ASI- Shock

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Presentation was given in the ASI meeting at Calicut -India


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“TRAUMA - SHOCK” Detection & Management:

“TRAUMA - SHOCK” Detection & Management Venugopalan.P.P DA,DNB,MNAMS Chief of Emergency Medicine MIMS

Definition :

Definition An abnormality of circulatory system that results in inadequate organ perfusion and tissue oxygenation Imbalance between oxygen delivery & consumption

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

Two Critical steps in the management:

Two Critical steps in the management Step one Recognize its presence – Initial diagnosis is based on clinical appreciation of the presence of inadequate tissue perfusion and oxygenation No laboratory test diagnoses shock

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Step two Identify the probable causes of the shock state. Hemorrhage (most common cause) Cardiogenic Neurogenic Tension pneumothorax [Even] Sepsis

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

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Shock does not result from isolated brain injuries.

Response to blood loss:

Response to blood loss Early circulatory responses to blood loss are compensatory – Progressive vasoconstriction of cutaneous, muscle, and visceral circulation to preserve blood flow to the kidneys, heart and brain

Earliest clinical signs :

Earliest clinical signs Tachycardia - the earliest measurable circulatory sign of shock Increased Diastolic blood pressure Reduced Pulse Pressure.

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Any injured patient who is cool and tachycardic is in “shock” until proven otherwise

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

Treatment goals:

Treatment goals Volume restoration Control hemorrhage Assess response to the initial therapy The presence of shock in an injured patient demands the immediate involvement of a surgeon

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V asopressors are contraindicated for the treatment of hemorrhagic shock because they worsen tissue perfusion

Estimate fluid and blood losses Based on Patient’s Initial Presentation:

Estimate fluid and blood losses Based on Patient’s Initial Presentation

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Class I Class II Class III Class IV Blood Loss (mL) Up to 750 750-1500 1500-2000 > 2000 Blood loss (% blood volume) Up to 15 % 15 %-30% 30% - 40 % > 40 % Pulse rate <100 > 100 >120 >140 Blood pressure Normal Normal Decreased Decreased Pulse pressure (mm Hg) Normal or increased Decreased Decreased Decreased Respiratory rate 14-20 20-30 30-40 > 35 Urine output (mL/hr) >30 20-30 5-15 Negligible CNS/Mental status Slightly anxious Mildly anxious Anxious confused Confused, lethargic Fluid replacement (3:1 rule) Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood

Management strategy :

Management strategy Assess and manage “ABC” Establish “IV -Oxygen –Monitors” Insert “2 large bore” cannulae in peripheral Veins Infuse “large volume” of warm crystalloids (2-4 liters) rapidly Insert NG tube and bladder catheter

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Assess the “response” to initial volume therapy

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Response to initial fluid resuscitation is the key to determining subsequent therapy Distinguish “Hemodynamically stable” from “Hemodynamically normal”

Response to initial fluid resuscitation:

Response to initial fluid resuscitation [2000 mL Ringer;s lactate solution in adults, 20 ml/kg Ringer’s lactate bolus in children] Rapid response Transient response Minimal or No response

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Rapid Response Transient response No response Vital signs Return to normal Transient improvement, recurrence of ↓ BP and ↑HR Remain abnormal Estimated blood loss Minimal (10% - 20%) Moderate and ongoing (20% - 40%) Severe (>40%) Need for more crystalloid Low High High Need for blood Low Moderate to high Immediate Blood preparation Type and cross match Type-specific Emergency blood release Need for operative intervention Possibly Likely Highly likely Early presence of surgeon Yes Yes Yes

Failure to respond to crystalloid and blood administration ?:

Failure to respond to crystalloid and blood administration ? Blunt myocardial injury Cardiac tamponade Tension pneumothorax Neurogenic shock Ongoing hemorrhage Retroperitonial bleed Internal organ injury Search Causes

Fluid of choice:

Fluid of choice Ringer’s lactate is the initial fluid of choice Normal saline is the second choice Blood and blood components as required

Special situations :

Special situations Age Athletes Pregnancy Medications Hypothermia Pacemaker Beware Unusual presentations

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Debate !

Permissive Hypotension in Trauma:

Permissive Hypotension in Trauma “One of the most controversial issues in trauma care today is restricting intravenous fluid resuscitation in hypotensive trauma patients who have uncontrolled hemorrhage” This new approach has the following goals : 1) Limiting hemorrhage 2) Preventing hemodilution 3) Not disrupting the clotting process.

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Permissive hypotension is still a relatively new concept for treating trauma patients who are hypotensive with uncontrolled hemorrhage. There is still no clear, universal recommendation regarding a standardized approach. Research and common sense does allow some initial conclusions to be drawn that definitely favor permissive hypotension.

Interesting Web Sites:

Interesting Web Sites (Research articles on permissive hypotension) (Allows you to calculate allowable blood loss)

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