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2- Hypovollemic Shock In Trauma.pptx
- 1. UTHSCSA Pediatric Resident Curriculum for the PICU Shock In Trauma Dr. Ashraf Hussein Whatis Shock? Inadequate perfusion and oxygenation of cells That leads to: –Cellular dysfunction and damage –Organ dysfunction and damage
- 2. UTHSCSA Pediatric Resident Curriculum for the PICU Why should youcare? Dr. Ashraf Hussein High mortality - 20-90% Early the effects of O2 deprivation on the cell are REVERSIBLE Early intervention reduces mortality
- 3. UTHSCSA Pediatric Resident Curriculum for the PICU Types of shock Dr. Ashraf Hussein •Hypovolemic • Cardiogenic • Obstructive • Distributive
- 4. UTHSCSA Pediatric Resident Curriculum for the PICU Hypovolemic Shock Dr. Ashraf Hussein Decreased Intravascularvolume (Preload) leads to Decreased Stroke Volume Blood loss: trauma, GI bleed, AAA rupture, ectopic pregnancy Fluid loss: burns, vomiting, diarrhea, dehydration, third spacing (e.g. pancreatitis, bowel obstruction), Addisonian crisis, Diabetic Ketoacidosis
- 5. UTHSCSA Pediatric Resident Curriculum for the PICU Cardiogenic Shock Dr. Ashraf Hussein Decreased Contractility(Myocardial Infarction, myocarditis, cardiomyopathy, Post resuscitation syndrome following cardiac arrest) Mechanical Dysfunction (Papillary muscle rupture post-MI, Severe Aortic Stenosis, rupture of ventricular aneurysms etc.) Arrhythmia (Heart block, ventricular tachycardia, SVT, atrial fibrillation etc.) Cardiotoxicity (B blocker and Calcium Channel Blocker Overdose)
- 6. UTHSCSA Pediatric Resident Curriculum for the PICU Obstructive Shock Dr. Ashraf Hussein Heart isworking but there is a block to the outflow • Massive pulmonary embolism • Aortic dissection • Cardiac tamponade • Tension pneumothorax Obstruction of venous return to heart • Vena cava syndrome - e.g. neoplasms, granulomatous disease • Sickle cell splenic sequestration
- 7. UTHSCSA Pediatric Resident Curriculum for the PICU Distributive Shock Dr. Ashraf Hussein Loss ofVessel tone • Inflammatory cascade • Sepsis and Toxic Shock Syndrome • Anaphylaxis • Post resuscitation syndrome following cardiac arrest Decreased sympathetic nervous system function • Neurogenic - C spine or upper thoracic cord injuries Toxins • Due to cellular poisons -Carbon monoxide, methemoglobinemia, cyanide • Drug overdose (a1 antagonists)
- 8. UTHSCSA Pediatric Resident Curriculum for the PICU Approach to HemorrhagicShock Dr. Ashraf Hussein Background: Hemorrhagic shock is caused by the loss of both circulating blood volume and oxygen-carrying capacity. The most common clinical etiologies are penetrating and blunt trauma, gastrointestinal bleeding, and obstetrical bleeding. Humans are able to compensate for a significant hemorrhage through various neural and hormonal mechanisms.
- 9. UTHSCSA Pediatric Resident Curriculum for the PICU Background Dr. Ashraf Hussein Modern advances intrauma care allow patients to survive when the adaptive compensatory mechanisms become overwhelmed. Although many clinical causes of shock exist, the basic cellular derangement in all types involves an imbalance of oxygen dynamics. Whenever cellular oxygen demand outweighs supply, both the cell and the organism are in a state of shock.
- 10. UTHSCSA Pediatric Resident Curriculum for the PICU Background Dr. Ashraf Hussein On a multicellularlevel, the definition of shock becomes more difficult because not all tissues and organs will experience the same amount of oxygen imbalance for a given clinical disturbance. Clinicians struggle daily to adequately define and monitor oxygen utilization on the cellular level and to correlate this physiology to useful clinical parameters and diagnostic tests.
- 11. UTHSCSA Pediatric Resident Curriculum for the PICU Pathophysiology Dr. Ashraf Hussein Well-described responses toacute loss of circulating volume exist. • Teleologically, these responses act to systematically divert circulating volume away from nonvital organ systems so that blood volume may be conserved for vital organ function. • Acute hemorrhage causes a decreased cardiac output and decreased pulse pressure. These changes are sensed by baroreceptors in the aortic arch and atrium. With a decrease in the circulating volume, neural reflexes cause an increased sympathetic outflow to the heart and other organs.
- 12. UTHSCSA Pediatric Resident Curriculum for the PICU Pathophysiology Dr. Ashraf Hussein • The responseis an increase in heart rate, vasoconstriction, and redistribution of blood flow away from certain nonvital organs such as the skin, gastrointestinal tract, and kidneys. • Concurrently, a multisystem hormonal response to acute hemorrhage occurs. Corticotropin-releasing hormone is stimulated directly. This eventually leads to glucocorticoid and beta-endorphin release. Vasopressin from the posterior pituitary is released, causing water retention at the distal tubules.
- 13. UTHSCSA Pediatric Resident Curriculum for the PICU Pathophysiology Dr. Ashraf Hussein Renin isreleased by the juxtamedullary complex in response to decreased mean arterial pressure, leading to increased aldosterone levels and eventually to sodium and water resorption. Hyperglycemia commonly is associated with acute hemorrhage. This is due to a glucagon and growth hormone–induced increase in gluconeogenesis and glycogenolysis. Circulating catecholamines relatively inhibit insulin release and activity, leading to increased plasma glucose.
- 14. UTHSCSA Pediatric Resident Curriculum for the PICU Pathophysiology Dr. Ashraf Hussein • The brainhas remarkable autoregulation that keeps cerebral blood flow constant over a wide range of systemic mean arterial blood pressures. • The kidneys can tolerate a 90% decrease in total blood flow for short periods of time. • With significant decreases in circulatory volume, intestinal blood flow is dramatically reduced by splanchnic vasoconstriction. Early and appropriate resuscitation may avert damage to individual organs as adaptive mechanisms act to preserve the organism.
- 15. UTHSCSA Pediatric Resident Curriculum for the PICU Age Dr. Ashraf Hussein Hemorrhagic shock istolerated differently, depending on the preexisting physiologic state and, to some extent, the age of the patient. Very young and very old people are more prone to early decompensation after loss of circulating volume.
- 16. UTHSCSA Pediatric Resident Curriculum for the PICU History Dr. Ashraf Hussein Obtaining a clearhistory of the type, amount, and duration of bleeding is very important. Many decisions in regard to diagnostic tests and treatments are based on knowing the amount of blood loss that has occurred over a specific time period. If the bleeding occurred at home or in the field, an estimate of how much blood was lost is helpful. For GI bleeding, knowing if the blood was per rectum or per os is important. Because it is hard to quantitate lower GI bleeding, all episodes of bright red blood per rectum should be considered major bleeding until proven otherwise.
- 17. UTHSCSA Pediatric Resident Curriculum for the PICU History Dr. Ashraf Hussein Bleeding because oftrauma is not always identified easily. The pleural space, abdominal cavity, mediastinum, and retroperitoneum are all spaces that can hold enough blood to cause death from exsanguination. External bleeding from trauma can be significant and can be underestimated by emergency medical personnel. Scalp lacerations are notorious for causing large underestimated blood loss. Multiple open fractures can lead to the loss of several units of blood.
- 18. UTHSCSA Pediatric Resident Curriculum for the PICU Physical Dr. Ashraf Hussein • The generalappearance of a patient in shock is very dramatic. The skin will have a pale, ashen color, usually with diaphoresis. The patient may appear confused or agitated and may become obtunded. • The pulse first becomes rapid and then becomes dampened as the pulse pressure diminishes. Systolic blood pressure may be in the normal range during compensated shock.
- 19. UTHSCSA Pediatric Resident Curriculum for the PICU Physical Dr. Ashraf Hussein • The conjunctivaeare inspected for paleness, a sign of chronic anemia. The nose and pharynx are inspected for blood. • The chest is auscultated and percussed to evaluate for hemothorax. This would lead to loss of breath sounds and dullness to percussion on the side of bleeding. • The abdominal examination searches for signs of intra- abdominal bleeding, such as distention, pain with palpation, and dullness to percussion.
- 20. UTHSCSA Pediatric Resident Curriculum for the PICU Physical Dr. Ashraf Hussein • The flanksare inspected for ecchymosis, a sign of retroperitoneal bleeding. • Ruptured aortic aneurysms are one of the most common conditions that cause patients to present in unheralded shock. Signs that can be associated with a rupture are a palpable pulsatile mass in the abdomen, scrotal enlargement from retroperitoneal blood tracking, lower extremity mottling, and diminished femoral pulses.
- 21. UTHSCSA Pediatric Resident Curriculum for the PICU Physical Dr. Ashraf Hussein • The rectumis inspected. If blood is noted, take care to identify internal or external hemorrhoids. On rare occasion, these are a source of significant bleeding, most notably in patients with portal hypertension. • Patients with a history of vaginal bleeding undergo a full pelvic examination. A pregnancy test is warranted to rule out ectopic pregnancy.
- 22. UTHSCSA Pediatric Resident Curriculum for the PICU Primary Survey Dr. Ashraf Hussein Airway: Cervical Spineimmobilization after neck examination Breathing: RR: Equal air entry bilateral with no adventitious sounds. Tenderness over the sternum. SpO2:
- 23. UTHSCSA Pediatric Resident Curriculum for the PICU Primary Survey Dr. Ashraf Hussein Circulation: • majorsite of bleeding • vital signs include • Capillary refill time • Neck veins • External wound
- 24. UTHSCSA Pediatric Resident Curriculum for the PICU Primary Survey Dr. Ashraf Hussein Disability • GCS •loss of cons, nausea or vomiting, bleeding per orifices, transient amnesia and no fits. • Pupils: equal bilateral and reactive to light. • Blood sugar Exposure • Major bleeding • Major deformity
- 25. UTHSCSA Pediatric Resident Curriculum for the PICU Secondary Survey Dr. Ashraf Hussein The secondaryexamination is a head-to-toe, careful examination that attempts to identify all injuries. • The scalp is inspected for bleeding • The mouth and pharynx are examined for blood • The abdomen is inspected and palpated. Distention, pain on palpation, and external ecchymosis are indications of intraabdominal bleeding. • The pelvis is palpated for stability. Crepitus or instability may be an indication of a pelvis fracture, which can cause life-threatening hemorrhage into the retroperitoneum.
- 26. UTHSCSA Pediatric Resident Curriculum for the PICU Secondary Survey Dr. Ashraf Hussein • Longbone fractures are noted by localized pain to palpation and boney crepitus at the site of fracture. All long bone fractures should be straightened and splinted to prevent ongoing bleeding at the sites. Femur fractures are especially prone to large blood losses and should be immobilized immediately in a traction splint. • Further diagnostic tests are warranted to diagnose intrathoracic, intra-abdominal, or retroperitoneal bleeding.
- 27. UTHSCSA Pediatric Resident Curriculum for the PICU Lab Studies Dr. Ashraf Hussein Generally, laboratoryvalues are not helpful in acute hemorrhage because values do not change from normal until redistribution of interstitial fluid into the blood plasma occurs after 8-12 hours. Many of the derangements that eventually occur are a result of replacing a large amount of autologous blood with resuscitation fluids.
- 28. UTHSCSA Pediatric Resident Curriculum for the PICU Lab Studies Dr. Ashraf Hussein Arterial bloodgas may the most important laboratory value in the patient in severe shock. Acidosis is the best indicator in early shock of ongoing oxygen imbalance at the tissue level. • Metabolic acidosis is a sign of underlying lack of adequate oxygen delivery or consumption and should be treated with more aggressive resuscitation, not exogenous bicarbonate. • Life-threatening acidemia (pH <7.2) initially may be buffered by the administration of sodium bicarbonate to improve the pH
- 29. UTHSCSA Pediatric Resident Curriculum for the PICU Lab Studies Dr. Ashraf Hussein A bloodspecimen for type and crossmatch should be obtained as soon as the patient arrives. For patients who are actively bleeding, 4 U of packed red blood cells (PRBCs) should be prepared, along with 4 U of fresh frozen plasma (FFP). Platelets may be obtained as well, depending on the physician's estimation of the likelihood of the need for platelet transfusion (less commonly needed compared to FFP).
- 30. UTHSCSA Pediatric Resident Curriculum for the PICU Imaging Studies Dr. Ashraf Hussein Imaging studiesare aimed at identifying the source of bleeding. • X- Rays • Fast • eFast • CT Scan • Angiography can be used for diagnosis and management of severe bleeding from pelvic fractures.
- 31. UTHSCSA Pediatric Resident Curriculum for the PICU Procedures Dr. Ashraf Hussein Diagnostic peritoneal lavage •If more than 5 mL of blood is aspirated, the test result is said to be grossly positive and laparotomy usually is indicated. • If blood is not aspirated, 1000 mL of warm lactated Ringer solution is infused into the abdomen and then allowed to drain out into the IV bag. The contents of the bag are examined in the lab. A red blood cell count of greater than 10,000 per mL is considered a microscopically positive test result. • white blood cell count greater than 500/mL; high levels of amylase, lipase, or bilirubin; and particulate matter that may be from an intraluminal source.
- 32. UTHSCSA Pediatric Resident Curriculum for the PICU Dr. Ashraf Hussein Large-bore (12F) centralresuscitation lines Central venous access Intra Oseos Line Labarotomy
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