2. shock on trauma.ppt

8/10/2019 2. Shock on trauma.ppt

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Shock on trauma

Tatat A. Agustian


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ObjectivesDefine shockRecognize the shock state

Determine the causeApply treatment principlesApply principles of fluid managementMonitor patients response Employ options for vasculer accessRecognize complications of vascular access


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Key Issues : Shock Management

Recognize inadequate organ perfusionIdentify the cause Hemorrhagic vs nonhemorrhagic

Treatment

Stop the bleeding! Restore volume


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Cardiac Physiology

CO = SV X HR

Preload Contractility Afterload

Venous

Capacitance

dp / dtVascular

Tone


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Cardiac PhysiologyCO = stroke volume x heart rate

Stroke volume is determined by: Preload

Volume of venous return to the heart Venous capacitance , volume status , differencebetween mean venous systemic pressure and right

atrial pressure. Myocardial contractility Starlings Law

Afterload Systemic vascular resistance


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Pathophysiology


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Cellular Alteration in shock


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Recognition of Shock State

1. Tachycardia2. Vasoconstriction

2. Cardiac outputNarrow pulse pressure 3. Map

3. Blood Flow

Caution : Compensatory mechanisms


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Pitfalls in shock Recognition

Extremes of ageAthletesPregnancyMedications

Hematocrit/hemoglobin concentration


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Etiology of Shock

HemorrhagicMost commonClinical clues History & Physical

examination Selected

diagnostic tests

NonhermorrhagicTension

pneumothoraxCardiogenic

NeurogenicSeptic


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Hemorrhagic ShockLoss of circulating blood volume

Normal blood volume

Adult 7% of ideal weight Child: 9 % of ideal weight


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Classification of HemorrhageClass I-IV

Not absolute

Only A clinical guideSubsequent treatment determined by

patient response


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Class I Hemorrhage

750 mL BVL


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Class II Hemorrhage

750 1500 ml BVL


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Class III Hemorrhage1500 2000 ml BVL


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Class IV Hemorrhage : 2000 ml 2000 ML BVL


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Fluid Shifts : Soft tissue Injury

Blood loss intoinjury site

Compoundsintravascular loss.

Tissueedema


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Assessment and ManagementRecognize shockStop the bleeding !

Replenish intravascular volumeRestore organ perfusion


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Assessment and Management

Airway and Breathing Oxygenate and ventilate Pao > 80 mm hg (10,6 kpa)

C irculation Assess

C ontrol T reat


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Assessment and Management

Disability cerebral perfusionE xposure/ E nvironment

Associated injuries Prevent hypothermia

Gastric and bladder decompression

Urinary output


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Management : Vascular Access

2 large caliber, peripheral IV sCentral access Femoral Jugular Subclavian

IntraosseousObtain blood for croossmatch


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Management : Fluid Therapy

Warmed crystalloid solutionRapid fluid bolus ringer,s lactate Adult: 2 Liters, Ringers Lactate Child :20 ml /kg Ringers lactate

Monitor response to initial therapy


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Reevaluate Organ perfusion

MonitorVital signsCNS statusSkin perfusionUrinary outputPulse oximetry


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Resuscitation Evaluation

Hourly Urinary Output Inadequate output suggests

inadequate resuscitation


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Acid Base Abnormalities

Monitor with ABGsUsual etiology

Adult : Acidosis due to inadequateperfusion

Child : Acidosis due to inadequateventilation


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Therapeutic Decisions

Patient response determinessubsequent therapyHemodynamically normal vshemodynamically stable

Recognize need to resuscitate inoperating room


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Rapid Response


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Transient Response20% -40% blood lossDeteriorates after initial fluidsSurgical consultation evaluation

Continued fluid plus bloodContinued hemorrhage : Operation


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Therapeutic DecisionsMinimal to No Response

> 40% Blood loss

No Response to fluid resuscitationImmediate surgical consultation

Exclude nonhemorrhagic ShockImmediate operation


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Volume Replacement

Warmed fluids Crossmatched PRBCs

Type specificType O, Rh negativeAutotransfusionCoagulopathy


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Pitfalls

Equating Bp withcardiac output

Extremes of ageHypothermia

AthletesPregnancy

MedicationsPacemaker


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Avoiding Complications

Continued hemorrhageFluid overload

Invasive monitoring (ICU) CVP Pulmonary artery catheter

Other problems


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Keys to Successful Treatment

Early control of hemorrhageEuvolemiaContinuous reevaluation


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Questions


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Summary

Restore organ perfusion Early recognition of the shock stateOxygenate and ventilateStop the bleedingRestore volume

Continuous monitoring of responseAnticipate pitfalls

2. shock on trauma.ppt

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