Assessment and management of shock in acute trauma setting based on ATLS recommendations .Lecture given in Trauma update at Perintalmanna on19th August 2014.

1. “TRAUMA - SHOCK”
Red flags & Deadlines
Dr.Venugopalan.P.P
DA,DNB,MNAMS.MEM -GWU
Director , Emergency Medicine, Aster DM healthcare
Founder& Executive Director
Active Network Group of Emergency Life Savers

2. Definition
An abnormality of circulatory system that
results in inadequate organ perfusion and
tissue oxygenation

3. Inadequate
Cellular
Oxygen
Delivery
Anaerobic
Metabolism
Inadequate
Energy
Production
Metabolic
Failure
Lactic
Acid
Production
Metabolic
CELL Acidosis
DEATH
Ultimate Effects
of Anaerobic
Metabolism

4. Two Critical steps in the management
Step one
Recognize its presence – Initial diagnosis is
based on clinical appreciation of the presence
of inadequate tissue perfusion and
oxygenation
No laboratory test diagnoses shock

5. Step two
Identify the probable causes of the shock state.
– Hemorrhage (most common cause)
– Cardiogenic
– Neurogenic
– Tension pneumothorax
– [Even] Sepsis

6. • The response to initial treatment couples with
the finding during the primary and secondary
patient surveys, usually provides sufficient
information to determine the cause of the
shock state.

7. Shock does not result from
isolated brain injuries.

8. Response to blood loss
Early circulatory responses to blood loss are
compensatory –
Progressive vasoconstriction of
cutaneous, muscle, and visceral circulation to
preserve blood flow to the kidneys, heart and
brain

9. Earliest clinical signs
• Tachycardia - the earliest measurable
circulatory sign of shock
• Increased Diastolic blood pressure
• Reduced Pulse Pressure.

10. Any injured patient
who is cool and tachycardic
is in “shock”
until proven otherwise

11. • > 160 - Infants
• > 140 -Preschool
child
• > 120 -School age to
puberty
• > 100 - Adult

12. Shock
How do I locate the bleeding?

13. Shock
How do I locate the bleeding?
● Physical examination
● Diagnostic adjuncts to
primary survey
● Chest X-ray
● Pelvic X-ray
● FAST / DPL

14. Shock
What is the cause of the shock state?
In the vast majority of trauma patients,
shock is due to blood loss.

15. Interventions
What can I do about it?
Direct pressure /
tourniquet
STOP
the
bleeding!
Reduce
pelvic
volume
Angio-embolization
Splint
fractures
Operation

16. Interventions
What can I do about it?
● Fluid resuscitation
● Vascular access?
● Type?
● Volume?
● Monitor response
● Prevent hypothermia!

17. Treatment goals
• Volume restoration
• Control hemorrhage
• Assess response to the initial therapy
The presence of shock
in an injured patient
demands the immediate involvement of a surgeon

18. Vasopressors
are contraindicated for
the treatment of hemorrhagic shock
because they worsen tissue perfusion

19. Estimate fluid and blood losses
Based on Patient’s Initial Presentation

20. Class I Class II Class III Class IV
Blood Loss (mL) Up to 750 750-1500 1500-2000 > 2000
Blood loss (% blood
volume)
Up to 15 % 15 %-30% 30% - 40 % > 40 %
Pulse rate <100 > 100 >120 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure
(mm Hg)
Normal or
increased
Decreased Decreased Decreased
Respiratory rate 14-20 20-30 30-40 > 35
Urine output
(mL/hr)
>30 20-30 5-15 Negligible
CNS/Mental status Slightly anxious Mildly anxious
Anxious
confused
Confused,
lethargic
Fluid replacement
(3:1 rule)
Crystalloid Crystalloid
Crystalloid and
blood
Crystalloid and
blood

21. Management strategy
• Assess and manage “ABC”
• Establish “IV -Oxygen –Monitors”
• Insert “2 large bore” cannulae in peripheral
Veins
• Infuse “large volume” of warm crystalloids (1
liter) rapidly
• Insert NG tube and bladder catheter

22. Assess
the “response” to initial volume therapy

23. • Response to initial fluid resuscitation is the
key to determining subsequent therapy
• Distinguish “Hemodynamically stable” from
“Hemodynamically normal”

24. Response to initial fluid resuscitation
• Rapid response
• Transient response
• Minimal or No response
[1000 mL Ringer;s lactate solution in adults,
20 ml/kg Ringer’s lactate bolus in children]

25. Rapid Response Transient response No response
Vital signs Return to normal
Transient
improvement,
recurrence of
↓ BP and ↑HR
Remain abnormal
Estimated blood loss
Minimal
(10% - 20%)
Moderate and
ongoing
(20% - 40%)
Severe (>40%)
Need for more crystalloid Low High High
Need for blood Low Moderate to high Immediate
Blood preparation
Type and cross
match
Type-specific
Emergency blood
release
Need for operative
intervention
Possibly Likely Highly likely
Early presence of surgeon Yes Yes Yes

26. Failure to respond to crystalloid and blood
administration ?
• Blunt myocardial injury
• Cardiac tamponade
• Tension pneumothorax
• Neurogenic shock
• Ongoing hemorrhage
– Retroperitonial bleed
– Internal organ injury
Search
Causes

27. Fluid of choice
• Ringer’s lactate is the initial fluid of choice
• Normal saline is the second choice
• Blood and blood components as required

28. Special situations
• Age
• Athletes
• Pregnancy
• Medications
• Hypothermia
• Pacemaker
Beware
Unusual presentations

29. Pitfalls
Complications of Shock and Shock Management
Pitfalls
● Hypothermia
● Early coagulopathy

30. Pitfalls
Complications of Shock
● Equating BP with cardiac
output
● Misleading hemoglobin and
hematocrit levels
Pitfalls

31. Debate !

32. Permissive Hypotension in Trauma
“One of the most controversial issues in trauma care today is
restricting intravenous fluid resuscitation in hypotensive
trauma patients who have uncontrolled hemorrhage”
This new approach has the following goals:
• 1) Limiting hemorrhage
• 2) Preventing hemodilution
• 3) Not disrupting the clotting process.

33. • Permissive hypotension is still a relatively new
concept for treating trauma patients who are
hypotensive with uncontrolled hemorrhage.
• There is still no clear, universal recommendation
regarding a standardized approach. Research and
common sense does allow some initial conclusions to
be drawn that definitely favor permissive
hypotension.

35. https://www.facebook.com/TheLancet
MedicalJournal
• CRASH-2: tranexamic acid and trauma patients
• Published March 24, 2011
• Executive summary
• A new analysis of the 2010 CRASH-2 study shows that
tranexamic acid should be given as early as possible to
bleeding trauma patients; if treatment is not given until
three hours or later after injury, it is less effective and
could even be harmful. In this new analysis, the
CRASH-2 investigators analysed subgroups of patients
who had received tranexamic acid less than one hour
after injury; between one and three hours after injury;
or more than three hours after injury.

36. conclusion
• Trauma shock management is challenge
• Protocol based approach is the best way to
solve puzzle
• Early surgical involvement is one of the corner
stones

37. Interesting Web Sites
• www.trauma.org/archives/permhypo.html
(Research articles on permissive hypotension)
• www.manuelsweb.com/blood_loss.htm
(Allows you to calculate allowable blood loss)

38. www.drvenu.net
THANK YOU