![Page 1: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/1.jpg)
Hemorraghic ShockSara Parker MD
VCU Trauma ConferenceSTICU FellowJuly 8, 2015
![Page 2: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/2.jpg)
Learning objectives
• 1) Review the classes of shock
• 2) Review treatment options
• 3) Review endpoints of resuscitation
![Page 3: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/3.jpg)
SL
• 26 yo female who presents from OSH as transfer with multiple GSW to chest, abdomen and extremities.
• At OSH, had L chest tube placed and was given 2u RBC and 1L crystalloid.
![Page 4: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/4.jpg)
Vital signs per EMS
• HR 120
• BP 98/53
• RR 30
• O2. Sats 99%
• SBP as low as 80s
![Page 5: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/5.jpg)
What next?
ABCD• Airway
• Breathing
• Circulation
• Disability
![Page 6: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/6.jpg)
Repeat Vitals
• HR 145
• BP 86/53
• RR 45
• Sats 95%
![Page 7: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/7.jpg)
What next?
• Diagnose hemorrhagic shock
• Treat the cause
![Page 8: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/8.jpg)
Shock
• Inadequate oxygen delivery unable to meet the demands of the tissue leading to global tissue hypoxia and metabolic acidosis
![Page 9: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/9.jpg)
With what class of hemorrhaghic shock do you have low blood pressure?
a) Class Ib) Class IIc) Class IIId) Class V
![Page 10: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/10.jpg)
Classification of Shock
Class 1 Class 2 Class 3 Class 4
Blood loss <750 750-1500 1500-2000 >2000
HR <100 100-120 120-140 >140
SBP Normal Normal Decreased
Decreased
Pulse Pressure
Normal Decreased
Decreased Decreased
![Page 11: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/11.jpg)
Fluid responsiveness
Infusion of 500cc IVF—improvement of HR, BP and UOP
Caveats: Athletes, pregnancy, extremes of age and medication use
![Page 12: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/12.jpg)
What type of shock is likely to be hypotensive and bradycardic?
a) Hemorrhagic shockb) Neurogenic shockc) Septic shockd) Anaphylatic shock
![Page 13: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/13.jpg)
Types of ShockCauses Pathophysiology Signs/symptoms
Hypovolemic Dehydration, Hemorrhage,
Burn
Decreased preload, CO and
increased SVRintravascular
volume loss
Increased HR, dec pulses, dry skin, delayed cap refill, dec
UOP
Distributive AnaphylacticNeurologic
Septic
Decreased Afterload
Low BP, resp distress.
Cardiogenic Decreased CO, variable SVR
Normal to inc HR, dec pulses,
delayed cap refil, JVD
![Page 14: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/14.jpg)
Diagnosis
• Hgb 12.5, platelets 350, coags pending
• Pulses are weak, skin clammy, patient can’t remember where she is
• Clinical diagnosis--early recognition is KEY
![Page 15: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/15.jpg)
Treatment of Shock
1 Hypotensive volume resuscitation
• crystalloid
• blood products
• Goal SBP <100 or MAP >50
• Control of bleeding
![Page 16: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/16.jpg)
![Page 17: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/17.jpg)
Hypotensive resuscitation
Titration of initial fluid therapy to a lower than normal SBP during active hemorrhage did not affect mortality. --Dutton.
• Hypotensive resuscitation results in a significant reduction in blood product transfusions and overall IV fluid administration. Specifically, resuscitating patients with the intent of maintaining a target minimum MAP of 50 mm Hg, rather than 65 mm Hg, significantly decreases postoperative coagulopathy and lowers the risk of early postoperative death and coagulopathy. --Morrison
![Page 18: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/18.jpg)
What is the 4th step of the massive transfusion protocol at VCU?
a) set up platelets and cyro, release 4 RBC and 4 plasma
b) setup 4 RBC and 2 Plasma, release 4 RBC and 2 plasma
c) keep ahead 4 RBC and 4 Plasmad) release 4 RBC and 4 plasma
![Page 19: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/19.jpg)
Massive Transfusion Protocol• Step 1: Set up 4 RBC, 2 Plasma. Keep Ahead 4 RBC and 4 plasma.
Release 4 RBC and 2 plasma
• Step 2: Release 4 RBC and 4 plasma
• Step 3: Setup platelets and cyro. Release 4 RBC, 4 plasma, Platelets and cyro.
• Step 4: Release 4 RBC and 4 plasma.
• Step 5: Release 4 RBC and 4 plasma.
• Step 6: Setup platelets and cyro. Release 4 RBC, 4 plasma, platelet, cyro.
• Step 7: Release 4 RBC and 4 plasma.
• Step 8: Release 4 RBC and 4 plasma.
• Step 9: Setup platelet and cyro. Release 4 RBC, 4 plasma, platelets, cyro.
![Page 20: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/20.jpg)
Massive transfusion• Patients who will require a massive transfusion will have
improved outcomes the earlier that this is identified and the earlier that damage control hematology is instituted. Current evidence does not describe the best ratio but the preponderance of the data suggests it should be greater than 2: 3 plasma-to-packed red blood cells. --Nunez et al.
• Trauma patients who arrived to the hospital with an elevated INR had a greater risk of death than those with a lower INR. However, as the ratio of FFP:PRBC transfused increased, mortality decreased similarly between the INR quartiles. --Brown L and Trauma Outcomes Group
![Page 21: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/21.jpg)
Ionotropes• Norepinephrine—preferred for shock/sepsis
• Stimulates beta1-adrenergic receptors and alpha-adrenergic receptors causing increased contractility and heart rate as well as vasoconstriction
• Vasopressin—refractory shock
• Increases systemic vascular resistance and mean arterial blood pressure and decreases heart rate and cardiac output
• Phenylephrine—alpha receptor only, peripheral use
• Potent, direct-acting alpha-adrenergic agonist with virtually no beta-adrenergic activity; produces systemic arterial vasoconstriction.
![Page 22: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/22.jpg)
What is the urine output goal for resuscitation for adults?
a) 0.2 mg/kg/hrb) 0.4 mg/kg/hrc) 0.5 mg/kg/hrd) 1.0 mg/kg/hr
![Page 23: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/23.jpg)
End Points of Resuscitation
• Skin perfusion
• Urinary output
• Lactate
![Page 24: Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow July 8, 2015](https://reader038.vdocuments.us/reader038/viewer/2022110405/56649eeb5503460f94bfc280/html5/thumbnails/24.jpg)
Bilbiography• ATLS Student Manual. Chicago: American College of Surgeons, 2012.
• Brown L et al with the Trauma Outcomes Group. A High FFP:PRBC Transfusion Ratio Decreases Mortality in All Massively Transfused Trauma Patients Regardless of Admission INR. J Trauma 2011: 71(2 O 3) S358-363.
• Cotton BA et al. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma 2009: 66: 41-9.
• Dutton, et al. Hypotensive resusciation during active hemorrhage: impact on in-hospital mortality. J Trauma 2002 52:1141-1146.
• Marino, Paul. The ICU Book, 4th ed. Philadelphia: Wolters Kluwer, 2014.
• Morrison C Anne et al. Hypotensive Resuscitation Strategy Reduces Transfusion Requirements and Severe Postoperative Coagulopathy in Trauma Patients With Hemorrhagic Shock: Preliminary Results of a Randomized Controlled Trial. J Trauma - Injury, Infection and Critical Care 2011 70:3: 652-663.
• Nunez TC. Transfusion therapy in massive hemorrhage. Current Opinion in Critical Care. 2009: 15 (6) 536-41.