“TRAUMA - SHOCK”Red flags & Deadlines

Dr.Venugopalan.P.P DA,DNB,MNAMS.MEM -GWU

Director , Emergency Medicine, Aster DM healthcareFounder& Executive Director

Active Network Group of Emergency Life Savers

Definition

An abnormality of circulatory system that results in inadequate organ perfusion and tissue oxygenation

Imbalance between

oxygen delivery & consumption

InadequateCellularOxygenDelivery

AnaerobicMetabolism

InadequateEnergyProduction

MetabolicFailure

LacticAcidProduction

MetabolicAcidosisCELL

DEATH

Ultimate Effects of Anaerobic Metabolism

Two Critical steps in the management

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 Identify the probable causes of the shock state.– Hemorrhage (most common cause)– Cardiogenic– Neurogenic– Tension pneumothorax – [Even] Sepsis

• 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.

Shock does not result from isolated brain injuries.

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

• Tachycardia - the earliest measurable circulatory sign of shock

• Increased Diastolic blood pressure • Reduced Pulse Pressure.

Any injured patient who is cool and tachycardic

is in “shock” until proven otherwise

• > 160 - Infants • > 140 -Preschool child • > 120 -School age to puberty• > 100 - Adult

Tachycardia

Shock

How do I locate the bleeding?

Shock

● Physical examination

● Diagnostic adjuncts to primary survey

● Chest X-ray

● Pelvic X-ray

● FAST / DPL

How do I locate the bleeding?

What is the cause of the shock state?

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

Shock

Interventions

Direct pressure / tourniquet

STOPthe

bleeding!Reduce pelvic volume

Angio-embolization

Splint fractures

Operation

What can I do about it?

Interventions

● Fluid resuscitation● Vascular access?● Type?● Volume?

● Monitor response● Prevent hypothermia!

What can I do about it?

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

Vasopressors are contraindicated for

the treatment of hemorrhagic shock because they worsen tissue perfusion

Estimate fluid and blood losses Based on Patient’s Initial 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

bloodCrystalloid and blood

Management strategy

• Assess and manage “ABC” • Establish “IV -Oxygen –Monitors” • Insert “2 large bore” cannulae in peripheral

Veins • Infuse “large volume” of warm crystalloids (1

liter) rapidly• Insert NG tube and bladder catheter

Assess the “response” to initial volume therapy

• Response to initial fluid resuscitation is the key to determining subsequent therapy

• Distinguish “Hemodynamically stable” from “Hemodynamically normal”

Response to initial fluid resuscitation

[1000 mL Ringer;s lactate solution in adults, 20 ml/kg Ringer’s lactate bolus in children]

• Rapid response• Transient response• Minimal or No response

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

Failure to respond to crystalloid and blood administration ?

• Blunt myocardial injury• Cardiac tamponade• Tension pneumothorax• Neurogenic shock• Ongoing hemorrhage – Retroperitonial bleed– Internal organ injury

Search Causes

Fluid of choice

• Ringer’s lactate is the initial fluid of choice

• Normal saline is the second choice

• Blood and blood components as required

Special situations

• Age• Athletes• Pregnancy• Medications• Hypothermia• Pacemaker

Beware Unusual presentations

●Hypothermia

●Early coagulopathy

Pitfalls

Pitfalls

Complications of Shock and Shock Management

●Equating BP with cardiac output

●Misleading hemoglobin and hematocrit levels

Pitfalls

Pitfalls

Complications of Shock

Debate !

Permissive Hypotension in Trauma

“One of the most controversial issues in trauma care today is restricting intravenous fluid resuscitation in hypotensive trauma patients who have uncontrolled hemorrhage”

This new approach has the following goals:

• 1) Limiting hemorrhage • 2) Preventing hemodilution • 3) Not disrupting the clotting process.

• Permissive hypotension is still a relatively new concept for treating trauma patients who are hypotensive with uncontrolled hemorrhage.

• There is still no clear, universal recommendation regarding a standardized approach. Research and common sense does allow some initial conclusions to be drawn that definitely favor permissive hypotension.

What is new?

https://www.facebook.com/TheLancetMedicalJournal

• CRASH-2: tranexamic acid and trauma patients• Published March 24, 2011• Executive summary• A new analysis of the 2010 CRASH-2 study shows that

tranexamic acid should be given as early as possible to bleeding trauma patients; if treatment is not given until three hours or later after injury, it is less effective and could even be harmful. In this new analysis, the CRASH-2 investigators analysed subgroups of patients who had received tranexamic acid less than one hour after injury; between one and three hours after injury; or more than three hours after injury.

conclusion

• Trauma shock management is challenge • Protocol based approach is the best way to

solve puzzle• Early surgical involvement is one of the corner

stones

Interesting Web Sites

• www.trauma.org/archives/permhypo.html (Research articles on permissive hypotension)

• www.manuelsweb.com/blood_loss.htm (Allows you to calculate allowable blood loss)

THANK YOU

www.drvenu.net