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Shock and Trauma Resuscitation

Shock and Trauma Resuscitation. Bonjo Batoon, CRNA, MS R Adams Cowley Shock Trauma Center Baltimore, MD. The Problem of Trauma. 50% die before they reach a hospital Head injury major cause of death in the field/hospital

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Shock and Trauma Resuscitation

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  1. Shock and Trauma Resuscitation Bonjo Batoon, CRNA, MS R Adams Cowley Shock Trauma Center Baltimore, MD

  2. The Problem of Trauma • 50% die before they reach a hospital • Head injury major cause of death in the field/hospital • Uncontrolled hemorrhage or MOF-related shock is the cause of death in about 40% of deaths • 20% of hemorrhagic deaths potentially preventable • 17% of military casualties from failed hemorrhage are potentially preventable • Dubick MA, et al. US Army Institute of Surgical Research, 2006; report # A508184

  3. Shock by definition • A failure of adequate oxygen delivery or utilization at the cellular level, perpetuated by cellular and humoral responses • Prolonged shock results in a cumulative “oxygen debt”, severe metabolic derangement, and disruption of end-organ integrity and homeostasis

  4. Shock by definition • A state of inadequate tissue perfusion • A cellular and end-organ disorder • Not a disorder of the macro-circulation • Decreased BP does not equal shock

  5. Oxygen Debt

  6. Types of shock • Hemorrhagic- Most common • Non-hemorrhagic • Cardiogenic • Neurogenic • Septic • Tension pneumothorax • Poisoning

  7. Signs & Symptom of Shock • Tachycardia • Tachypnea • Decreased capillary refill • Hypotension • Narrow pulse pressure • Altered mental status • Cyanosis, pallor, diaphoresis • Hypothermia • Decreased urine output • Absent pulse oximetry signal* • +FAST/CT*

  8. Classification of Shock

  9. Lethal Triad Coagulopathy Acidosis Hypothermia

  10. More than the Lethal Trial Hess  JR, Brohi  K, Dutton  RP;  et al.  The coagulopathy of trauma: a review of mechanisms, J Trauma 2008 654 748-754.

  11. Resuscitation Goals • Early recognition of the shock state • Oxygenate and ventilate • Restore organ perfusion • Restore homeostasis / repay “oxygen debt” • Stop the bleeding- Surgeon’s job • Treat coagulopathy • Restore the circulating volume • Continuous monitoring of the response

  12. Components to Resuscitation • Airway • Breathing • Circulation • Exposure

  13. Airway • DL • Video laryngoscopy • AFOI • RSI vs MRSI • Cricoid pressure • C-spine issues • Surgical cricothyrotomy when all else fails

  14. Breathing • Secure airway most important • Adequately oxygenate • Monitor CO2 • Consider lower Vt in hypotensive pts

  15. Circulation • Adequate IV access • Peripheral • 16G or greater • Know flow rates for each cathether • Preferably central access • IJ vs SC vs femoral • Cordis vs double lumen catheters vs triple lumen

  16. Exposure • 34° C was the critical point at which enzyme activity slowed significantly, and at which significant alteration in platelet activity was seen. Fibrinolysis was not significantly affected at any of the measured temperatures • Watts, Dorraine Day, et al. "Hypothermic coagulopathy in trauma: effect of varying levels of hypothermia on enzyme speed, platelet function, and fibrinolytic activity." The Journal of Trauma and Acute Care Surgery 44.5 (1998): 846-854. • Keeping pt warm • Warm blood products • Bair hugger type devices • Warm operating room

  17. Monitoring • Basic • Advanced • A line • CVP? • PPV- FloTrac • TEE • Labs- CBC, coags, lytes, ABGs • POC • Hemoque- Hgb • iStat- lytes/gases • ROTEM- coagulation

  18. Clotting Dynamics

  19. Components to Resuscitation • Crystalloids • Colloids • Blood products

  20. Crystalloids • LR • NS • Plasmalyte • Crystalloids are not and should not be the mainstay of trauma resuscitation!!

  21. Prehospital fluids

  22. Prehospital Fluids

  23. Colloids • Starches • Coagulopathy • Hespan max dose 20ml/kg • Albumin • Allergic rxs

  24. Blood Products • RBCs • FFP • Plts • Cryoprecipitate • Other hemostatic agents • fVIIa, PCCs, fibrinogen concentrate

  25. Resuscitation Strategies • Ratio based resuscitation • RBC;FFP; RBC:FFP:PLTs • Laboratory based resuscitation • Lab delays • Lost samples • Point of Care • Coagulation concentrates • ROTEM

  26. Component Therapy Dutton, R. P. (2012), Resuscitative strategies to maintain homeostasis during damage control surgery. Br J Surg, 99: 21–28. doi: 10.1002/bjs.7731

  27. Damage Control Anesthesia Dutton, RP. Damage Control Anesthesia. Trauma Care. 2005;15:197-201.

  28. Thank you!!

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