Initial Resuscitation in Surgical Emergencies The document discusses the initial steps in resuscitation for surgical emergencies, including assessing and treating the ABCDEs (airway, breathing, circulation, disability, exposure/environment). It covers open airway methods, types of airway equipment, needle decompression for tension pneumothorax, chest seals for open pneumothorax, and classifications of shock. Pathophysiology of hemorrhagic shock is explained in terms of cardiovascular, hormonal, microcirculatory responses. Fluid resuscitation is discussed, including types of fluids, ideal properties, and evolution of resuscitation solutions. Blood transfusion components like packed red blood cells, plasma

1. Initial Resuscitation
In
Surgical Emergency
By
Dr. SUTHEE INTHARACHAT
Emergency Physician

2. Surgical Conditions
• Trauma conditions
-Airways
-Breathing
-Circulation
-Disability
-Environments/Exposure
• Non-Trauma conditions
-ABCDE

3. Combat Casualty Care
• Care under fire
-CAB
• Tactical field care
-ABCDE
• Tactical evacuation
-ABCDE

5. Open Airway Methods
Jaw thrust
Head tilt chin lift

7. Airway equipments
Non Definitive Airways Definitve Airways

8. Laryngeal Tube

9. Needle &Surgical Cricothyroidotomy

10. Equipments

12. Life threatening condition
• Tension pneumothorax
• Opened pneumothrax
• Pneumohemothorax

13. Tension pneumothotax

14. Needle Chest Decompression

15. Equipments

16. Open pneumothorax

17. Bolin Chest Seal
Asherman Chest Seal

18. Massive Hemothorax

19. Flail chest
อกรวน

20. PARADOXICAL RESPIRATIONS

22. Shock
• 1937 : Henri Francis LC Dran “ Choc”
• 1734 : Clarke “ Shock ”
Classified Shock
-Obstructive shock
-Hypovolemic shock
-Inflamatory shock
-Neurogenic shock
-Cardiogenic shock

23. Historical Background
Claude Bernard, 1879
• Milieu interieur

24. Historical Background
Walter B. Cannon, 1918
• World War I
• “Toxic factor”
• “ Restoration of blood
pressure prior to control of
active bleeding may result in
loss of blood that is sorely
needed.”

25. Historical Background
Alfred Blalock, 1934
• Reduce cardiac output due to
volume loss, not a “toxic
factor”
Categories of shock
• Hypovolemic shock
• Vasogenic shock
• Neurogenic shock
• Cardiogenic shock

26. Hemorrhagic Shock Model
Carl J. Wiggers

28. 1. Cardiovascular response
2. Hormonal response
3. Microcirculatory response
Pathophysiology in Hemorrhagic Shock

29. Pathophysiology:
Cardiovascular/Hormonal
Baroreceptor reflex JGA
Renin-angiotensin system
Aldosterone
ECF osmolarity
AVP/ADH
End organ perfusion
NE/E
Osmoreceptor
Hypotension
Na reabsorption
+inotropism
+chronotropism
Water reabsorption

30. Pathophysiology: Overview
Sympatico-Adrenergic Reaction Central Venous Pressure 
Vascular System
Vasoconstriction Hypotension
 TISSUE PERFUSION
DO2 VO2
Anaerobic metabolism Tissue acidosis
Oxygen Free Radicals NO
Capillary Leakage
Heart
Contractility Tachycardia
Cardiac VO2
Pump Failure
Coagulopathy
Coagulation Factor
Platelets
Consumption Loss
DIC Fribinolysis
MULTIPLE ORGAN DYSFUNCTION SYNDROME
Immune System
Innate immunity
Adaptive immunity
Hyperinflammation
Immunosupression Bloody
Vicious cycle
H
Y
P
O
T
H
E
R
M
IA

31. Major Torso Trauma
Iatrogenic
factor
Cellular
shock
Tissue
injury
Pre-existing
diseases
Clotting factor
deficiencies
Contact
activation
Active hemorrhage
Metabolic
acidosis
Progressive
coagulopathy
Core
hypothermia
Massive
transfusion

32. Pathophysiology: Microcirculation
• Decreased capillary
hydrostatic pressure
• Extracellular fluid shift
G. Tom Shires

33. Pathophysiology: Microcirculation
• ATP depletion
• Down regulation of
membrane Na+-K+ ATPase
• Na+ in
• K+ out
• Water in
• Intracellular Ca++
• Cell death

34. Pathophysiology: Microcirculation
No-reflow

35. Cellular Effects: Anaerobic Glycolysis

36. Cellular Effects: Apoptosis
• Ischemic-reperfusion injury
• Intestinal mucosal cell
– Bacterial translocation
• Lymphocyte apoptosis
– Immunosuppression

37. Inflammatory
Response

38. การประเมินความรุนแรงการเสียเลือดผู้ป่วยอุบัติเหตุ
Class I Class II Class III Class IV
ปริมาณเลือดที่เสีย <750 750-1,500 1,500-2,000 >2,000
ปริมาณเลือดที่เสีย
(%)
<15% 15% – 30% 30% - 40% >40%
ชีพจร <100 > 100 >120 >140
ความดันโลหิต ปกติ ปกติ ลดลง ลดลง
Pulse pressure ปกติ ลดลง ลดลง ลดลง
อัตราการหายใจ 14-20 20-30 30-40 >35
ปัสสาวะ(ml/hr) >30 20-30 5-15 เล็กน้อย
CNS กระสับกระส่ายน้อย
มาก
กระสับกระส่ายเล็กน้อย กระสับกระส่าย/ สับสน สับสน / ซึม
ATLS

39. Symptom/Sign
Mild Dehydration
< 5%
Moderate
5-10%
Severe Dehydration
>10%
LOC Alert Lethargic Obtunded
Capillary refill* 2 Seconds 2-4 Seconds > 4 seconds, cool limbs
Mucous Normal Dry Parched, cracked
Heart rate Normal Increased Very increased
Blood pressure Normal
Normal, but
orthostasis
Decreased
Pulse Normal Thready Faint or impalpable
Skin turgor Normal Slow Tenting
Eyes Normal Sunken Very sunken
Urine output Normal Oliguria Oliguria/anuria
Axillary sweat Normal Decrease Absent
Urine spec. </= 1.020 >/=1.030 >/=1.035
BUN Normal Elevated Markedly elevated
Arterial pH. 7.30-7.40 7.10-7.30 <7.10
Clinical Findings of Dehydration in Adult
Rosen ed6.

40. Symptom/Sign Mild Dehydration
Moderate
Dehydration
Severe Dehydration
Level of
consciousness*
Alert Lethargic Obtunded
Capillary refill* 2 Seconds 2-4 Seconds
Greater than 4 seconds,
cool limbs
Mucous Normal Dry Parched, cracked
Tears* Normal Decreased Absent
Skin turgor Normal Slow Tenting
Fontanel Normal Depressed Sunken
Eyes Normal Sunken Very sunken
Urine output Decreased Oliguria Oliguria/anuria
Heart rate Slight increase Increased Very increased
Respiratory rate Normal Increased
Increased and
hyperpnea
Blood pressure Normal
Normal, but
orthostasis
Decreased
Pulse Normal Thready Faint or impalpable
Clinical Findings of Dehydration in Pediatric

41. Severity
Infants (weight <10
kg)
Children (weight
>10 kg)
Mild dehydration 5% or 50 mL/kg 3% or 30 mL/kg
Moderate
dehydration
10% or 100 mL/kg 6% or 60 mL/kg
Severe dehydration 15% or 150 mL/kg 9% or 90 mL/kg
Estimated Fluid Deficit in Pediatrics
Rosen ed.6

43. STOP BLEEDING

44. 1. ชนิด และ ขนาด

45. Flow dynamics
• Poiseuille law :
¶ x R x pressure gradient Rate
of flow =
8 x dynamic fluid viscosity
4
Temperature
Catheter length

46. Needle size Diameter
(mm)
Flow rate
(ml/min)
16 1.70 210
18 1.30 100
20 1.10 65
22 0.9 38
24 0.70 24

47. ตาแหน่ง
1.Peripheral

48. 2.Intraosseous
3.Central

49. Intraosseous

50. FAST

51. Evolution of Fluid Resuscitation
1831: 1st Cholera pandemic
•William Brooke
O’Shaughnessy
•Injection of high oxygenated
salt into the venous system
•0.5-1% NaCl: Indifferent
solution

52. Evolution of Fluid Resuscitation
1892 Spencer “normal saline”
1896 Hartog Jakob Hamburger
• 0.92% saline was normal
• Isotonic to human serum
1883 Sydney Ringer
•0.75%saline in pipe water for
frog heart

53. Evolution of Fluid Resuscitation
1932 Alexis Hartmann
• Add sodium lactate to
Ringer’s solution
• Hartmann’s solution
• Lactated Ringer’s solution

54. Ideal Resuscitation Fluid
The ideal resuscitation fluid would have to have the
properties of an elixir of life: a small-volume cocktail
that among its virtues improves perfusion, enhances
oxygen (O2) delivery and diffusion, provides adequate
metabolic substrates, neutralizes toxic molecules
released as a result of tissue injury, provides
antimicrobial activity, renders the recipient globally
less vulnerable to the effects of hemorrhagic shock,
and has prolonged beneficial effects. The solution
should further be stable for lengthy periods at a variety
of temperatures, be easy to prepare and administer,
and, if not inexpensive, be at least affordable

55. Characteristic of Resuscitation Fluids

56. Characteristic of Resuscitation Fluids

57. Crystalloids: 0.9% Saline
• 9 g sodium chloride in 1 L water
• Osmolarity 308 mOsm/L
• pH 5
• Na 154 mEq/L, Cl 154 mEq/l
“Abnormal saline”
• Fluid retention
• Hyperchloremic metabolic acidosis
• Activation of neutrophils

58. Crystalloids: Lactated Ringer’s Solution
• 6 g sodium chloride + 3.22 g sodium lactate
(racemic: D- and L-lactate) + 400 mg potassium
chloride + 270 mg calcium chloride in 1 L water
• Osmolarity 275 mOsm/L
• pH 6.5
• Vietnam conflicts: DaNang lung, shock lung,
Traumatic wet lung…ARDS
• Neutrophils activation
• Increase ICAM-1
• Increase expression of Bax

59. Crystalloids: Hypertonic Saline
• De Felippe et al.1980; Velasco et al.,1980
• 7.5% sodium chloride
• Osmolarity 2567
• Small volume: Infusion of 250 mL, plasma volume
expansion 1000 mL
• Protect microcirculation
• Immunologic protection
• Kramer 1986: 7.5% saline with 6% Dextran 70
(Hypertonic saline-dextran, HSD)

60. Resuscitation Outcome Consortium (ROC)
• Sponsored by NIH and USDD
• HSD: HTS: NSS Resuscitation in
1. Survival in blunt/penetrating trauma
2. Long term neurologic status after STBI
Crystalloids: Hypertonic Saline

64. Colloids: Conclusion
• Cochrane Injuries Group Albumin Reviewers,
CIGAR 1998: RR of death with albumin was 1.68
• CIGAR 2004: Fail to show benefit of colloid over
crystalloid
• Cochrane 2008: no evidence that one crystalloid
was safer than another, and because no
reduction in risk for death was evident in critically
ill patients, continued use of these agents in
these patients could not be justified outside the
setting of RCT Martin K Angele et al, Critical Care 2008;12(4)

65. Ideal Resuscitation Fluid
The ideal resuscitation fluid would have to have the
properties of an elixir of life: a small-volume cocktail
that among its virtues improves perfusion, enhances
oxygen (O2) delivery and diffusion, provides adequate
metabolic substrates, neutralizes toxic molecules
released as a result of tissue injury, provides
antimicrobial activity, renders the recipient globally
less vulnerable to the effects of hemorrhagic shock,
and has prolonged beneficial effects. The solution
should further be stable for lengthy periods at a variety
of temperatures, be easy to prepare and administer,
and, if not inexpensive, be at least affordable
Still on there way

67. Crystalloid Colloid
intravascular
compartment
สั้น นาน
ปริมาณที่ใช้ มากกว่า 3 เท่า น้อย
การเกิดเนื้อเยื่อบวมน้า มาก น้อย
ราคา ถูก แพง
การหามาใช้ ง่าย ต้องจัดหา
ผลข้างเคียง น้อย มากกว่า เช่น รบกวนการ
แข็งตัวของเลือด , RF

68. Oxygen carrying resuscitation fluids
• Hemoglobin-based oxygen carriers
• Flurocarbon-based oxygen carriers

69. Blood transfusion
• Fully crossmathed –> 1 hr or more
• Type specific –> 10-15 min
• Type O low titer Rh +/-
Stored blood ไม่ดีเท่า fresh blood เพราะ
: reduced oxygen carrying capacity (2,3-DPG)
: platelets are inactive
: clotting factors may be degraded

70. • Autotransfusion:
: directly anticoagulated and reinfused into
the patients using a macroaggregate filter.
: use of a cell-saver and provision of washed
RBCs.
• Massive transfusion:
: Transfusion of at least one blood volume or
10 units of blood in a 24 hr

72. Whole blood:
• ประกอบด้วย colloids (plasma proteins), clotting
factors including platelets, red blood cells for
oxygen carrying capacity
• Indications: acute blood loss, concurrent
anemia and hypoproteinemia, clotting defects
• Dose 5 – 15 ml/kg/hr and 40-60 ml/kg/hr ( life-
threatening emergency. )

73. Packed red blood cells:
• 1 U Hct 3% ให้ใน 2-3 ชั่วโมง
• เด็ก 10-15 ml/kg
• Indication : 1. Anemia Hb < 7 g/dl
2. O2 carrying capacity

74. • Leukoreduction,
• ข้อดี Alloimmunization and febrile
transfusion reactions.
• CMV transmission.
• Indication :
– Chronically transfused patients
– Potential transplant recipients
– Patients with previous febrile nonhemolytic
transfusion reactions
– CMV seronegative at-risk patients

75. Irradiation.
• ข้อดี Graft- versus-host
• Indication :
– ผู้ป่วยภูมิคุ้มกันบกพร่อง ( hereditary immune
deficiencies, Chemotherapy ,Transplantation,
AIDs (controversial).
– Patients receiving blood transfusions from
relatives in directed-donation programs
Washed PRC : กรณีแพ้ plasma เช่น IgA deficiency

76. Fresh Frozen Plasma:
• ประกอบด้วย colloids, active platelets, and
clotting factors ( 1U = 3-5% cofactor)
• เด็ก 10-15 ml/kg
• Indication :
– bleeding ร่วมกับขาด Coagulation factor
– แก้ coagulation defects
– Massive transfusion
– hypoproteinemia and maintaining normal
colloidal osmotic pressure

77. Platelet
• Platelet conc. 6 U / Single donor 1U
เพิ่ม Platelet 50,000 /ml
• Indication : Therapeutic / Prophylaxis
< 10,000 Asymtomatic
< 15,000 Cogulation disorder / bleeding
< 20,000 Major bleed
< 50,000 Invasive procedure/ massive transfusion
<100,00 Neurologic / cardiac surgery

78. Cryoprecipitate
• Dose : 1U/5 kg เพิ่ม Fibrinogen 75 mg/dl
ให้ 10 U
: 1U/kg เพิ่ม 2% factor VIII activity
• Indication :
– Bleeding with fibrinogen < 100mg/dl เช่น DIC
– Von Willenbrand disease
– Hemophelia A

79. Complications การให้สารน้า
• Infection : local: swelling, redness, and fever ,
septicemia
• Phlebitis : irritation(foreign body (the IV
catheter)) or the fluids or medication
Symptoms : swelling, pain, and redness
Mx. warmth, elevation of the affected limb, or
a change flow rate

80. • Fluid overload : hypertension, heart failure,
and pulmonary edema
• Electrolyte imbalance
• Embolism
• A blood clot or other solid mass, or an air
bubble,
• Air bubbles < 30 mL dissolve into the
circulation harmlessly.
• Extremely large (3-8 mL/kg),  Arrest
• Extravasation

81. Febrile non-hemolytic transfusion reaction
• most common ,benign
• fever and dyspnea 1 to 6 hours
Complication การรับผลิตภัณฑ์เลือด
Acute hemolytic reaction.
•Medical Emergency
•Hemolysis ของ donor RBC โดย host antibody.
•The most common “wrong unit to wrong patient”
•อาการ ไข้ หนาวสั่น ปวดหลัง ปัสสาวะสีชมพูแดง เหนื่อย หัวใจเต้นเร็ว ช็อก DIC ,
Renal failure

82. Management
• หยุดการให้เลือดทันที
• IV hydration ให้ปัสสาวะออกดี
• Oxygen
• ส่งเลือดในถุง และเลือดผู้ป่วยกลับไปตรวจซ้้า
• Hemolytic work up : Direct / Indirect coombs
test , CBC, Creatinine ,Coagulogram ,LDH
,Indirect bilirubin , Urine for hemoglobin

83. • Paracetamol
• Meperidine (pethidine)
• Antihistamine ถ้ามีผื่นคัน หรือคัน

84. • Viral infection. : HBV( 1 in 250,000 units ) HIV or
HCV ( at 1 per 2 million units ).
• Bacterial infection. The risk is highest with
platelet transfusion (1 in 50,000 platelet
transfusions), and 1 in 500,000 red blood cell
transfusions
• Volume overload.
• Anaphylactic reaction.

85. • Transfusion-associated acute lung injury
(TRALI).
• อาการ ไข้ , non-cardiogenic pulmonary edema ,
and hypotension.
• Self limited within 96 hours,
• Iron overload. .
• Transfusion-associated graft-vs-host disease
(GVHD).

86. Large Volume Crystalloid Resuscitation
• World War II: Blood for resuscitation lead to post-
traumatic ARF
• Vietnam: Large volume of crystalloid resuscitation
decreased incidence of ARF
• ATLS® protocol: 2L of crystalloid bolus and check
for response, if non-responder, call for blood
• Crystalloid: short term hemodynamic benefit,
adverse consequences of hemostasis
– Dilutional coagulopathy
– Secondary clot disruption
Increase blood flow
Increase perfusion pressure
Decrease blood viscosity

87. 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
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). The mean estimated intraoperative blood loss was similar in the two
groups. Among the 238 patients in the delayed-resuscitation group who survived
to the postoperative period, 55 (23 percent) had one or more complications
(adult respiratory distress syndrome, sepsis syndrome, acute renal failure,
coagulopathy, wound infection, and pneumonia), as compared with 69 of the 227
patients (30 percent) in the immediate-resuscitation group (P = 0.08). The
duration of hospitalization was shorter in the delayed-resuscitation group.

89. Disabilities and Immobilization
• Rapid neurogic evaluation
– GCS, conciousness, pupillary size and reaction,
localizing signs

96. Pathophysiology: Microcirculation

97. LRS and Neutrophils Activation