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Emergency lectures - Shock

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  • 3-1 Title Slide Introduce the topic Explain to the students that, based on their preparation for the course, a series of questions will be asked throughout the lecture. Their active participation and response is expected.
  • 3-2 Case Scenario Emphasize organ perfusion deficit as indicated by confusion.
  • 3-3 Objectives Review the objectives as provided on the slide. Emphasize the clinical and other important aspects of the approach to the injured patient who is in shock.
  • 3-4 What is shock? Encourage active student discussion to arrive at the required definition. Query the students about the effects of hypoperfusion on cellular function and microcellular alterations.
  • 3-5 Shock: Is the patient in shock? Clarify that initially, recognition of the shock state is related to the patient’s signs and symptoms. You may need to remind the students of the definition of shock and the effects of hypoperfusion on organs available for assessment, eg, brain, kidney, skin, heart, etc. Emphasize that altered level of consciousness does NOT equate with LOSS of consciousness and is a late sign.
  • 3-6 Shock: How do I recognize shock? You may need to provide additional guidance to the students about other important factors that facilitate the recognition of shock or cause suspicion of the potential for and/or presence of shock. For example, event history, mechanism of injury, and the need for AMPLE history. Point out that organ dysfunction is what the student should recognize, but that this is due to inadequate perfusion.
  • 3-7 Shock: What is the cause of the shock state? Explain that cardiogenic shock may be caused by myocardial infarction, dysrhythmia, and cardiac failure. Remind the students that bradycardia is not a constant finding in neurogenic shock. Explain that cord lesions below the T4 level may lead to shock with a well perfused periphery and reflex tachycardia. Shock can be caused by “medical” conditions, such as adrenal insufficiency or diabetes.
  • 3-9 Shock: How do I locate the bleeding? Reveal the items on the next slide after eliciting responses from the students. Ask the students for possible sites of blood loss in the injured patient. The students should identify possible external sources of bleeding as well as the thorax, abdomen, pelvis and long bone fractures as internal sources of bleeding. Query the students as to how these sites can be assessed for the presence of hemorrhage. The students should respond with physical examination and diagnostic adjuncts to the primary survey, including chest x-ray, chest tube insertion, DPL, FAST (focused assessment ultrasonography in trauma), CT scan, pelvic x-ray, etc. Emphasize that, as soon as shock has been diagnosed and a tension pneumothorax has been excluded during “B,” a focused search should be made for the cause of the blood loss. Remember, “Blood on the floor and four places more.”
  • 3-10 Shock: How do I locate the bleeding? Ask the students for possible sites of blood loss in the injured patient. The students should identify possible external sources of bleeding, as well as the thorax, abdomen, pelvis and long bone fractures as internal sources of bleeding. Query the students as to how these sites can be assessed for the presence of hemorrhage. The students should respond with physical examination and diagnostic adjuncts to the primary survey, including chest x-ray, chest tube insertion, DPL, FAST (focused assessment ultrasonography in trauma), CT scan, pelvic x-ray, etc. Emphasize that, as soon as shock has been diagnosed and a tension pneumothorax has been excluded during “B,” a focused search should be made for the cause of the blood loss. Remember, “Blood on the floor and four places more.”
  • 3-8 Shock: What is the cause of the shock state? Ask the students for the most common cause of shock in the injured patient. The students should respond with “hemorrhage” as the most common cause.
  • 3-11 Interventions: What can I do about it? Ask a student to recall the most common cause of shock in the injured patient, emphasizing the need to identify and stop the hemorrhage by the most direct and simplest means available while avoiding blind clamping. These might include direct pressure to control external hemorrhage, reducing pelvic volume, and splinting fractures. In civilian circumstances, applying a tourniquet is a matter of last resort (things may be different in the military arena). Emphasize that fractures of the “smaller” long bones are also accompanied by, albeit smaller, blood loss. Students’ responses to this question also should include controlling hemorrhage with operative intervention, such as laparotomy and/or thoracotomy.
  • 3-12 Interventions: What can I do about it? Explain that shock should be treated as if it were hemorrhagic in nature until proven otherwise. Emphasize that the patient should be reassessed frequently for response to therapy as well as other causes of shock. Students should indicate the role of adequate intravenous access with a short, large-caliber IV catheter. They also should identify the need to prevent hypothermia by administering warmed intravenous fluids and assessing the patient’s body temperature with an appropriate type of thermometer. Before proceeding, the students need to state that the patient’s response to therapy must be frequently reassessed to determine the accuracy of diagnosis and plan for further management.
  • 3-13 Patient Response: How do I evaluate the patient’s response? Ask the students to recall the definition of shock and the signs of organ hypoperfusion before asking this question. The students should respond by stating that the patient needs to be assessed for return to hemodynamic normalcy, eg, heart rate, level of consciousness, skin perfusion, and urinary output.
  • 3-14 Patient Response: What is the patient’s response? Ask the students for the types of patient responses that might be anticipated. This should lead the students to classify the types of patient responses: rapid responder, transient responder, and nonresponder. Answers are revealed on next slide.
  • 3-15 Patient Response: What is the patient’s response? Emphasizes that a transient or absent response should lead to “immediate” surgical intervention, and not to “endless” infusion (thereby avoiding “yo-yo resuscitation”). Ask the students what the normal blood volume is based on (weight and age). Relate blood loss to the classes of hemorrhage, vital signs, and requirements for intravenous fluid administration and/or operation. This discussion leads to the next three slides (Classifications of Hemorrhage), including a summary of the signs and symptoms and appropriate therapy associated with each class of hemorrhage.
  • 3-16 Class I Hemorrhage Use this slide to summarize the type of physical findings associated with a blood loss of up to 15% or 750mL. Emphasize that normal vital signs, urinary output, and mild tachycardia are associated with this class of hemorrhage.
  • 3-17 Class II Hemorrhage Use this slide to summarize the type of physical findings associated with a blood loss of up to 30% or 1500 mL. Summarize this class of hemorrhage by noting an increase in tachycardia, confusion, beginning oliguria, and maintenance of the systolic blood pressure while pulse pressure is decreased.
  • 3-18 Class III Hemorrhage Use this slide to summarize the type of physical findings associated with a blood loss of up to 40% or 2000 mL. Summarize this class of hemorrhage by noting increasingly somnolent, worsening renal perfusion with oliguria, increased respiratory rate, increased heart rate, and decreased blood pressure with a further decrease in pulse pressure.
  • 3-19 Class IV Hemorrhage Use this slide to summarize the type of physical findings associated with a blood loss of greater than 40% or 2000 mL. Summarize the changes in clinical signs, including unconsciousness, oliguria and hypotension, and the need for blood and an operation.
  • 3-20 Pitfalls: Complications of Shock – Patient Factors Discuss the hemodynamic changes related to athletes and elderly patients. Explain the necessary precautions to take in patients with pacemakers and their inability to increase their heart rate. Some medications can affect the patient’s hemodynamic status (eg, beta blockers). Discuss the effects of pregnancy on the hemodynamic status of injured patients.
  • 3-21 Pitfalls: Complications of Shock and Shock Management Discuss the effects of hypothermia on the hemodynamic status of injured patients.
  • 3-22 Pitfalls: Evaluation and Management of Shock Explain the unreliability of blood pressure as an early sign of shock. Discuss the role of early hemoglobin analysis.
  • 3-23 Questions Allow for adequate time for additional questions from the students and further discussion before proceeding to the summary slides.
  • 3-24 Summary Begin with the definition of shock as a state of generalized cellular hypoperfusion. Relates that the cause of shock is primarily hemorrhagic in the injured patient and that the first management priority is to identify the source of bleeding and to stop it. Describe the role of operative intervention, adequate IV access, monitoring the patient’s response to therapy, and the previously discussed pitfalls.
  • 3-25 Summary Begin with the definition of shock as a state of generalized cellular hypoperfusion. Relates that the cause of shock is primarily hemorrhagic in the injured patient and that the first management priority is to identify the source of bleeding and to stop it. Describe the role of operative intervention, adequate IV access, monitoring the patient’s response to therapy, and the previously discussed pitfalls.
  • Transcript

    • 1. Initial Assessment and Management Committee on Trauma Presents Shock
    • 2. 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?
    • 3. 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.
    • 4. What is shock? Cell death Inadequate oxygen delivery Catecholamines and other responses Anaerobic metabolism Cellular dysfunction Generalized State of Hypoperfusion
    • 5. Shock
        • Alteration in level of consciousness, anxiety
        • Cold, diaphoretic skin
        • Tachycardia
        • Tachypnea, shallow respirations
        • Hypotension
        • Decreased urinary output
      Is the patient in shock?
    • 6. Shock
        • Scene information / mechanism of injury
        • AMPLE history
      How do I recognize shock? Inadequate perfusion Organ dysfunction
    • 7. Shock What is the cause of the shock state?
        • Blood loss
        • Fluid loss
        • Tension pneumothorax
        • Cardiac tamponade
        • Cardiogenic
        • Septic
        • Neurogenic
      Hypovolemic Nonhemorrhagic vs
    • 8. Shock How do I locate the bleeding?
    • 9. Shock
      • Physical examination
      • Diagnostic adjuncts to primary survey
        • Chest X-ray
        • Pelvic X-ray
        • FAST / DPL
      How do I locate the bleeding?
    • 10. What is the cause of the shock state?
        • In the vast majority of trauma patients, shock is due to blood loss.
      Shock
    • 11. Interventions What can I do about it? Direct pressure / tourniquet STOP the bleeding! Reduce pelvic volume Angio-embolization Splint fractures Operation
    • 12. Interventions
      • Fluid resuscitation
        • Vascular access?
        • Type?
        • Volume?
      • Monitor response
      • Prevent hypothermia!
      What can I do about it?
    • 13. 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?
    • 14. Patient Response What is the patient’s response?
    • 15. Patient Response
      • Rapid responder
      • Transient responder
      • Nonresponder
      Related to volume or persistence of hemorrhage Operation What is the patient’s response?
    • 16. 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
    • 17. 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
    • 18. 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
    • 19. 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
    • 20. Pitfalls
      • Age extremes
      • Athletes
      • Pregnancy
      • Medications
      • Pacemaker
      Complications of Shock – Patient Factors Pitfalls
    • 21.
      • Hypothermia
      • Early coagulopathy
      Pitfalls Complications of Shock and Shock Management Pitfalls
    • 22.
      • Equating BP with cardiac output
      • Misleading hemoglobin and hematocrit levels
      Pitfalls Complications of Shock Pitfalls
    • 23.  
    • 24. 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.
    • 25. Summary
      • Conduct a rapid initial assessment and resuscitation.
      • Determine cause of shock.
      • Stop the bleeding.
      • Reevaluate.