The hemodynamically  unstable patient Jeannouel van Leeuwen MD Trauma in the Caribbean II November 6-8, 2009
Causes of Shock <ul><li>Severe bleeding </li></ul><ul><li>Severe burns </li></ul><ul><li>Heart failure </li></ul><ul><li>H...
 
Signs and Symptoms of Shock <ul><li>Restlessness, anxiety </li></ul><ul><li>Extreme thirst </li></ul><ul><li>Rapid, weak p...
Shock (Hypoperfusion) <ul><li>Results from the inadequate delivery of oxygenated blood to body tissues </li></ul><ul><li>M...
Hypovolemic Shock <ul><li>CNS response to hypovolemia  </li></ul><ul><ul><li>Rapid: peripheral vasoconstriction, increased...
Signs and Symptoms of Internal Bleeding <ul><li>Discolored, tender, swollen or hard skin, rigid abdomen </li></ul><ul><li>...
Identification of the Site of Bleeding <ul><li>External Hemorrhage </li></ul><ul><li>Pleural Space </li></ul><ul><li>Perit...
 
External Bleeding <ul><li>Significant blood loss </li></ul><ul><ul><li>1 liter  - adult </li></ul></ul><ul><ul><li>1/2 lit...
Bleeding Control <ul><li>Direct local pressure </li></ul><ul><ul><li>Most effective </li></ul></ul>
What is the optimal fluid strategy? <ul><li>In trauma you only need “resuscitation” if you are bleeding </li></ul><ul><li>...
Resuscitation from Hemorrhagic Shock <ul><li>Reversal of hypovolemia </li></ul><ul><li>Control of hemorrhage </li></ul>The...
Priorities in initial resuscitation of the trauma patient <ul><li>Secure the airway </li></ul><ul><li>Control of hemorrhag...
<ul><li>The major cause of shock is decreased circulatory volume. Replace body fluids by the best means at hand.  -Alfred ...
Fluid resuscitation practice <ul><li>The rate of ARDS and MOFS are decreasing due to change in fluid resuscitation practic...
Fluid Resuscitation Practice <ul><li>Permissive hypotension is : </li></ul><ul><li>not to infuse fluids when a casualty is...
In the emergency department <ul><li>No fluid resuscitation in majority only IV for medication </li></ul><ul><li>Fluids (sa...
In the operating room <ul><li>In majority no fluid resuscitation for patients without major blood loss, such as orthopedic...
Acute Coagulopathy of Trauma (ACoTS) Hess et al. J Trauma 2008
Goals for Early Resuscitation <ul><li>Systolic BP 80-100 mmHg  </li></ul><ul><li>Hematocrit 25-30% </li></ul><ul><li>PT, P...
Risks of Aggressive Volume Resuscitation <ul><li>↑  hemorrhage + excessive hemodilution due to  ↑  BP,  ↓  blood viscosity...
Pathophysiology <ul><li>Hypovolemic Shock: </li></ul><ul><ul><li>Most common </li></ul></ul><ul><ul><li>Most of the blood ...
Degree of Hemorrhagic Shock <ul><li>Mild Hemorrhagic Shock: </li></ul><ul><ul><li>< 20% blood lost </li></ul></ul><ul><ul>...
Degree of Hemorrhagic Shock <ul><li>Moderate Hemorrhagic Shock: </li></ul><ul><ul><li>20 – 40% blood loss </li></ul></ul><...
 
Compensatory Mechanism <ul><li>Adrenergic discharge </li></ul><ul><li>Hyperventilation: </li></ul><ul><ul><li>with spontan...
<ul><li>Monitoring: </li></ul><ul><li>Management: </li></ul><ul><ul><li>resuscitate patient and control blood lost and cor...
<ul><li>Causes of Refractory Shock: </li></ul><ul><ul><li>Continuing blood loss from primary injury or another source </li...
Traumatic Shock <ul><li>Traumatized tissue activates coagulation system forming: </li></ul><ul><ul><li>Microthrombi: </li>...
Degree of Hemorrhagic Shock <ul><li>Severe Hemorrhagic Shock: </li></ul><ul><ul><li>40% blood lost </li></ul></ul><ul><ul>...
 
Beware <ul><li>More bloodloss if restoration of volume due to increased bloodpressure </li></ul>Patients bleed whole blood...
SBP > 100 vs. SBP > 70 led to no difference in mortality
Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries William H. Bickell, ...
Does ATLS work? <ul><li>Most patients do fine with just the crystalloid fluid  </li></ul><ul><li>Rates of renal failure an...
Breaking the  “Bloody Vicious Cycle” <ul><li>Prevent hemodilution </li></ul><ul><li>Treat coagulopathy </li></ul><ul><li>C...
 
<ul><li>THANK YOU </li></ul>
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The Hemodynamic

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Shock and Fluid therapy

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  • * 07/16/96 * ## Coagulopathy associated with traumatic injury is the result of multiple independent but interacting mechanisms. Early coagulopathy is driven by shock and requires thrombin generation from tissue injury as an initiator. Initiation of coagulation occurs with activation of anticoagulant and fibrinolytic pathways. This Acute Coagulopathy of Trauma-Shock is altered by subsequent events and medical therapies, in particular acidemia, hypothermia, and dilution. There is significant interplay between all mechanisms.
  • * 07/16/96 * ## Goals. Systolic BP 80-100 mmHg, Hematocrit 25-30%, PT, PTT, INR in normal range, Platelet count &gt; 50,000, Normal serum ionized calcium, Core temp &gt; 36 C, Prevent acidosis from worsening. Increase ambient room temperature, Warmed IV fluids, Level 1or similar infusor, Blood warmers, Forced air warming device,
  • * 07/16/96 * ##
  • To attack the problems of hemodilution and coagulopathy, it is important to attack the “bloody vicious cycle” at all points. One obvious conclusion is to start blood products early in patients who look they will require large amounts. There is no point in achieving hemodilution any sooner than absolutely necessary.
  • The Hemodynamic

    1. 1. The hemodynamically unstable patient Jeannouel van Leeuwen MD Trauma in the Caribbean II November 6-8, 2009
    2. 2. Causes of Shock <ul><li>Severe bleeding </li></ul><ul><li>Severe burns </li></ul><ul><li>Heart failure </li></ul><ul><li>Heart attack </li></ul><ul><li>Head or spinal injuries </li></ul><ul><li>Allergic reactions </li></ul><ul><li>Dehydration </li></ul><ul><li>Electrocution </li></ul><ul><li>Serious infection </li></ul><ul><li>Extreme emotional reactions (temporary/less dangerous) </li></ul>
    3. 4. Signs and Symptoms of Shock <ul><li>Restlessness, anxiety </li></ul><ul><li>Extreme thirst </li></ul><ul><li>Rapid, weak pulse </li></ul><ul><li>Rapid, shallow respirations </li></ul><ul><li>Mental status changes </li></ul><ul><li>Pale, cool, moist skin </li></ul><ul><li>Decreased blood pressure (late sign) </li></ul>All bleeding eventually ceases
    4. 5. Shock (Hypoperfusion) <ul><li>Results from the inadequate delivery of oxygenated blood to body tissues </li></ul><ul><li>May result from any condition involving: </li></ul><ul><ul><li>Failure of the heart to provide oxygenated blood (pump failure) </li></ul></ul><ul><ul><li>Abnormal dilation of the vessels (pipe failure) </li></ul></ul><ul><ul><li>Blood volume loss (fluid failure) </li></ul></ul>
    5. 6. Hypovolemic Shock <ul><li>CNS response to hypovolemia </li></ul><ul><ul><li>Rapid: peripheral vasoconstriction, increased cardiac activity </li></ul></ul><ul><ul><li>Sustained: arterial vasoconstriction, Na/water retention, increased cortisol </li></ul></ul><ul><li>Hemorrhage or fluid loss </li></ul><ul><li>Classes of hemorrhage: </li></ul><ul><ul><li>I: 15% </li></ul></ul><ul><ul><li>II: 30% = tachycardia </li></ul></ul><ul><ul><li>III: 40% = decreased SBP, confusion </li></ul></ul><ul><ul><li>IV: >40% = lethargy, no UOP </li></ul></ul>It is not the blood loss you can see that will get you, it’s the blood loss you can’t see
    6. 7. Signs and Symptoms of Internal Bleeding <ul><li>Discolored, tender, swollen or hard skin, rigid abdomen </li></ul><ul><li>Absence of distal pulse </li></ul><ul><li>Increased respiratory and pulse rates </li></ul><ul><li>Pale, cool, moist skin </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Thirst </li></ul><ul><li>Mental status changes </li></ul><ul><li>Bleeding from body orifices </li></ul>
    7. 8. Identification of the Site of Bleeding <ul><li>External Hemorrhage </li></ul><ul><li>Pleural Space </li></ul><ul><li>Peritoneal Cavity </li></ul><ul><li>Extremity Fracture </li></ul><ul><li>Retroperitoneal Space </li></ul>One set of vital signs isn’t “hemodynamically stable”
    8. 10. External Bleeding <ul><li>Significant blood loss </li></ul><ul><ul><li>1 liter - adult </li></ul></ul><ul><ul><li>1/2 liter - child </li></ul></ul><ul><ul><li>100 to 200 ml - infant </li></ul></ul><ul><li>Result may be HYPOVOLEMIC shock </li></ul>Ventilate, perfuse , and piss is all that it is about
    9. 11. Bleeding Control <ul><li>Direct local pressure </li></ul><ul><ul><li>Most effective </li></ul></ul>
    10. 12. What is the optimal fluid strategy? <ul><li>In trauma you only need “resuscitation” if you are bleeding </li></ul><ul><li>The best fluid is the fresh whole blood from your identical twin </li></ul><ul><li>If your car leaks gasoline, we don’t resuscitate it with water </li></ul>Even a dead patient’s vital signs are stable
    11. 13. Resuscitation from Hemorrhagic Shock <ul><li>Reversal of hypovolemia </li></ul><ul><li>Control of hemorrhage </li></ul>The most important clotting factor is the surgeon
    12. 14. Priorities in initial resuscitation of the trauma patient <ul><li>Secure the airway </li></ul><ul><li>Control of hemorrhage ASAP :generally operative control </li></ul><ul><li>Fluid resuscitation : restore volume status and sufficient red cells </li></ul><ul><li>Endpoints in resuscitation :restore bloodpressure, adequate urine output </li></ul>
    13. 15. <ul><li>The major cause of shock is decreased circulatory volume. Replace body fluids by the best means at hand. -Alfred Blalock, 1899-1964 </li></ul>
    14. 16. Fluid resuscitation practice <ul><li>The rate of ARDS and MOFS are decreasing due to change in fluid resuscitation practice </li></ul>One set of vital signs isn’t “hemodynamically stable”
    15. 17. Fluid Resuscitation Practice <ul><li>Permissive hypotension is : </li></ul><ul><li>not to infuse fluids when a casualty is awake and alert, and </li></ul><ul><li>to infuse fluids to keep a casualty alive if they get hypotensive. </li></ul><ul><li>The main goal is </li></ul><ul><li>not fluid resuscitation but hemorrhage control </li></ul>
    16. 18. In the emergency department <ul><li>No fluid resuscitation in majority only IV for medication </li></ul><ul><li>Fluids (saline/RL or colloids) only if there is suspected bleeding and they are hypotensive. To keep alive until you get them to the operating room. </li></ul>If you can feel a pulse don’t panic
    17. 19. In the operating room <ul><li>In majority no fluid resuscitation for patients without major blood loss, such as orthopedic injuries or hollow viscus injuries.Crystalloids to maintain adequate urine output. </li></ul><ul><li>For bleeding patients crystalloids followed by Packed Red Blood Cells. After the 6 th unit, FFP followed by platelets and cryoprecipitate. </li></ul>
    18. 20. Acute Coagulopathy of Trauma (ACoTS) Hess et al. J Trauma 2008
    19. 21. Goals for Early Resuscitation <ul><li>Systolic BP 80-100 mmHg </li></ul><ul><li>Hematocrit 25-30% </li></ul><ul><li>PT, PTT, INR in normal range </li></ul><ul><li>Platelet count > 50,000 </li></ul><ul><li>Normal ionized calcium </li></ul><ul><li>Prevent acidosis from worsening </li></ul><ul><li>Core temp > 36 C </li></ul>
    20. 22. Risks of Aggressive Volume Resuscitation <ul><li>↑ hemorrhage + excessive hemodilution due to ↑ BP, ↓ blood viscosity, ↓ hematocrit, ↓ clotting factor concentration </li></ul>
    21. 23. Pathophysiology <ul><li>Hypovolemic Shock: </li></ul><ul><ul><li>Most common </li></ul></ul><ul><ul><li>Most of the blood is lost from systemic and small veins (50%) ----> decrease cardiac return ----> low cardiac output ----> decrease blood pressure </li></ul></ul>
    22. 24. Degree of Hemorrhagic Shock <ul><li>Mild Hemorrhagic Shock: </li></ul><ul><ul><li>< 20% blood lost </li></ul></ul><ul><ul><li>adrenergic constriction of blood vessels in the skin </li></ul></ul><ul><ul><li>thirsty, feels cold </li></ul></ul><ul><ul><li>normal BP, PR and urine output </li></ul></ul>
    23. 25. Degree of Hemorrhagic Shock <ul><li>Moderate Hemorrhagic Shock: </li></ul><ul><ul><li>20 – 40% blood loss </li></ul></ul><ul><ul><li>& low urine output </li></ul></ul><ul><ul><ul><li>Due to aldosteron and ADH </li></ul></ul></ul>
    24. 27. Compensatory Mechanism <ul><li>Adrenergic discharge </li></ul><ul><li>Hyperventilation: </li></ul><ul><ul><li>with spontaneous deep breathing there is a decreased intra-thoracic ----> increase ventricular end diastolic volume ----> increase cardiac output. </li></ul></ul><ul><li>Collapse: </li></ul><ul><ul><li>Displaced blood from extremity to the heart and the brain </li></ul></ul>
    25. 28. <ul><li>Monitoring: </li></ul><ul><li>Management: </li></ul><ul><ul><li>resuscitate patient and control blood lost and correct dehydration </li></ul></ul><ul><ul><li>give balance salt solution (crystalloid) </li></ul></ul><ul><ul><li>disadvantage of giving colloid resuscitation. </li></ul></ul><ul><ul><ul><li>Increase intravascular volume at the expense of necessary interstitial fluid </li></ul></ul></ul><ul><ul><ul><li>Depression of albumin synthesis </li></ul></ul></ul><ul><ul><ul><li>Depression of circulating immunoglobulin </li></ul></ul></ul><ul><ul><ul><li>More expensive and less easier to titrate </li></ul></ul></ul>
    26. 29. <ul><li>Causes of Refractory Shock: </li></ul><ul><ul><li>Continuing blood loss from primary injury or another source </li></ul></ul><ul><ul><li>Inadequate replacement of fluids </li></ul></ul><ul><ul><li>Massive trauma or other derangement </li></ul></ul><ul><ul><li>Myocardial infarction </li></ul></ul><ul><ul><li>Concomitant septic shock </li></ul></ul>
    27. 30. Traumatic Shock <ul><li>Traumatized tissue activates coagulation system forming: </li></ul><ul><ul><li>Microthrombi: </li></ul></ul><ul><ul><ul><li>Occludes pulmonary vasculature ---> increase pulmonary vascular resistance ----> increase right arterial pressure </li></ul></ul></ul><ul><ul><li>Humoral products of microthrombi : </li></ul></ul><ul><ul><ul><li>cytoxines </li></ul></ul></ul><ul><ul><ul><li>Increases vascular permeability ---> loss of plasma </li></ul></ul></ul>
    28. 31. Degree of Hemorrhagic Shock <ul><li>Severe Hemorrhagic Shock: </li></ul><ul><ul><li>40% blood lost </li></ul></ul><ul><ul><li>In addition to above s/sx pt has low BP and rapid pulse rate </li></ul></ul><ul><ul><li>signs of M.I. ---> Q waves and depressed </li></ul></ul><ul><ul><li>St-T segments </li></ul></ul>
    29. 33. Beware <ul><li>More bloodloss if restoration of volume due to increased bloodpressure </li></ul>Patients bleed whole blood-not components
    30. 34. SBP > 100 vs. SBP > 70 led to no difference in mortality
    31. 35. 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 The New England Journal of Medicine Methods: We conducted a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a prehospital systolic blood pressure ≤ 90 mm Hg. Results: 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). Volume 331:1105-1109      October 27, 1994      Number 17
    32. 36. Does ATLS work? <ul><li>Most patients do fine with just the crystalloid fluid </li></ul><ul><li>Rates of renal failure and multiple organ failure are going down. </li></ul>
    33. 37. Breaking the “Bloody Vicious Cycle” <ul><li>Prevent hemodilution </li></ul><ul><li>Treat coagulopathy </li></ul><ul><li>Control hemorrhage </li></ul><ul><li>Use best possible resuscitation products </li></ul><ul><li>Prevent hypothermia </li></ul>Coagulopathy Hemorrhage Resuscitation Hemodilution and Hypothermia
    34. 39. <ul><li>THANK YOU </li></ul>

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