABC score relies on 4 parameters that can be determined upon arrival to the ED: Penetrating mechanism of injury Positive FAST (Focused Assessment with Sonography in Trauma) examination ( ie , evidence of hemorrhage) SBP of 90 mmHg or less Heart rate of 120 beats per minute (bpm) or greater

15. monitoring The following parameters may be used to guide prolonged resuscitation of traumatic shock Blood pressure: Maintain MAP above 65 mmHg for penetrating trauma, and above 85 mmHg for blunt trauma that may involve TBI or SCI. Heart rate (HR): Maintain between 60 and 100 beats per minute. Oxygen saturation: Maintain above 94 percent. Urine output: Maintain above 0.5 mL/kg per hour. Lactate and base deficit :.Reasonable goals of resuscitation include a serum lactate <2  mmol /L and normalization of any base deficit. Mixed central venous oxygen saturation: Monitor every four hours and goal is to maintain above 70 percent.

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