emergency lectures - shock
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Initial Assessment and Management
Committee on Trauma Presents
Shock
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Case Scenario
● 28-year-old female in 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?
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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.
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What is shock?
Cell death
Inadequate oxygen delivery
Catecholamines and other responses
Anaerobic metabolism
Cellular dysfunction
Generalized State of Hypoperfusion
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Shock
●Alteration in level of consciousness, anxiety
●Cold, diaphoretic skin
●Tachycardia
●Tachypnea, shallow respirations
●Hypotension
●Decreased urinary output
Is the patient in shock?
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Shock
●Scene information / mechanism of injury
●AMPLE history
Inadequate perfusion
Organ dysfunction
How do I recognize shock?
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Shock
What is the cause of the shock state?
●Blood loss
●Fluid loss
●Tension pneumothorax
●Cardiac tamponade
●Cardiogenic
●Septic
●Neurogenic
Hypovolemic
Nonhemorrhagic
vs
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Shock
How do I locate the bleeding?
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Shock
●Physical examination
●Diagnostic adjuncts to primary survey
● Chest X-ray
● Pelvic X-ray
● FAST / DPL
How do I locate the bleeding?
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What is the cause of the shock state?
In the vast majority of trauma patients, shock is due to blood loss.
Shock
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Interventions
Direct pressure / tourniquet STOP
thebleeding!
Reduce pelvic volume
Angio-embolization
Splint fractures
Operation
What can I do about it?
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Interventions
●Fluid resuscitation
● Vascular access?
● Type?
● Volume?
●Monitor response
●Prevent hypothermia!
What can I do about it?
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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?
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Patient Response
What is the patient’s response?
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Patient Response
●Rapid responder
●Transient responder
●Nonresponder
Related to volume or persistence of hemorrhage
Operation
What is the patient’s response?
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Class I Hemorrhage
●Slightly anxious
●Normal blood pressure
●Heart rate < 100 / min
●Respirations 14-20 / min
●Urinary output 30 mL / hour
750 mL BVL (15%)
Crystalloid
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Class II Hemorrhage
●Anxious
●Normal blood pressure
●Heart rate > 100 / min
●Decreased pulse pressure
●Respirations 20-30 / min
●Urinary output 20-30 mL / hour
750-1500 mL BVL (15-30%)
Crystalloid,? blood
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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
1500-2000 mL BVL (30-40%)
Crystalloid, blood
components, operation
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Class IV Hemorrhage
●Confused, lethargic
●Hypotension
●Heart rate > 140 / min
●Decreased pulse pressure
●Respirations >35 / min
●Urinary output negligible
>2000 mL BVL (>40%)
Definitive control, blood components
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Pitfalls
●Age extremes
●Athletes
●Pregnancy
●Medications
●Pacemaker
Complications of Shock – Patient Factors
Pitfalls
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●Hypothermia
●Early coagulopathy
Pitfalls
Pitfalls
Complications of Shock and Shock Management
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●Equating BP with cardiac output
●Misleading hemoglobin and hematocrit levels
Pitfalls
Pitfalls
Complications of Shock
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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.
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Summary
●Conduct a rapid initial assessment and resuscitation.
●Determine cause of shock.
●Stop the bleeding.
●Reevaluate.