Trauma Shock- Deten and manment

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Lecture delivered in EMCME 2010 at Calicut on Trauma shock management based on ATLS guidelines

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“TRAUMA - SHOCK” : 

“TRAUMA - SHOCK” Venugopalan.P.P DA,DNB,MNAMS Chief of Emergency Medicine, MIMS Executive Director Angels Detection , assessment & management Lecture based on American college of Surgeons - ATLS guidelines

Case Scenario: 

Case Scenario 28-year-old female in high speed MVC Pulse: 126; BP: 96/70; RR: 28 Confused and anxious How would you manage this patient? Is this patient in shock? If so, what type?

Objectives: 

Objectives Define shock. Recognize the shock state. Determine the cause of shock. Discuss treatment principles. Recognize the importance of early identification and control of hemorrhage.

Definition : 

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

PowerPoint Presentation: 

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

Shock –Animation Video : 

Shock –Animation Video

Shock: 

Shock Scene information / mechanism of injury AMPLE history How do I recognize shock?

SAMPLE / AMPLE: 

SAMPLE / AMPLE Allergy/Anaphylaxis Medications Past Medical/Surgical history/Pregnancy Last meal /LMP Event

Shock: 

Shock Alteration in level of consciousness, anxiety Cold, diaphoretic skin Tachycardia Is the patient in shock?

Shock: 

Shock Tachypnea, shallow respirations Hypotension Decreased urine output Is the patient in shock?

ABCDE : 

ABCDE Airway Breathing Circulation Disability [ Neurological status] Exposure / Environment F O C U S

Follow Concepts of Initial Assessment: 

Follow Concepts of Initial Assessment Definitive Care Reevaluation Adjuncts Adjuncts Primary Survey Resuscitation Reevaluation Detailed Secondary Survey

Shock: 

Shock Physical examination Diagnostic adjuncts to primary survey Chest X-ray Pelvic X-ray FAST / DPL How do I locate the bleeding?

How to decide the causes?: 

How to decide the causes? 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.

Two Critical steps : 

Two Critical steps 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

Step -Two: 

Step -Two What is the cause of the shock state? Blood loss Fluid loss Tension pneumothorax Cardiac tamponade Cardiogenic Septic Neurogenic Hypovolemic Nonhemorrhagic

PowerPoint Presentation: 

In the vast majority of trauma patients, shock is due to blood loss.

PowerPoint Presentation: 

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 .

PowerPoint Presentation: 

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

PowerPoint Presentation: 

Tachycardia >140 Preschool >100 Adult >120 School children >160 Infants ]

Caution !: 

Caution ! Extremes of age Athletes Pregnancy Beta blockers Cardiac Pacemakers Cardiac Transplants Special groups

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

PowerPoint Presentation: 

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

Class I Hemorrhage: 

Class I Hemorrhage Slightly anxious Normal blood pressure Heart rate < 100 / min Respirations 14-20 / min Urinary output 30 mL / hour Crystalloid 750 mL BVL (15%)

Class II Hemorrhage: 

Class II Hemorrhage Anxious Normal blood pressure Heart rate > 100 / min Decreased pulse pressure Respirations 20-30 / min Urinary output 20-30 mL / hour Crystalloid, ? blood 750-1500 mL BVL (15-30%)

Class III Hemorrhage: 

Class III Hemorrhage Confused, anxious Decreased blood pressure Heart rate > 120 / min Decreased pulse pressure Respirations 30-40 / min Urinary output 5-15 mL / hour Crystalloid, blood components, operation 1500-2000 mL BVL (30-40%)

Class IV Hemorrhage: 

Class IV Hemorrhage Confused, lethargic Hypotension Heart rate > 140 / min Decreased pulse pressure Respirations >35 / min Urinary output negligible Definitive control, blood components >2000 mL BVL (>40%)

PowerPoint Presentation: 

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

PowerPoint Presentation: 

Assess the “response” to initial volume therapy

Patient Response: 

Patient Response Skin: warm, capillary refill Renal: increased urinary output Vital signs CNS: improved level of consciousness Identify improved organ function How do I evaluate the patient’s response?

Urine output: 

Urine output 1.5 – 2 mL / kg 0 – 2 years 1 mL / kg 3 – 5 years 0.5 – 1 mL / kg 6 – 12 years

Decide & Defferentiate : 

Decide & Defferentiate 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

PowerPoint Presentation: 

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

Management strategy : 

Management strategy Assess and manage “ABCDE” Establish “ IV line - Oxygen –Monitors”

Management strategy: 

Management strategy Insert “2 large bore” cannulae in peripheral Veins Infuse “large volume” of warm crystalloids (2-4 liters) rapidly

Management strategy: 

Management strategy Decompress Bowel and Bladder Rule out urethral injury

Management strategy: 

Management strategy Monitor Response Prevent hypothermia

Interventions: 

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

Failure to respond to crystalloid and blood administration ?: 

Failure to respond to crystalloid and blood administration ? Blunt myocardial injury Cardiac tamponade Tension pneumothorax Search Causes

Failure to respond to crystalloid and blood administration ?: 

Failure to respond to crystalloid and blood administration ? 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

PowerPoint Presentation: 

Pitfalls Age extremes Athletes Pregnancy Medications Pacemaker Complications of Shock – Patient Factors Pitfalls

PowerPoint Presentation: 

Hypothermia Early coagulopathy Pitfalls Pitfalls Complications of Shock and Shock Management

PowerPoint Presentation: 

Equating BP with cardiac output Misleading hemoglobin and hematocrit levels Pitfalls Pitfalls Complications of Shock

Pediatric Trauma- shock: 

Pediatric Trauma- shock Pitfalls

Summary: 

Summary Shock is inadequate organ perfusion and tissue oxygenation. Hypovolemia is the cause of shock in most trauma patients. Patients may present with mild to severe shock.

Summary: 

Summary Conduct a rapid initial assessment and resuscitation. Determine cause of shock. Stop the bleeding. Reevaluate.

PowerPoint Presentation: 

A B C D E Thanks .... www.drvenu.net www.emergencymedicinemims.com www.angelsindia.org