Shock is a state of acute circulatory failure leading to decreased organ perfusion, with inadequate delivery of oxygenated blood to tissues and resultant end-organ dysfunction. The mechanisms that can result in shock are divided into 4 categories: (1) hypovolemic, (2) distributive, (3) cardiogenic, and (4) obstructive. While much is known regarding treatment of patients in shock, several controversies continue in the literature. Assessment begins with identifying the need for critical interventions such as intubation, mechanical ventilation, or obtaining vascular access. Prompt workup should be initiated with laboratory testing (especially of serum lactate levels) and imaging, as indicated. Determining the intravascular volume status of patients in shock is critical and aids in categorizing and informing treatment decisions. This issue reviews the 4 primary categories of shock as well as special categories, including shock in pregnancy, traumatic shock, septic shock, and cardiogenic shock in myocardial infarction. Adherence to evidence-based care of the specific causes of shock can optimize a patient's chances of surviving this life-threatening condition.
POLYTRAUMA AND DAMAGE CONTROL ORTHOPAEDICSDr Slayer
polytrauma is Injury to 2 or more organ systems leading potentially to a life threatening condition
Damage control orthopaedics is an approach to contain and stabilize an orthopaedic injury to improve patient’s physiology which are designed to avoid worsening pt’s condition due to “second hit” phenomenon
In the United States each year approximately 75,00 children develop severe sepsis, ap-proximately 6,800 of whom will die. Many of these cases may include missed or delayed diagnosis. As an EMS provider you play a decisive role in the identification and early treatment of these critically ill children. This program will show EMS providers how to identify, assess, and begin treatment for pediatric patients with sepsis as well as how to coordinate care with emergency department and critical care staff. This program is in-tended for both advanced and basic providers whether working or not your EMS system currently has formal sepsis alert protocols. Learn the latest updates and take home the knowledge of how you can make the biggest difference for our littlest patients.
For more information go to www.RomDuck.com
Shock is a state of acute circulatory failure leading to decreased organ perfusion, with inadequate delivery of oxygenated blood to tissues and resultant end-organ dysfunction. The mechanisms that can result in shock are divided into 4 categories: (1) hypovolemic, (2) distributive, (3) cardiogenic, and (4) obstructive. While much is known regarding treatment of patients in shock, several controversies continue in the literature. Assessment begins with identifying the need for critical interventions such as intubation, mechanical ventilation, or obtaining vascular access. Prompt workup should be initiated with laboratory testing (especially of serum lactate levels) and imaging, as indicated. Determining the intravascular volume status of patients in shock is critical and aids in categorizing and informing treatment decisions. This issue reviews the 4 primary categories of shock as well as special categories, including shock in pregnancy, traumatic shock, septic shock, and cardiogenic shock in myocardial infarction. Adherence to evidence-based care of the specific causes of shock can optimize a patient's chances of surviving this life-threatening condition.
POLYTRAUMA AND DAMAGE CONTROL ORTHOPAEDICSDr Slayer
polytrauma is Injury to 2 or more organ systems leading potentially to a life threatening condition
Damage control orthopaedics is an approach to contain and stabilize an orthopaedic injury to improve patient’s physiology which are designed to avoid worsening pt’s condition due to “second hit” phenomenon
In the United States each year approximately 75,00 children develop severe sepsis, ap-proximately 6,800 of whom will die. Many of these cases may include missed or delayed diagnosis. As an EMS provider you play a decisive role in the identification and early treatment of these critically ill children. This program will show EMS providers how to identify, assess, and begin treatment for pediatric patients with sepsis as well as how to coordinate care with emergency department and critical care staff. This program is in-tended for both advanced and basic providers whether working or not your EMS system currently has formal sepsis alert protocols. Learn the latest updates and take home the knowledge of how you can make the biggest difference for our littlest patients.
For more information go to www.RomDuck.com
SHOCK SYNDROMESHOCK SYNDROME
• Shock is a condition in which the cardiovascular system
fails to perfuse tissues adequately
• An impaired cardiac pump, circulatory system, and/or
volume can lead to compromised blood flow to tissues
• Inadequate tissue perfusion can result in:
– generalized cellular hypoxia (starvation)
– widespread impairment of cellular metabolism
– tissue damage organ failure
– death
ATHOPHYSIOLOGYPATHOPHYSIOLOGY
Cells switch from aerobic to anaerobic metabolism
lactic acid production
Cell function ceases & swells
membrane becomes more permeable
electrolytes & fluids seep in & out of cell
Na+/K+ pump impaired
mitochondria damage
cell death
3. Autoresuscitation
1. Peripheral and splanchnic vasoconstriction
(epinephrine, norepinephrine and vasopressin)
increases peripheral resistance and
reduces intravascular plasma loss
2. Hormonal response
(vasopressin, Renin-Angiotensin II, Cortisol)
4. Clinical signs of shock
CNS : anxiety , confuse , drowsy ,coma
CVS : tachycardia , vasoconstriction
RS : tachypnea
KUB : decreased urine output
GI : decreased movement
Skin : pale , cool
MS : decreased blood supply
5. Shock
What is the cause of the shock ?
● Blood loss
● Fluid loss
● Tension
pneumothorax
● Cardiac tamponade
● Cardiogenic
● Septic
● Neurogenic
● Anaphylactic
● Hypoadrenal
Hypovolemic Nonhemorrhagicvs
13. Hemorrhagic shock
Source of bleeding
External bleeding
Internal bleeding
Chest
Abdomen
Pelvis
Long bonenot intracranial hemorrhage
14. Save Life and Save Limb
Stop bleeding
Direct pressure
Tourniquet
Splinting
Rudge WBJ, Rudge BCJ, Rudge CJ. Ann R Coll Surg Engl.
2010 January;92(1):77-78
15. Classes of Shock
class I class II class III class IV
Blood loss <15% 15-30% 30-40% >40%
BP normal normal SBP<90 SBP<70
Pulse <100 100-120 120-140 >140
Mental anxiety anxiety confused lethargic
Urine >30 20-30 <20 negligible
Fluid crystalloid crystalloid+blood
• Adult blood : 70ml/kg
• Child blood : 80ml/kg
16. Class I Hemorrhage
● Slightly anxious
● Normal blood pressure
● Heart rate < 100 / min
● Respirations 14-20 / min
● Urinary output 30 ml / hour
BVL (15%) ; adult 70ml/kg , child 80mi/kg
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
BVL (15-30%) ; adult 70ml/kg , child 80ml/kg
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
BVL (30-40%) ; adult 70ml/kg , child 80ml/kg
Crystalloid, blood
components,
operation
20. Fluid Resuscitation
Fluid challenge test : 2000ml I.V. in 15 min
: 20ml/kg in 15 min
Warm fluid and patient
Blood for lab test
Cross-match 2 x estimated blood loss
Uncross matched blood : gr.O ,Rh +ve PRC
24. Fracture Pelvis
High mortality and morbidity rate
* 39% from hemorrhage
* 31% from associated injuries
* 30% from complications
Causes : traffic accident 84%
: falling from height 9%
: others 7%
25. Anatomy
Volume of Pelvis : ¶H( R² + 2Rr + r² )/3
R or r ↑ 2cm → vol. ↑ 1.3 litre
R or r ↑ 5cm → vol. ↑ 5.0 litre
26. Diagnosis
1. History of injury
* car accident
* motorcycle accident
* pedestrian accident
* falling from height
* crush injury
27. Diagnosis
2. Physical examination
* marks at pelvis and perineum
* leg deformity or length discrepancy
* signs of ruptured urethra or bladder
* anorectal or vaginal lacerations
* pelvic compression test ???
37. Hypotensive Resuscitation
“ Delivery of limited volumes of intravenous fluids to
sustain blood pressure lower than normal until control
of hemorrhage has been established “
“ Rapid resuscitation can exacerbate bleeding by
dislodging fragile clots , decreasing blood viscosity
and creating compartment syndrome of cranial vault,
abdomen, extremities and it also exacerbate the
Lethal Triad of hypothermia, acidosis and
coagulopathy “
38. Trauma Induced
Coagulopathy
Lethal triad
Dilutional coagulopathy
Consumptive coagulopathy
Hyperfibrinolysis
Anemia
Electrolyte imbalance
Hypocalcemia
Sorensen B, Fries D. British Journal of Surgery 2012; 99(Suppl 1): 40–
50
Hypothermia
Acidosis
Coagulopathy
39. Hypotensive Resuscitation
“ Tissue injury from regional hypoperfusion
is a risk “
“ Early control of hemorrhage was
paramount and attempts at fluid
resuscitation prior to this would result in
increased bleeding and mortality “
40. Hypotensive Resuscitation
“ In penetrating injury an SBP of 80-90 mmHg
may be adequate “
“ Currently, patients with blunt injury should be
managed with traditional strategies ”
“ A significant association exists between
prehospital hypotension (SBP<90) and worse
outcomes in severe traumatic brain injury “
41. Hypotensive Resuscitation
“ Early identification of bleeding sources and
control of hemorrhage will lead to more
rapid replacement of intravascular volume
and decreased morbidity and mortality “
42.
43. Neurogenic Shock
Circulatory shock
Spinal shock: neurological shock
Bradycardia
May not present if injury occur
below T4
Vasopressor usually needed
Clinical recognition
Decreased sensation
Motor impairment
Loose sphincter tone
44. Choices of Fluids
“ Extracellular fluid redistributed into both
intravascular and intracellular spaces
during shock and rapid correction of this
extracellular deficit required an infusion of
a 3:1 ratio of crystalloid fluid to blood loss “
45. Crystalloids
: replace interstitial and intravascular fluid loss
: do not cause allergic reaction
: inexpensive
: limited intravascular expansion
: tissue edema ( pulmonary edema , bowel
edema and compartment syndrome )
46. Colloids
: longer intravascular half-life
: may improve organ perfusion and cause less tissue
edema in early phase
: allergic reaction , impaired blood cross-matching ,
altered platelet function , hyperchloremic acidosis
: greater expense
“ There is no clear basis to give colloid products over
crystalloid solutions for fluid resuscitation “
47. RLS VS NSS
: large volume of NSS can lead to hyperchloremic
metabolic acidosis
: large volume of RLS can increase lactate level
but not cause acidosis
: RLS does not increase clots when giving blood
: no literature supporting the use of NSS over
RLS for the treatment of severe head injury to
reduce intracerebral swelling
48. Hypertonic Saline
“ causes influx of fluid into intravascular space
with small volume”
“ In head trauma patients, it can limit cerebral
edema , lower intracranial pressure and
improve cerebral perfusion “
“ 3% hypertonic saline plus 6% dextran showed
the greatest benefit in shock patients with
concomitant severe closed head injury “
49. Artificial Oxygen-Carrying Blood
Substitutes
“ improve oxygen-carrying capacity without the
storage, availability, immune suppression,
transfusion reaction, compatibility, disease
transmission problems associated with
standard transfusions”
“ fail to restore coagulation components causing
hemorrhage “
50. Blood Transfusion
“ Patient in shock who fails to response
adequately to 2 liters of crystalloid is in
need of blood transfusion “
“ Hemoglobin levels of 10g/dl were optimal
for shock resuscitation but recent studies
show that hemoglobin levels of 7-9g/dl do
well “
51. Massive Blood Transfusion
“ Blood transfusion of total blood volume in 24
hours or 50% of blood volume in 1 hours “
“ Bleeding > 150ml/min or > half of blood
volume in 20 minutes “
“ PRC : FFP : PLT = 1:1:1 “
52.
53. Complications of Transfusion
Hypothermia : mild = 32-35 degrees Celsius
: mod = 28-32 degrees Celsius
: sev = < 28 degrees Celsius
Trauma victims with core temperature
< 32 degrees Celsius have 100% mortality
54. Complications of Resuscitation
Coagulopathy
: dilutional ( one blood volume replacement )
: hypothermia
: INR >2
: PTT >1.5 times
: plt < 50000/mcl
: fibrinogen level < 100mg/dl
: head injury ( release of thromboplastin )
55. Complications of Resuscitation
Acidosis
: NSS >> RLS
: pH < 7.1 independently predicted
coagulopathy
: decreases fibrinogen and platelet
: increases PTT and bleeding time
56. Complications of Resuscitation
Compartment Syndromes
“ tissue edema is a frequent result of large
volume resuscitation , in restricted body
compartments , the resulting increase in
pressure can lead to ischemia and
subsequent tissue necrosis “
“ The three affected areas are the
extremities, abdomen and cranial vault “
