Initial ResuscitationIn

Surgical Emergency By

Dr. SUTHEE INTHARACHAT

Emergency Physician

Surgical Conditions

• Trauma conditions

-Airways

-Breathing

-Circulation

-Disability

-Environments/Exposure

• Non-Trauma conditions-ABCDE

Combat Casualty Care

• Care under fire

-CAB

• Tactical field care

-ABCDE

• Tactical evacuation

-ABCDE

Open Airway Methods

Jaw thrust

Head tilt chin lift

Airway equipments

Non Definitive Airways Definitve Airways

Laryngeal Tube

Needle &Surgical Cricothyroidotomy

Equipments

Life threatening condition • Tension pneumothorax

• Opened pneumothrax

• Pneumohemothorax

Tension pneumothotax

Needle Chest Decompression

Equipments

Open pneumothorax

Bolin Chest Seal

Asherman Chest Seal

Massive Hemothorax

Flail chest อกรวน

PARADOXICAL RESPIRATIONS

Shock

• 1937 : Henri Francis LC Dran “ Choc”

• 1734 : Clarke “ Shock ”

Classified Shock

-Obstructive shock

-Hypovolemic shock

-Inflamatory shock

-Neurogenic shock

-Cardiogenic shock

Historical Background

Claude Bernard, 1879

• Milieu interieur

Historical Background

Walter B. Cannon, 1918

• World War I

• “Toxic factor”

• “ Restoration of blood pressure prior to control of active bleeding may result in loss of blood that is sorely needed.”

Historical Background

Alfred Blalock, 1934

• Reduce cardiac output due to volume loss, not a “toxic factor”

Categories of shock

• Hypovolemic shock

• Vasogenic shock

• Neurogenic shock

• Cardiogenic shock

Hemorrhagic Shock Model

Carl J. Wiggers

1. Cardiovascular response

2. Hormonal response

3. Microcirculatory response

Pathophysiology in Hemorrhagic Shock

Pathophysiology: Cardiovascular/Hormonal

Baroreceptor reflex JGA

Renin-angiotensin system

Aldosterone

ECF osmolarity

AVP/ADH

End organ perfusion

NE/E

Osmoreceptor

Hypotension

Na reabsorption+inotropism

+chronotropism

Water reabsorption

Pathophysiology: OverviewSympatico-Adrenergic Reaction Central Venous Pressure

Vascular System

Vasoconstriction Hypotension

TISSUE PERFUSION

DO2 VO2

Anaerobic metabolism Tissue acidosis

Oxygen Free Radicals NO

Capillary Leakage

Heart

Contractility Tachycardia

Cardiac VO2

Pump Failure

Coagulopathy

Coagulation Factor

Platelets

Consumption Loss

DIC Fribinolysis

MULTIPLE ORGAN DYSFUNCTION SYNDROME

Immune System

Innate immunity

Adaptive immunity

Hyperinflammation

Immunosupression BloodyVicious cycle

HYPOTHERMIA

Major Torso Trauma

Iatrogenicfactor

Cellularshock

Tissueinjury

Pre-existingdiseases

Clotting factordeficiencies

Contact activation

Active hemorrhage

Metabolicacidosis

Progressivecoagulopathy

Corehypothermia

Massivetransfusion

Pathophysiology: Microcirculation

• Decreased capillary hydrostatic pressure

• Extracellular fluid shift

G. Tom Shires

Pathophysiology: Microcirculation

• ATP depletion

• Down regulation of membrane Na+-K+ ATPase

• Na+ in

• K+ out

• Water in

• Intracellular Ca++

• Cell death

Pathophysiology: Microcirculation

No-reflow

Cellular Effects: Anaerobic Glycolysis

Cellular Effects: Apoptosis

• Ischemic-reperfusion injury

• Intestinal mucosal cell– Bacterial translocation

• Lymphocyte apoptosis– Immunosuppression

Inflammatory Response

การประเมินความรุนแรงการเสียเลอืดผู้ป่วยอุบัติเหตุ

Class I Class II Class III Class IV

ปริมาณเลือดท่ีเสีย <750 750-1,500 1,500-2,000 >2,000

ปริมาณเลือดท่ีเสีย (%)

<15% 15% – 30% 30% - 40% >40%

ชีพจร <100 > 100 >120 >140

ความดันโลหิต ปกติ ปกติ ลดลง ลดลงPulse pressure ปกติ ลดลง ลดลง ลดลง

อัตราการหายใจ 14-20 20-30 30-40 >35

ปัสสาวะ(ml/hr) >30 20-30 5-15 เล็กน้อย

CNS กระสับกระส่ายน้อยมาก

กระสับกระส่ายเล็กนอ้ย กระสับกระส่าย/ สับสน สับสน / ซึม

ATLS

Symptom/SignMild Dehydration

< 5%

Moderate

5-10%

Severe Dehydration

>10%

LOC Alert Lethargic Obtunded

Capillary refill* 2 Seconds 2-4 Seconds > 4 seconds, cool limbs

Mucous Normal Dry Parched, cracked

Heart rate Normal Increased Very increased

Blood pressure NormalNormal, but

orthostasisDecreased

Pulse Normal Thready Faint or impalpable

Skin turgor Normal Slow Tenting

Eyes Normal Sunken Very sunken

Urine output Normal Oliguria Oliguria/anuria

Axillary sweat Normal Decrease Absent

Urine spec. </= 1.020 >/=1.030 >/=1.035

BUN Normal Elevated Markedly elevated

Arterial pH. 7.30-7.40 7.10-7.30 <7.10

Clinical Findings of Dehydration in Adult

Rosen ed6.

Symptom/Sign Mild DehydrationModerate

DehydrationSevere Dehydration

Level of

consciousness*Alert Lethargic Obtunded

Capillary refill* 2 Seconds 2-4 SecondsGreater than 4 seconds,

cool limbs

Mucous Normal Dry Parched, cracked

Tears* Normal Decreased Absent

Skin turgor Normal Slow Tenting

Fontanel Normal Depressed Sunken

Eyes Normal Sunken Very sunken

Urine output Decreased Oliguria Oliguria/anuria

Heart rate Slight increase Increased Very increased

Respiratory rate Normal IncreasedIncreased and

hyperpnea

Blood pressure NormalNormal, but

orthostasisDecreased

Pulse Normal Thready Faint or impalpable

Clinical Findings of Dehydration in Pediatric

SeverityInfants (weight <10

kg)

Children (weight

>10 kg)

Mild dehydration 5% or 50 mL/kg 3% or 30 mL/kg

Moderate

dehydration10% or 100 mL/kg 6% or 60 mL/kg

Severe dehydration 15% or 150 mL/kg 9% or 90 mL/kg

Estimated Fluid Deficit in Pediatrics

Rosen ed.6

STOP BLEEDING

1. ชนิด และ ขนาด

Flow dynamics

• Poiseuille law :

¶ x R x pressure gradient Rate of flow =

8 x dynamic fluid viscosity

4

Temperature

Catheter length

Needle size Diameter

(mm)

Flow rate (ml/min)

16 1.70 210

18 1.30 100

20 1.10 65

22 0.9 38

24 0.70 24

ต าแหน่ง

1.Peripheral

2.Intraosseous

3.Central

Intraosseous

FAST

Evolution of Fluid Resuscitation

1831: 1st Cholera pandemic •William Brooke O’Shaughnessy•Injection of high oxygenated salt into the venous system

•0.5-1% NaCl: Indifferent solution

Evolution of Fluid Resuscitation

1892 Spencer “normal saline”

1896 Hartog Jakob Hamburger

• 0.92% saline was normal

• Isotonic to human serum

1883 Sydney Ringer•0.75%saline in pipe water for frog heart

Evolution of Fluid Resuscitation

1932 Alexis Hartmann

• Add sodium lactate to Ringer’s solution

• Hartmann’s solution

• Lactated Ringer’s solution

Ideal Resuscitation Fluid

The ideal resuscitation fluid would have to have the properties of an elixir of life: a small-volume cocktail that among its virtues improves perfusion, enhances oxygen (O2) delivery and diffusion, provides adequate metabolic substrates, neutralizes toxic molecules released as a result of tissue injury, provides antimicrobial activity, renders the recipient globally less vulnerable to the effects of hemorrhagic shock, and has prolonged beneficial effects. The solution should further be stable for lengthy periods at a variety of temperatures, be easy to prepare and administer, and, if not inexpensive, be at least affordable

Characteristic of Resuscitation Fluids

Characteristic of Resuscitation Fluids

Crystalloids: 0.9% Saline

• 9 g sodium chloride in 1 L water

• Osmolarity 308 mOsm/L

• pH 5

• Na 154 mEq/L, Cl 154 mEq/l

“Abnormal saline”

• Fluid retention

• Hyperchloremic metabolic acidosis

• Activation of neutrophils

Crystalloids: Lactated Ringer’s Solution

• 6 g sodium chloride + 3.22 g sodium lactate (racemic: D- and L-lactate) + 400 mg potassium chloride + 270 mg calcium chloride in 1 L water

• Osmolarity 275 mOsm/L• pH 6.5• Vietnam conflicts: DaNang lung, shock lung,

Traumatic wet lung…ARDS• Neutrophils activation• Increase ICAM-1• Increase expression of Bax

Crystalloids: Hypertonic Saline

• De Felippe et al.1980; Velasco et al.,1980

• 7.5% sodium chloride

• Osmolarity 2567

• Small volume: Infusion of 250 mL, plasma volume expansion 1000 mL

• Protect microcirculation

• Immunologic protection

• Kramer 1986: 7.5% saline with 6% Dextran 70 (Hypertonic saline-dextran, HSD)

Resuscitation Outcome Consortium (ROC)

• Sponsored by NIH and USDD

• HSD: HTS: NSS Resuscitation in

1. Survival in blunt/penetrating trauma

2. Long term neurologic status after STBI

Crystalloids: Hypertonic Saline

Colloids: Conclusion

• Cochrane Injuries Group Albumin Reviewers, CIGAR 1998: RR of death with albumin was 1.68

• CIGAR 2004: Fail to show benefit of colloid over crystalloid

• Cochrane 2008: no evidence that one crystalloid was safer than another, and because no reduction in risk for death was evident in critically ill patients, continued use of these agents in these patients could not be justified outside the setting of RCT

Martin K Angele et al, Critical Care 2008;12(4)

Ideal Resuscitation Fluid

The ideal resuscitation fluid would have to have the properties of an elixir of life: a small-volume cocktail that among its virtues improves perfusion, enhances oxygen (O2) delivery and diffusion, provides adequate metabolic substrates, neutralizes toxic molecules released as a result of tissue injury, provides antimicrobial activity, renders the recipient globally less vulnerable to the effects of hemorrhagic shock, and has prolonged beneficial effects. The solution should further be stable for lengthy periods at a variety of temperatures, be easy to prepare and administer, and, if not inexpensive, be at least affordable

Still on there way

Crystalloid Colloid

intravascular compartment

สั้น นาน

ปริมาณทีใ่ช้ มากกว่า 3 เท่า น้อย

การเกิดเนื้อเยื่อบวมน้ า มาก น้อย

ราคา ถูก แพง

การหามาใช้ ง่าย ต้องจดัหา

ผลข้างเคียง น้อย มากกว่า เช่น รบกวนการแข็งตัวของเลือด , RF

Oxygen carrying resuscitation fluids

• Hemoglobin-based oxygen carriers

• Flurocarbon-based oxygen carriers

Blood transfusion

• Fully crossmathed –> 1 hr or more

• Type specific –> 10-15 min

• Type O low titer Rh +/-

Stored blood ไม่ดีเท่า fresh blood เพราะ: reduced oxygen carrying capacity (2,3-DPG): platelets are inactive: clotting factors may be degraded

• Autotransfusion:

: directly anticoagulated and reinfused into the patients using a macroaggregate filter.

: use of a cell-saver and provision of washed RBCs.

• Massive transfusion:

: Transfusion of at least one blood volume or 10 units of blood in a 24 hr

Whole blood:

• ประกอบด้วย colloids (plasma proteins), clotting factors including platelets, red blood cells for oxygen carrying capacity

• Indications: acute blood loss, concurrent anemia and hypoproteinemia, clotting defects

• Dose 5 – 15 ml/kg/hr and 40-60 ml/kg/hr ( life-threatening emergency. )

Packed red blood cells:

• 1 U Hct 3% ให้ใน 2-3 ชั่วโมง

• เด็ก 10-15 ml/kg

• Indication : 1. Anemia Hb < 7 g/dl

2. O2 carrying capacity

• Leukoreduction, • ข้อดี Alloimmunization and febrile

transfusion reactions.

• CMV transmission.

• Indication :– Chronically transfused patients

– Potential transplant recipients

– Patients with previous febrile nonhemolytic transfusion reactions

– CMV seronegative at-risk patients

Irradiation. • ข้อดี Graft- versus-host

• Indication :

– ผู้ป่วยภูมิคุ้มกันบกพร่อง ( hereditary immune deficiencies, Chemotherapy ,Transplantation, AIDs (controversial).

– Patients receiving blood transfusions from relatives in directed-donation programs

Washed PRC : กรณีแพ้ plasma เช่น IgA deficiency

Fresh Frozen Plasma:

• ประกอบด้วย colloids, active platelets, and

clotting factors ( 1U = 3-5% cofactor)

• เด็ก 10-15 ml/kg

• Indication :

– bleeding ร่วมกับขาด Coagulation factor

– แก้ coagulation defects

– Massive transfusion

– hypoproteinemia and maintaining normal colloidal osmotic pressure

Platelet

• Platelet conc. 6 U / Single donor 1U

เพิ่ม Platelet 50,000 /ml

• Indication : Therapeutic / Prophylaxis

< 10,000 Asymtomatic

< 15,000 Cogulation disorder / bleeding

< 20,000 Major bleed

< 50,000 Invasive procedure/ massive transfusion

<100,00 Neurologic / cardiac surgery

Cryoprecipitate

• Dose : 1U/5 kg เพิ่ม Fibrinogen 75 mg/dl

ให้ 10 U

: 1U/kg เพิ่ม 2% factor VIII activity

• Indication :– Bleeding with fibrinogen < 100mg/dl เช่น DIC

– Von Willenbrand disease

– Hemophelia A

Complications การให้สารน้ า

• Infection : local: swelling, redness, and fever , septicemia

• Phlebitis : irritation(foreign body (the IV catheter)) or the fluids or medication

Symptoms : swelling, pain, and redness

Mx. warmth, elevation of the affected limb, or

a change flow rate

• Fluid overload : hypertension, heart failure, and pulmonary edema

• Electrolyte imbalance

• Embolism

• A blood clot or other solid mass, or an air bubble,

• Air bubbles < 30 mL dissolve into the circulation harmlessly.

• Extremely large (3-8 mL/kg), Arrest

• Extravasation

Febrile non-hemolytic transfusion reaction

• most common ,benign

• fever and dyspnea 1 to 6 hours

Complication การรับผลิตภัณฑ์เลือด

Acute hemolytic reaction. •Medical Emergency•Hemolysis ของ donor RBC โดย host antibody. •The most common “wrong unit to wrong patient”•อาการ ไข้ หนาวสั่น ปวดหลัง ปัสสาวะสีชมพูแดง เหนื่อย หัวใจเต้นเร็ว ช็อก DIC , Renal failure

Management

• หยุดการให้เลอืดทันที

• IV hydration ให้ปัสสาวะออกดี

• Oxygen

• ส่งเลือดในถุง และเลือดผู้ป่วยกลับไปตรวจซ้้า

• Hemolytic work up : Direct / Indirect coombs test , CBC, Creatinine ,Coagulogram ,LDH ,Indirect bilirubin , Urine for hemoglobin

• Paracetamol

• Meperidine (pethidine)

• Antihistamine ถ้ามีผื่นคัน หรือคัน

• Viral infection. : HBV( 1 in 250,000 units ) HIV or HCV ( at 1 per 2 million units ).

• Bacterial infection. The risk is highest with

platelet transfusion (1 in 50,000 platelet transfusions), and 1 in 500,000 red blood cell transfusions

• Volume overload.

• Anaphylactic reaction.

• Transfusion-associated acute lung injury (TRALI).

• อาการ ไข้ , non-cardiogenic pulmonary edema , and hypotension.

• Self limited within 96 hours,

• Iron overload. .

• Transfusion-associated graft-vs-host disease (GVHD).

Large Volume Crystalloid Resuscitation

• World War II: Blood for resuscitation lead to post-traumatic ARF

• Vietnam: Large volume of crystalloid resuscitation decreased incidence of ARF

• ATLS® protocol: 2L of crystalloid bolus and check for response, if non-responder, call for blood

• Crystalloid: short term hemodynamic benefit, adverse consequences of hemostasis– Dilutional coagulopathy– Secondary clot disruption

Increase blood flowIncrease perfusion pressureDecrease blood viscosity

Immediate versus Delayed Fluid Resuscitation for

Hypotensive Patients with Penetrating Torso Injuries

William H. Bickell, Matthew J. Wall, Paul E. Pepe, R. Russell Martin,

Victoria F. Ginger, Mary K. Allen, and Kenneth L. Mattox

Among the 289 patients who received delayed fluid resuscitation, 203 (70 percent) survived and were discharged from the hospital, as compared with 193 of the 309 patients (62 percent) who received immediate fluid resuscitation (P = 0.04). The mean estimated intraoperative blood loss was similar in the two groups. Among the 238 patients in the delayed-resuscitation group who survived to the postoperative period, 55 (23 percent) had one or more complications (adult respiratory distress syndrome, sepsis syndrome, acute renal failure, coagulopathy, wound infection, and pneumonia), as compared with 69 of the 227 patients (30 percent) in the immediate-resuscitation group (P = 0.08). The duration of hospitalization was shorter in the delayed-resuscitation group.

Disabilities and Immobilization

• Rapid neurogic evaluation

– GCS, conciousness, pupillary size and reaction, localizing signs

Pathophysiology: Microcirculation

LRS and Neutrophils Activation