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Shock and Fluid Resuscitation

Shock and Fluid Resuscitation. ผศ.นพ.เรวัต ชุณหสุวรรณกุล สาขาวิชาศัลยศาสตร์อุบัติเหตุ คณะแพทยศาสตร์ศิริราชพยาบาล. Shocks. “ Inadequate tissue perfusion and oxygenation “. Shock. What is the cause of the shock state?. Hypovolemic. vs. Nonhemorrhagic. Blood loss Fluid loss.

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Shock and Fluid Resuscitation

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  1. Shock and Fluid Resuscitation ผศ.นพ.เรวัต ชุณหสุวรรณกุล สาขาวิชาศัลยศาสตร์อุบัติเหตุ คณะแพทยศาสตร์ศิริราชพยาบาล

  2. Shocks “ Inadequate tissue perfusion and oxygenation “

  3. Shock What is the cause of the shock state? Hypovolemic vs Nonhemorrhagic • Blood loss • Fluid loss • Tension pneumothorax • Cardiac tamponade • Cardiogenic • Septic • Neurogenic • Anaphylactic

  4. 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)

  5. 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

  6. Shock What is the cause of the shock state? Hypovolemic vs Nonhemorrhagic • Blood loss • Fluid loss • Tension pneumothorax • Cardiac tamponade • Cardiogenic • Septic • Neurogenic • Anaphylactic

  7. Tension pneumothorax High pressure pneumothorax causing cardiovascular compromised status * chest injury * dyspnea & tachypnea * distended neck vein * deviated trachea * hypotension * tympanic on percussion * absent breath sound

  8. Cardiac Tamponade Obstructive shock Beck’s triad : Hypotension : Distant heart sound : Engorged neck vein Pericardiocentesis Thoracotomy

  9. Class I Hemorrhage BVL (15%) ; adult 70ml/kg , child 80mi/kg • Slightly anxious • Normal blood pressure • Heart rate < 100 / min • Respirations 14-20 / min • Urinary output 30 mL / hour Crystalloid

  10. Class II Hemorrhage BVL (15-30%) ; adult 70ml/kg , child 80ml/kg • Anxious • Normal blood pressure • Heart rate > 100 / min • Decreased pulse pressure • Respirations 20-30 / min • Urinary output 20-30 mL / hour Crystalloid, ? blood

  11. Class III Hemorrhage BVL (30-40%) ; adult 70ml/kg , child 80ml/kg • Confused, anxious • Decreased blood pressure • Heart rate > 120 / min • Decreased pulse pressure • Respirations 30-40 / min • Urinary output 5-15 mL / hour Crystalloid, blood components, operation

  12. Class IV Hemorrhage BVL (>40%) ; adult 70ml/kg , child 80ml/kg • Confused, lethargic • Hypotension • Heart rate > 140 / min • Decreased pulse pressure • Respirations >35 / min • Urinary output negligible Definitive control, blood components

  13. 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

  14. 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 Uncrossmatched blood : gr. O , Rh +vePRC

  15. Fluid Resuscitation Response • Rapid response : <20% , cease • Transient response : 20-40% , on going • Unresponsive : >40% , active bleeding

  16. Adjuncts • Monitors : V/S , O2 sat , EKG , urine output : GCS , ABG • Catheters : N-G , Foley catheter • Investigations : FAST , DPL , CT , Angiogram : CXR , Film pelvis & limb

  17. Sources of bleeding • External bleeding • Internal bleeding : chest ( hemothorax ) : abdomen : pelvis : long bone

  18. 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%

  19. Fracture Pelvis Associated injuries : Head injury 51% Extremity fracture 48% Abdominal injury 28% Peripheral nerve injury 26% KUB injury 23% Chest injury 22%

  20. 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

  21. Diagnosis • History of injury * car accident * motorcycle accident * pedestrian accident * falling from height * crush injury

  22. 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 ???

  23. Diagnosis 3. Investigations * pelvic film : AP , Inlet , Outlet , Judet * FAST * DPL * CT scan * Angiography

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

  25. 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 “

  26. 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 “

  27. 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 “

  28. 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 “

  29. 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 “

  30. 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 )

  31. 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 “

  32. 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

  33. Hypertonic Saline “ causes influx of fluid into intravascular spacewith small volume” “ In head trauma patients, it can limit cerebral edema , lower intracranial pressure and improve cerebral perfusion “ “ 3% hypertonic saline plus 6% dextranshowed the greatest benefit in shock patients with concomitant severe closed head injury “

  34. 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 “

  35. Blood Transfusion “ Patient in shock who fails to response adequately to 2 liters of crystalloidis 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 “

  36. 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 “

  37. Complications of Transfusion Hypothermia : mild = 32-35 degrees celcius : mod = 28-32 degrees celcius : sev = < 28 degrees celcius Trauma victims with core temperature < 32 degrees celcius have 100% mortality

  38. 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 )

  39. Complications of Resuscitation Acidosis : NSS >> RLS : pH < 7.1 independently predicted coagulopathy : decreases fibrinogen and platelet : increases PTT and bleeding time

  40. 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 “

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