2. Learning Objectives
• Recognize and respond appropriately to a
patient with hemorrhagic shock
• Assess via bedside methods the source
of hemorrhage
• Respond appropriately to evidence of
intra-abdominal hemorrhage with regards
to initial management and disposition
3. Introduction
• Blunt abdominal trauma is common.
• Unknown history, distracting injuries, and
altered mental status make these patients
difficult to diagnose and manage.
• Victims frequently have both abdominal
and extraabdominal injuries.
• Family physicians need to be able to
recognize and treat hemorrhagic shock.
4. Recognition of Hemorrhagic Shock
• Shock: oxygen delivery < tissue demands
• Treatment must restore tissue perfusion not
just blood pressure
• Shock does NOT SBP < 90mmHg
• Recognition includes: mechanism of injury,
patient’s appearance, vitals, level of
mentation, peripheral perfusion and urine
output
• Clinical parameters should be coupled with
objective markers of tissue perfusion--serum
lactate, base deficit, etc.
5. Practical Diagnosis of Shock
• Perform a targeted physical examination
• Diagnostic testing should include chest
radiography, pelvis radiography, and
bedside ultrasound
• Objective serum makers of tissue
perfusion (serum lactate or base deficit)
• Point of care H/H, send CBC, type/cross
• DON’T delay resuscitation for lab results
6. 6 Steps to Treat Hemorrhagic Shock
• Step 1: Effectively manage the airway and
optimize oxygenation.
• Step 2: Identify and control immediate threats to
central perfusion.
• Step 3: Identify and address severe intracranial
injuries.
• Step 4: Identify and control other potentially life-
threatening thoracic and abdominal injuries.
• Step 5: Identify and control potentially limb-
threatening injuries.
• Step 6: Identify and treat noncritical injuries.
7. Treatment of Hemorrhagic Shock
• Obtain immediate type and crossmatch
for 6-8 units of blood
• Massive transfusion defined as > 10 U of
PRBCs in 24 hrs
• Consider use of PRBC to platelet to FFP
ratio of 1:1:1
• May result in decreased need for blood
products
• Give calcium to prevent citrate toxicity
8. Assessing for Sources of Hemorrhage
• Chest radiography:
• Tension pneumothorax? Massive hemothorax?
Aortic injury?
• Pelvis radiography:
• Pelvic ring disruption?
• Focused Assessment with Sonography for
Trauma (FAST):
• Pneumo/hemothorax? Hemopericardium?
Hemoperitoneum?
• If positive, then emergency laparotomy.
• If negative, continue resuscitation, treat other causes.
9. FAST Facts
• Reliably identifies 200-250ml of
intraperitoneal fluid
• Cannot reliably evaluate
retroperitoneum/hollow viscous injury
• Sensitivity/specificity: 75%/98%, NPV:
94%; 86-97% accurate
• Performed using a curvilinear 2.5 or 3.5
MHz probe
10. FAST Views
• Cardiac: parasternal or subxiphoid,
hepatocardiac interface, pericardial space.
• RUQ: hepatorenal interface (Morrison’s
Pouch), diaphragm, inferior pole of kidney.
• LUQ: splenorenal interface, diaphragm,
inferior pole of kidney, inferior tip of spleen.
• Suprapubic: outline of bladder, silhouette of
uterus (females).
11. FAST Algorithm
• Unstable patient: + FAST = OR.
• Stable pt: + FAST = abdominal CT.
• Stable pt, low mechanism of injury:
- FAST = observation, serial exams.
• CT is the “Gold Standard”.
12. What About Diagnostic Peritoneal
Aspiration (DPA)?
• Can be performed if - FAST in blunt
abdominal trauma.
• If DPA +, then emergency laparotomy.
• If DPA -, then seek and treat other
sources.
• Perform serial abdominal exams.
• Perform serial FAST exams.
• If patient stabilizes, then CT.
• Get surgery involved!
13. Indications for Emergency
Laparotomy
• Peritonism
• Free air under the diaphragm
• Significant gastrointestinal hemorrhage
• Hypotension with + FAST scan or + DPA
• Do NOT keep trauma patients if you lack
resources to care for them!
14. Summary
• Recognize and treat hemorrhagic shock
aggressively with blood products
• Assess for hemorrhage with bedside
methods: CXR, pelvis, and FAST
• Unstable patient: + FAST = OR.
• Stable pt: + FAST = abdominal CT.
• Stable pt, low mechanism of injury:
- FAST = observation, serial exams.
15. References
1. Puskarich MA. Initial evaluation and management of blunt
abdominal trauma in adults. In: UpToDate, Hockberger RS,
Moreira ME (Ed), UpToDate, Waltham, MA, 2012.
2. Nickson C. “Trauma! Blunt abdominal trauma decision
making.” Weblog entry. Life in the Fastlane Blog.
http://lifeinthefastlane.com/2012/03/trauma-tribulation-023/
3. Eastern Association for the Surgery of Trauma Guidelines
Workgroup. Evaluation of blunt abdominal trauma. 2010
Edition. Chicago, IL.
http://www.east.org/resources/treatment-
guidelines/category/trauma
4. American College of Surgeons. ATLS Textbook, 9th Edition. 1
September 2012.
17. CRITICAL ACTIONS ME NI M SUSTAIN IMPROVE
Completes Primary Survey:
recognizes shock
MK2
Safety net – IV, oxygen,
monitors (2 x 16G IV)
MK2
Completes Secondary Survey:
recognizes abdominal source
MK2
Completes bedside FAST
(+ Morrison’s Pouch)
PC5
Recognizes positive FAST: calls
surgery
PC5
Bedside labs: POC CBC, lactate,
BAL, VBG, blood type/screen/X-
match
MK2
Bedside rads: port chest, lat C-
spine, AP pelvis
MK2
Gives emergency release blood
transfusion
MK2
If unstable: no CT, to OR
If stabilizes: CT, then OR
MK2
TOTAL
SBP
4
SCENARIO ALGORITHM
SET UP:
“Rural” ER Simulated Room
Bedside US and/or FAST simulator
Real patient with simulated skin/abdomen
PRE ARRIVAL:
FP in rural ER, lab, rad, OR
35 y/o male s/p unrestrained driver MVA
arrives via EMS, in c-collar. VS BP 90/50, HR
110, RR 18, SpO2 97% on RA, GCS 15
ARRIVAL:
Full spinal precautions, has 1 IV in place. Pt
awake, alert, conversing, but in mild distress,
no meds, no allergies, no sig PMHx or PSHx
PRIMARY SURVEY:
A – talking initially, then somnolent
B – labored, RR 24, nl breath sounds
C – BP 85/40, HR 130, cool extremities
D – GCS 14, somnolent, oriented to person
when responds to voice
E – no other trauma, mild abd distension,
hypoactive BS
SECONDARY SURVEY:
Other exam normal, c-spine non tender,
pelvis stable, rectal guaiac negative
Abdominal exam tense, tender, absent BS
LABS & IMAGES:
Chest, c-spine, pelvis negative
Labs – WBC 9, H/H 8/24, platelets 150,
lactate 4, VBG: 7.35/46/40/50%/-8
Positive FAST in RUQ, no CT indicated
Blood type and screen/X-match
DISPOSITION:
Must transfuse blood , call Surgeon and direct
to OR, otherwise pt dies of hemorrhage
Simulation Training Assessment Tool (STAT)– Blunt Abdominal Trauma
Date: 1 May 2013 Instructor(s): Clark, Maurer, Cuda Learner(s):
Learning Objectives:
1. Recognize and respond appropriately to a patient with hemorrhagic shock.
2. Assess via bedside methods the source of hemorrhage.
3. Respond appropriately to evidence of intra-abdominal hemorrhage with regards to initial
management and disposition.
ME = Meets Expectations; NI = Needs Improvement, M = Milestones (see debriefing sheet)
