Shock in

According to latest ATLS guidelines.

1. Shock in Polytrauma Dr. lala robin Dept. of general surgery Cmc Ludhiana

2. D efinition of shock Shock is a systemic state of low tissue perfusion which is inadequate for normal cellular respiration .

3. Inadequate Cellular Oxygen Delivery Anaerobic Metabolism Inadequate Energy Production Metabolic Failure Lactic Acid Production Metabolic Acidosis CELL DEATH Ultimate Effects of Anaerobic Metabolism

4. Initial Patient Assessment Two important questions in a patient presenting to ER 1. Is the patient in shock ? 2. What is the cause of shock?

5. RECOGNITION OF SHOCK Airway, Breathing ensured C irculatory status evaluated carefully to identify the early manifestations of shock, including tachycardia and cutaneous vasoconstriction Any injured patient who is cool and has tachycardia is considered to be in shock until proven otherwise pulse rate, pulse character, respiratory rate, skin circulation, and pulse pressure

6. > 160 - Infants > 140 -Preschool child > 120 -School age to puberty > 100 - Adult Tachycardia

7. pitfalls Reliance solely on systolic blood pressure delays diagnosis of shock Compensatory mechanisms can preclude a measurable fall in systolic pressure until up to 30% of the patient’s blood volume . Elderly patients may not exhibit tachycardia A narrowed pulse pressure suggests significant blood loss and involvement of compensatory mechanisms Laboratory values for hematocrit or haemoglobin concentration may be unreliable. Serial measurement of these parameters may be used to monitor a patient’s response to therapy

8. CLINICAL DIFFERENTIATION OF CAUSE OF SHOCK Hemorrhage (most common cause) Cardiogenic Neurogenic Tension pneumothorax Sepsis

9. The response to initial treatment coupled with the finding during the primary and secondary patient surveys, usually provides sufficient information to determine the cause of the shock state.

10. Hemorrhagic Shock Assessment of hemorrhagic includes a rapid determination of the site of blood loss. Sources of potential blood loss—chest, abdomen , pelvis, retroperitoneum , extremities, and external bleeding Chest x-ray , pelvic x-ray, abdominal assessment with either focused assessment sonography in trauma ( FAST) or diagnostic peritoneal lavage (DPL), and bladder catheterization may all be necessary to determine the source of blood loss

11. on the floor plus four more A ) the chest ; ( B) the abdomen; (C) the pelvis; and (D) the femur.

12. Nonhemorrhagic Shock Cardiogenic Shock - blunt cardiac injury, cardiac tamponade , air embolus, or, rarely, a myocardial infarction  constant electrocardiographic ( ECG) monitoring to detect injury patterns and dysrhythmias. Cardiac Tamponade penetrating thoracic trauma, Tachycardia, muffled heart sounds, and dilated,engorged neck veins with hypotension resistant to fluid therapy suggest cardiac tamponade Thoracotomy, pericardiocentesis .

13. Tension Pneumothorax acute respiratory distress , subcutaneous emphysema, absent breath sounds , hyperresonance to percussion, and tracheal shift Needs chest tube/ needle decompressoion immediately Do not wait for chest xray

14. Neurogenic Shock Isolated int r acranial injuries do not cause shock . The classic picture of neurogenic shock is hypotension without tachycardia or cutaneous vasoconstriction. Cervical or upper thoracic spinal cord injury can produce hypotension due to loss of sympathetic tone often have concurrent torso trauma should be treated initially for hypovolemia. The failure of fluid resuscitation to restore organ perfusion suggests either continuing haemorrhage or neurogenic shock CVP monitoring may be helpful

15. Septic Shock Septic shock can occur in patients with penetrating abdominal injuries and contamination of the peritoneal cavity by intestinal contents difficult to distinguish from those in hypovolemic shock , as both groups can manifest tachycardia, cutaneous vasoconstriction, impaired urinary output, decreased systolic pressure, and narrow pulse pressure

16. Hemorrhagic Shock Hemorrhage is the most common cause of shock in trauma patients Hemorrhage is defined as an acute loss of circulating blood volume Advanced Trauma Life Support (ATLS) manual describes four classes of hemorrhage to emphasize the early signs of the shock state. Normal Adult blood volume = Approximately- 7% of body weight ( 70 kg= 5 L) Children = 8-9% of Body weight (80-90 ml/kg). Volume replacement is determined by patient’s response to initial therapy.

17. Hemorrhage control and balanced fluid resuscitation must be initiated  when early signs and symptoms of blood loss are apparent or suspected  not when the blood pressure is falling or absent Bleeding patients need blood ! Definitive control of haemorrhage and restoration of adequate circulating volume are the goals of treatment of hemorrhagic shock

18. Question A 70-kg patient arrives at an ED or trauma center with hypotension. What is the minimum amount of blood loss in this patient? Class III haemorrhage  atleast 30% blood loss 70 kg x 7% x 30 % = 1.47 L, or 1470 mL Resuscitation will likely require crystalloid, pRBCs, and blood products Nonresponse to fluid administration almost always indicates persistent blood loss with the need for operative or angiographic control.

19. FLUID CHANGES SECONDARY TO SOFT TISSUE INJURYAND FRACTURES B lood is lost into the site of injury, particularly in cases of major fractures fractured tibia or humerus  750 mL Fracture femur  1 500 mL pelvic fracture  retroperitoneal hematoma  more than 3 L Edema that occurs in injured soft tissues

20. Initial Management of Hemorrhagic Shock The diagnosis and treatment of shock must occur almost,simultaneously The basic management principle is to stop the bleeding and replace the volume loss.

21. PHYSICAL EXAMINATION Immediate diagnosis of life-threatening injuries and includes assessment of the ABCDEs Airway and Breathing Circulation— Hemorrhage Control Disability—Neurologic Examination Exposure—Complete Examination Gastric Dilation—Decompression Urinary Catheterization

22. Interventions Direct pressure / tourniquet STOP the bleeding! Reduce pelvic volume Angio-embolization Splint fractures Operation What can I do about it?

23. VASCULAR ACCESS LINES inserting two large- caliber (minimum of 16-gauge in an adult) peripheral intravenous catheters Forearms and antecubital veins The rate of flow is proportional to the fourth power of the radius of the cannula and inversely related to its length ( Poiseuille’s law) Fluid warmers and rapid infusion pumps are used in the presence of massive haemorrhage and severe hypotension . In children younger than 6 years - intraosseous needle Blood samples, ABG

24. INITIAL FLUID THERAPY Warmed isotonic electrolyte solutions, such as lactated Ringer’s and normal saline 1 to 2 L for adults 20 mL/kg for pediatric patients assess the patient’s response to fluid resuscitation and identify evidence of adequate end-organ perfusion and oxygenation ( urinary output, level of consciousness, and peripheral perfusion) Persistent infusion of large volumes of fluid and blood in an attempt to achieve a normal blood pressure is not a substitute for definitive control of bleeding.

25. Blood Replacement Patients who are transient responders or nonresponders—those with Class III or Class IV haemorrhage will need pRBCs and blood products as an early part of their resuscitation complete crossmatching process requires approximately 1 hour Type-specific blood can be provided by most blood banks within 10 minutes type O negative packed cells are indicated for patients with exsanguinating hemorrhage

26. WARMING FLUIDS—PLASMA AND CRYSTALLOID heat the fluid to 39°C (102.2° F) before infusing it. This can be accomplished by storing crystalloids in a warmer AUTOTRANSFUSION - Collection of shed blood for autotransfusion should be considered for any patient with a major hemothorax . MASSIVE TRANSFUSION PROTOCOL - defined as >10 units of pRBCs within the first 24 hours of admission. balanced, hemostatic or damage control resuscitation.

27. COAGULOPATHY present in up to 30% of severely injured patients on admission Massive fluid resuscitation, with the resultant dilution of platelets and clotting factors , along with the adverse effect of hypothermia on platelet aggregation and the clotting cascade platelets, cryoprecipitate, and fresh-frozen plasma CALCIUM ADMINISTRATION - guided by measurement of ionized calcium

28. Special Considerations Equating blood pressure with cardiac output Advanced age Athletes Pregnancy Medications Hypothermia Presence of pacemaker

29. Conclusion Management of shock in trauma is a challenge Most of trauma deaths can be prevented by followings ATLS protocols Early involvement of surgeon is mandatory in trauma patients.

30. THANK YOU