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TRAUMATIC SHOCK

TRAUMATIC SHOCK. Do Ngoc Son MD., PhD. Emergency Department Bach Mai Hospital, Hanoi. Objectives. Definition of traumatic shock Recognition of shock stages and severity Management of shock according to stages and severity. DEFINITION AND PATHOPHISIOLOGY OF SHOCK. DEFINITION OF SHOCK.

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TRAUMATIC SHOCK

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  1. TRAUMATIC SHOCK Do Ngoc Son MD., PhD. Emergency DepartmentBach Mai Hospital, Hanoi

  2. Objectives • Definition of traumatic shock • Recognition of shock stages and severity • Management of shock according to stages and severity

  3. DEFINITION AND PATHOPHISIOLOGY OF SHOCK

  4. DEFINITION OF SHOCK • Inadequate organ perfusion and tissue oxygenation. • Circulatory system failed to meet the metabolic demand of the body

  5. HUMAN CIRCULATORY SYSTEM

  6. Preload Stroke volume Cardiac output Blood pressure ARTERIAL BLOOD PRESSURE Cardiac contractility Afterload Heart rate Systemic vascular resistance

  7. BOOD PRESSURE REGULATION(ROLE OF NEURO-ENDOCRINE SYSTEM) • Pressure receptors located at the aortic arch and carotids • Sympathoadrenal axis  regulate the release of catecholamine • Renin-angiotensin-aldosteron system  blood vessel tone and urine secretion

  8. VOLUME STATUS BLOOD VOLUME

  9. PHYSIOLOGICAL RESPONSES DURING SHOCK • In normal condition, the body can compensate for the reduction of tissue perfusion • When the compensated capabilities are overloaded  SHOCK  irreversible shock if undetected and untreated

  10. PHYSIOLOGICAL RESPONSES DURING SHOCK • Systemic vascular constriction • Increased blood flow primarily to important organs (brain, heart) • Increased cardiac output • Increased respiratory rate and tidal volume • Decreased urine output • Decreased gastroenterological activity

  11. COMPENSATED SHOCK • Defense mechanism try to maintain the blood perfusion to main organs by: • Constrict the pre-capillary sphincter, blood bypasses capillary through shunt • Increased heart rate and cardiac muscle contractility • Increased respiratory activity, bronchial dilation

  12. COMPENSATED SHOCK • Progresses until causes of shock are treated or continues to next stage • Difficult to diagnose due to obscure symptoms • Tachycardia • Signs of reduced skin perfusion • Altered mental status • Some medication (B- blockers) could undermine the symptoms by preventing the tachycardia.

  13. UNCOMPENSATED SHOCK • Physiological responses • Pre-capillary sphincter opens • Hypotension • Reduced cardiac output • Blood accumulate in capillary bed • Aggregation of the erythrocytes

  14. UNCOMPENSATED SHOCK • Easier to diagnose than compensated shock: • Longer capillary refill time • Marked increased heart rate • Increased and thready pulses • Agitated, disorientated and confused • Hypotension

  15. IRIVERSIBLE SHOCK • Failed compensated mechanism • Sometimes difficult to distinguish • Resuscitatable but high mortality (ARDS, ARF, hepatic failure, sepsis) • Prolonged organ ischemia, cellular death, MODS: brain, lung, heart and kidney • Coagulation disorders (DIC)

  16. Cellular O2 deficiency A. Lactic production Cellular energy starvation Anaerobic metabolism Metabolic disorders Metabolic acidosis CELL DEATH CELULAR O2 DIFFICENCY

  17. INITIAL ASSESSMENT AND MANGAGEMENT OF SHOCK • Initial clinical manifestation may be poor • Identification of the causes is not so as important as prompt treatment for shock • Aim of treatment is recover the circulatory volume and shock management • It is important to exam shock patient regularly to assess their response

  18. ETIOLOGIES • Blood lost • Trauma • Fracture of long bone or opened fracture • Plasma lost due to burn

  19. ETIOLOGIES • Fluid lost to third compartment • Causes: • Peritonitis • Burn

  20. INTERNAL HEMORRHAGE • Hematemesis, black or bloody stools • Hemoptysis • Pleural effusion of blood (Hemothorax) • Peritoneal effusion of blood (Hemoperitoneum) 22

  21. STAGES OF HEMORRHAGIC SHOCK

  22. STAGES OF HEMORRHAGIC SHOCK • Stage 1: blood lost < 15% total blood volume • Stage 2: 15-30% total blood volume • Stage 3: 30-40% total blood volume • Stage 4: > 40% total blood volume

  23. STAGES OF HEMORRHAGIC SHOCK

  24. STAGE 1 • Blood lost < 750 mL • Total blood volume (%): 0-15% • Central nervous manifestation: slightly anxious • Systolic BP: normal • Diastolic BP: normal • Respiratory rate: 14 - 20 BPM • Pulse < 100 • Urine output: > 30 ml/h • Treatment : Crystalloid infusion (ratio 3/1)

  25. STAGE 2 • Blood lost : 750 – 1500 mL • Total blood volume (% ): 15 – 30% • Central nervous manifestation: mild anxious • Systolic BP: normal • Diastolic BP: increased • Respiratory rate: 20 - 30 BPM • Pulse > 100 • Urine output: 20 - 30 ml/h • Treatment: Crystalloid or blood transfusion

  26. STAGE 3 • Blood lost: 1500 - 2000 mL • Total blood volume (%): 30 – 40% • Central nervous manifestation: Anxious and confused • Systolic BP: decreased • Diastolic BP: decreased • Respiratory rate: 30 – 40 BPM • Pulse > 120 • Urine output: 5 - 15 ml/h • Treatment: Crystalloid or blood transfusion

  27. STAGE 4 • Blood lost > 2000 mL • Total blood volume (%) > 40% • Central nervous manifestation: Confused Lethargic • Systolic BP: decreased • Diastolic BP: decreased • Respiratory rate > 40 BPM • Pulse > 140 • Urine output: Negligible • Treatment: colloid, blood and surgery

  28. PITFALLS • Not all traumatic shock patients go through all 4 stages • In healthy young adults, the heart rate may be normal even patients are on stage 2 or 3

  29. DIAGNOSIS

  30. SEQUENCES OF EXAMINATION Order of ABC • A = Airway • B = Breathing: + O2 supply + Assisted ventilation

  31. SEQUENCES OF EXAMINATION Order of ABC • C = Circulation: + Hemostasis by local bandage + Blood volume replacement by fluid infusion + Identification of obstructive shock: - Tension pneumothorax: prompt thoracocentesis - Cardiac tamponade: prompt Pericardiocentesis

  32. Symptoms and diagnosis • Hemorrhagic shock: • Manifestations: • Obvious blood lost: Hematemesis, black or bloody stools. • Tachycardia, hypotension, low CVP. • Thirsty, dizziness, vertigo, agitation, LOC. • Pale, cold, sweating, cyanosis.

  33. Symptoms and diagnosis • Hemorrhagic shock: •  Respiratory disorders: tachypnea, cyanosis • Oliguria, anuria • Monitor, assessment of the severity of blood lost: • Orthostatic hypotension: BP  > 20 mmHg, pulse > 20 BPM: 10-20% blood lost • Supine hypotension: >20% blood lost

  34. Symptoms and diagnosis • Non-hemorrhagic shock (Hypovolemia): • Causes: dehydration or electrolyte disturbance • Manifestation: mainly symptoms of dehydration and electrolyte disturbance • ECF dehydration • ICF dehydration • Others: oliguria, cold

  35. Consequences of shock Consequences of shock: • Kidney: acute renal failure • Lungs: ARDS • Heart: hypoxic heart failure, metabolic acidosis, cardiac muscle stress • GE: gastric ulcers or bleeding • Liver: failure • Pancreas: edema, necrosis • Endocrinological glands: pituitary gland is most vulnerable in bleeding  necrosis (Sheehan syndrome)

  36. MANAGEMENT

  37. Emergency treatment Emergency treatment • Position: head down, open the airway • Breathing: O2 4-8 LPM. Ambu bag or endotracheal intubation for ARF • Monitoring for heart rate, blood pressure, SpO2, EKG • Basic labs: CBC, hematocrit, platelets, blood group, fibrinogen, prothrombin.

  38. Emergency treatment • Large venous access: • 500-1000ml Ringer lactate (NaCl 0.9%)/15-20 min. Continue infusion until BP increase and heart rate slow down  infusion rate • Fluid infusion helps to replace the blood lost until blood arrival

  39. Emergency treatment • Large venous access: • Blood transfusion should be started after 3 liters of fluid infusion • If blood is not available, fluid infusion should be continued • It should be remembered that fluid is not able to carry O2

  40. Emergency treatment • Blood transfusion: for hemorrhagic shock • Packed red blood cells: targeted Ht 25 - 30% • Fresh plasma or packed platelet if platelet <50.000/mm3 or Prothrombin < 50% • Many trauma centers now resuscitate patients with a 1:1:1 strategy. For every unit of red blood cells, a unit of platelets and a unit of fresh plasma is given: • 1 unit blood cell : 1 unit plasma : 1 unit platelets • Consider auto transfusion

  41. Emergency treatment • Urinary catheter placement • If fluid infusion and blood transfusion is adequate, CVP >7 but still hypotension: • Dopamine: 5- 20 g/kg/min • If failed: add Dobutamine • If failed: add Norepinephrine

  42. Emergency treatment • Ventilatory support if respiratory failure is detected • Identify and treat the causes • Trauma  operate

  43. FLUID MANAGEMENT • Large venous access> 18 F if possible • 2 lines in case of stage 3-4 of shock • Vasopressors are not indicated if circulatory volume is not adequate

  44. FLUID MANAGEMENT • Start with large bore venous access: + Can use compressor bag + Ringers lactate is common - Choose NS 0.9% if suspected hyperkalemia - NS 0.9% can be used for the line of blood transfusion.

  45. POSITION OF INFUSION • Upper extremity peripheral vein: preferred  precaution in case of upper extremity fracture • Central veins: sub-clavian and internal jugular vein: best choice even at stage 4  risk of pneumothorax (chest X ray is needed after procedure)

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