3. TYPES
• PRIMARY: at time of surgery
• REACTIONARY: with 24 hrs due to
slipping of ligature, dislodgement of a clot
or cessation of reflex vasospasm
• SECONDARY: after 7 to 14 days due to
infection, sloughing of a part of wall of an
artery as a result of pressure of drainage
tube, fragment of a bone, ligature in
infected area or cancer.
4. Blood loss estimation
• Clenched fist is roughly equal to 500ml.
• Moderate swelling in closed fracture of tibia
equals 500- 1500 ml and in fracture shaft of
femur equals 500 – 2000 ml.
• Swab weighing :1gm =1ml is added to the
volume of blood collected in suction bottles.
5. pulse
• appearance of tachycardia indicates a loss
of 15–30% of circulating blood volume
• Approximate SBP on basis of pulse
• Radial- 90mm Hg
• Brachial – 80 mm Hg
• Femoral – 70 mm Hg
• Carotid – 60 mmHg
6. Hypovolemia
Bld Loss Blood Vol. Heart Blood Pulse Resp Urine Mental
Hemorrhage (L.) Lost (%) Rate Pressure Pressure Rate ml./hr. Status
Class I <1 <15% <100 Normal Normal or 14-20 >=30 Slight
Increased Anxiety
Class II 0.75-1.5 15%-30% >100 Normal Decreased 20-30 20-30 Mild
Anxiety
Class III 1.5-2.0 30%-40% >120 Decreased Decreased 30-40 <15 Anxious
Confused
Class IV >2.0 >=40% >=140 Decreased Decreased Rapid Neg Confused
Shallow Lethargic
(Committee on Trauma, American College of Surgeons. Advanced Trauma Life Support for Physicians
Chicago, Ill.: American College of Surgeons)
7. Blood pressure
• the length of the bladder of the cuff should
be at least 80% of the circumference of the
upper arm, and the width at least 40% of the
circumference of the upper arm in order for
the measurement to be accurate.
• listening for sounds generated from the
artery (Korotkoff sounds) as the cuff
deflates can be very inaccurate, especially
during hypotension. On the other hand,
automated blood pressure cuffs are not
consistently accurate when systolic blood
pressures are below 110 mmHg
8. Arterial line
• the transducer must be zeroed at the level of
the right atrium or else reading will be
erroneous: falsely elevated if the transducer
is too low, falsely depressed if the
transducer is too high.
• Catheter whip is due to movement of the
catheter within the lumen of the vessel. This
usually occurs when the catheter is placed
in a relatively large vessel, such as the
femoral artery, and can cause the
measurements of systolic pressure to vary
by approximately 20 mmHg.
9. Central venous pressure
• transducer must be placed at the zero
reference point, known as the phlebostatic
axis, for central venous pressures to be
accurate. This phlebostatic axis is the
artificial point on the thorax where the
fourth intercostal space meets the
• midaxillary line, and corresponds to the
position of the right and left atria in the
supine position.
• ‘‘normal’’ CVP is quoted as between 4–8
mmHg
10. Pulmonary artery catheter
• the pulmonary capillary wedge pressure
approximates the left atrial pressure (except
in cases of pulmonary hypertension) which
will equal left-ventricular end diastolic
pressure in patients with competent mitral
valves.
11. Serum lactate
• elevated blood lactate is a reliable marker of
hypoperfusion. Furthermore, failure to clear
the lactate level to normal levels with 24 h
was associated with a mortality of > 75%.
12. Physiological Consequences of
Hemorrhage
• Adverse effects of hemorrhage
on young, healthy are directly
related to two primary factors
– 1.) Decreased intravascular
volume
– 2.) Inadequate oxygen-carrying
capacity
13. Cardiovascular Response
• The immediate response to the fall in venous
return to the heart, and decrease in pressure to the
aortic arch and carotid baro-receptors is a diffuse
activation of the sympathetic nervous system
• Release of catecholamines from adrenal medulla
– Increase in heart rate and contractility
– Increase in systematic vascular resistance due to
vasoconstriction of skeletal muscles and viscera
• This response preserves central organs
– Heart & brain at the expense of peripheral organs
14. Fluid Compartment Shifts
• After a casualty sustains a major
hemorrhage, restoration of the intravascular
fluid compartment may require many hours
as interstitial fluid (extra-vascular) is drawn
into the intravascular compartment
15. Extra-vascular Fluid Loss
• casualties presenting for care several hours
after being injured may suffer from:
– Hemorrhage-induced intravascular volume
depletion
– Preexisting depletion of the extra-cellular fluid
compartment that is caused by concomitant
dehydration, secondary to environmental or
nutritional factors
16. Extra-vascular Fluid Loss Cont.
– Because crystalloids (Normal Saline (NS) /Lactated
Ringers (LR)) are distributed through the body water, a
study showed 3-4 ml/1 ml blood loss is required to
replace intravascular volume
– Recommendations for replacing the third-space fluid
sequestration is four, six, and eight ml/kg/hr for
minimal, moderate, and severe trauma (respectively) in
addition to estimated hourly maintenance fluids
17. Oxygen Transport
• Hemorrhage interferes with normal tissue oxygenation
by two mechanisms
– 1.) The anemic (Inadequate oxygen carrying capacity)
– 2.) The hemorrhagic (Inadequate tissue perfusion)
• In the setting of severe hemorrhage, however, reduced
hemoglobin content is rarely the cause of tissue
hypoxia
• A 20-year-old healthy soldier can lose 40-50% of his
blood volume and hemodynamically compensate with
cardiac output and vasoconstriction to maintain
adequate tissue perfusion
18. Oxygen Transport
• This example demonstrates blood
replacement is frequently unnecessary and
volume restoration is the key
• If the circulating plasma volume is
maintained then the metabolic
consequences of severe hemorrhage can be
minimized
19. Hypovolemia
• Class I (<15%) Suspected blood loss in absence of
tachycardia or hypotension
– Resuscitate with clear fluids (crystalloids (NS / LR)
• Class II (15%-30%) Tachycardia without
hypotension
– Transfuse with crystalloid or colloid, transfuse early
with continual bleeding
• Class III (30%-40%) or Class lV (>=40%)
Hypotension and tachycardia require immediate
blood volume replacement with crystalloid,
colloids, and or packed red blood cells
20. Investigations
• routine trauma panel (type and cross-match,
complete blood count, blood chemistries,
coagulation studies, lactate level, and
arterial blood gas analysis) should be sent to
the laboratory.
21. • four life-threatening injuries that must be identified
are (a) massive hemothorax, (b) cardiac tamponade,
(c) massive hemoperitoneum, and (d) mechanically
unstable pelvic fractures.
• Three critical tools used to differentiate these in the
multisystem trauma patient are chest radiograph,
pelvis radiograph, and focused abdominal
sonography for trauma (FAST)
22. • any episode of hypotension (defined as a SBP <90
mmHg) is assumed to be caused by hemorrhage
until proven otherwise. Blood pressure and pulse
should be measured manually at least every 5
minutes in patients with significant blood loss until
normal vital sign values are restored.
• Two broad categories of shock causing persistent
hypotension are hemorrhagic and cardiogenic. An
evaluation of the CVP will usually distinguish
between these two categories. A patient with flat
neck veins and a CVP of <5 cm H2O is hypovolemic
and is likely to have ongoing hemorrhage. A patient
with distended neck veins or a CVP of >15 cm H2O
23. • IV access with two peripheral catheters, 16-gauge or
larger in adults. Blood should be drawn
simultaneously and sent for measurement of
hematocrit level, as well as for typing and cross-
matching for possible blood transfusion. According
to Poiseuille's law, the flow of liquid through a tube
is proportional to the diameter and inversely
proportional to the length; therefore, venous lines
for volume resuscitation should be short with a large
diameter
24. Resuscitation
Fluid resuscitation begins with a 2 L (adult) or 20
mL/kg (child) IV bolus of isotonic crystalloid,
typically Ringer's lactate. For persistent
hypotension, this is repeated once in an adult and
twice in a child before red blood cells (RBCs) are
administered. Patients who have a good response
to fluid infusion (i.e., normalization of vital signs,
clearing of the sensorium) and evidence of good
peripheral perfusion (warm fingers and toes with
normal capillary refill) are presumed to have
adequate overall perfusion. Urine output is a
quantitative, reliable indicator of organ perfusion.
Adequate urine output is 0.5 mL/kg per hour in an
adult
25. • PRBC transfusion should occur once the patient's
hemoglobin level is <7 g/dL, in the acute phase of
resuscitation the endpoint is 10 g/dL.
• Fresh-frozen plasma is transfused to keep the patient's
International Normalized Ratio (INR) less than 1.5 and
partial thromboplastin time (PTT) <45 seconds. Primary
hemostasis relies on platelet adherence and aggregation to
injured endothelium, and a platelet count of 50,000/L is
considered adequate if platelet function is normal. With
massive transfusion, however, platelet dysfunction is
common, and therefore a target of 100,000/L is advocated.
• If fibrinogen levels drop below 100 mg/dL, cryoprecipitate
should be administered.
26. Colloid Solutions
(Dextran, Hespan, & Albumin)
• Rapidly replenishes
intravascular compartment
with smaller fluid volume
than crystalloids
• Gives more prolonged
expansion of the plasma
volume and less peripheral
edema
• Has Disadvantages
27. DAMAGE CONTROL
SURGERY
• Goal of DCS is to control surgical bleeding
and limit GI spillage. The operative
techniques used are temporary measures,
with definitive repair of injuries delayed
until the patient is physiologically replete.
28. • Hypothermia from evaporative and conductive heat
loss and diminished heat production occurs despite
the use of warming blankets and blood warmers.
The metabolic acidosis of shock is exacerbated by
aortic clamping, administration of vasopressors,
massive transfusions, and impaired myocardial
performance. Coagulopathy is caused by dilution,
hypothermia, and acidosis. Once the cycle starts,
each component magnifies the others, which leads to
a downward spiral and ultimately a fatal arrhythmia.
The purpose of DCS is to limit operative time so
that the patient can be returned to the SICU for
physiologic restoration and the cycle thus broken.
29.
30. • Indications to limit the initial operation and institute
DCS techniques include temperature <35°C (95°F),
arterial pH <7.2, base deficit <15 mmol/L (or <6
mmol/L in patients over 55 years of age), and INR
or PTT >50% of normal. The decision to abbreviate
a trauma laparotomy is made intraoperatively as
laboratory values become available
33. Pneumatic Antishock Garment
• A compression device first known as the Military
Anti-Shock Trousers (MAST) introduced by the
U.S. Army during the Vietnam War
34. Supplemental Oxygen
• Beneficial in multiple or massive
injury
– Flail chest, fat embolus and other
injuries associated with impaired
oxygenation
35. Vasopressors
• Transiently supporting blood pressure with
vasoconstrictors until volume replacement or
control of bleeding is possible
• Intense vasoconstriction is typical hemostatic
response to hemorrhagic shock and may be
primarily responsible for adverse consequences of
hypovolemia (acidosis and tissue hypoxia)
36. Hyperthermia and Dehydration
• Physical exertion and inadequate supplies
on the battlefield combine to develop heat
injury and dehydration
• Coincidental trauma and hemorrhage
• Rapid replacement of intravascular and
intracellular fluids
37. Hypothermia
Temperatures <30 Degrees C
• Decreases renal blood flow 75%
• Restoration of fluid deficits
• Re-warming the patient frequently develops
metabolic acidosis
• Fluid resuscitation & maintenance will
correct acidotic state
• Treat acidosis with sodium bicarbonate
38. Hemorrhagic Shock and Head
Injury
• Hypovolemia and head injury is ominous
• Increased intracranial pressure and hypotension,
secondary to hypovolemia, further decreases
cerebral perfusion pressure and potentiates
cerebral ischemic injury
• When colloid solutions have been advocated, the
blood-brain barrier may have been damaged
contributing to worsening edema with fluid
resuscitation
