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Shock and Trauma
John Miller
Meet the Heroes of Harborview's ER https://youtu.be/2zyshR2NvAE
Types of Trauma
 Minor trauma
 Major (multiple) trauma
 Blunt trauma
 Penetrating trauma
 Inhalation injuries
 Burn or freezing injuries
 Blast injuries
Journal of Trauma Nursing (Society of Trauma Nurses)
http://journals.lww.com/journaloftraumanursing/pages/default.aspx
Head and neck effects—airway obstruction
 Airway assessment is highest priority.
 Initial management
o Determine airway patency
o Identify any potential obstruction
o Assessment of breathing
 Closed head injury
 Maxillofacial trauma
 Direct airway trauma
 Cervical spine injury
 Burns
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Trauma Levels Explained http://www.amtrauma.org/?page=traumalevels
Thoracic effects
 Pneumothorax
 Flail Chest
 Thoracic contusion and rupture
o Diaphragmatic rupture
o Myocardial contusion
o Cardiac tamponade
o Aortic rupture (transection)
Effects of Traumatic Injury
 Hemorrhage
 External hemorrhage
o Control bleeding by applying direct pressure
 Internal hemorrhage
o Results from blunt or penetrating trauma
o Third spacing can follow injury.
o Interventions
 Operative control of bleeding
 Continual assessment of patient
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Integumentary effects
 Risk for contamination and infection
 Contusions
o Result from blunt trauma
 Abrasions
o Result from falls or scrapes
 Puncture wounds
o Result from penetration of sharp or blunt object
 Lacerations
o Open wounds
 Full-thickness avulsion injuries
o Result from loss of all skin layers
Abdominal effects
 Direct trauma
 Lacerate and compress solid organs
 Organs displaced from blood supply
 Bowel ischemia and infarction from damage to mesenteric vessels
 Effects of injury to stomach, pancreas, small bowel
o Digestive enzymes leaking into abdominal cavity
 Effects of injury to large bowel
o Escape of feces, causing peritonitis
Musculoskeletal effects
 Usually not a high priority
 May provide clues to other serious injuries
Neurological effects
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Head injuries most common
Sources include car crashes, falls, sports injuries, assault.
Multiple Organ Dysfunction Syndrome Assessment
 Progressive impairment of two or more organ systems
 Primary organ systems involved
o Respiratory, renal, hepatic, hematologic, cardiovascular, gastrointestinal, neurological
Multiple Organ Dysfunction Syndrome Treatment
 Surgical intervention, antibiotic administration, corticosteroid administration, or correction
coagulopathies
Multiple Organ Dysfunction Syndrome in Sepsis http://emedicine.medscape.com/article/169640-overview
Effects on the family
 May lead to psychological crisis
 Some ERs allow families to be present during resuscitation.
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Prehospital Care Injury Identification
 Scoring systems
o Champion Revised Trauma Scoring System
o Glasgow Coma Scale
 Primary trauma assessment
o A: airway
o B: breathing
o C: circulatory
o D: disability
o E: expose/environment

Revised Trauma Score http://www.trauma.org/archive/scores/rts.html
Secondary trauma assessment
 Injury identification
o F: full set of vital signs
o G: giving comfort measures
o H: head-to-toe assessment and medical history
o I: inspection of posterior surfaces
Prehospital Treatment
 Critical interventions
o Life support
o Immobilize cervical spine
o Manage airway
o Treat hemorrhage and shock
 Rapid transport
o Ground and air ambulance
Airlift Northwest Landing Zone Training Video https://youtu.be/Nlo1W2G8_Cs
Emergency Department Care
 Diagnosis
o Blood type and crossmatch
o Complete blood count (CBC)
o Arterial blood gas (ABG)
o Blood alcohol level
o Urine drug screen
o Pregnancy test
MLS Hematocrit https://youtu.be/trOHqwOtwkg
Emergency Department Care
 Diagnosis
o Focused assessment by sonography in trauma (FAST)
o Diagnostic peritoneal lavage
o Computerized tomography (CT)
o Magnetic resonance imaging (MRI)
Focused assessment with sonography for trauma (FAST) ATLS https://youtu.be/wjUiL_Rfnno
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Medications
 Blood components and crystalloids
 Inotropic medications: Dopamine, Dobutamine
 Vasopressors: Dopamine, Epinephrine
 Opioids
 Immunizations
Volume resuscitation therapies, p. 237 Lemone
Blood Transfusions
 Four blood types: A, B, AB, O
 A Type and crossmatch
 Reactions
o Febrile
o Hypersensitivity
o Hemolytic reaction
 Autotransfusion
Setup and Operation of Atrium Autotransfusion for Chest Drains and ATS Blood Bags
https://youtu.be/WknbHqvotE4
Emergency Surgery
 Needed when patient remains in shock despite resuscitation and no obvious sign of blood loss
 Identifying source of blood loss
o Abdominal and chest x-rays
o Ultrasound studies
o Diagnostic peritoneal lavage
o CT scan
Open Thoracotomy (Viewer Discretion Advised) https://youtu.be/8BlPxQI2C90
Diagnostic Peritoneal Lavage (DPL) - Dennis Kim, MD https://youtu.be/O9BZamRlXVA
Organ Donation
 The Uniform Anatomical Gift Act (1968, 1987)
 Exceptions for organ donation
o Currently abuse intravenous drugs
o Preexisting untreated infections
o Any malignancy other than primary brain tumor
o Have active TB
o HIV positive
Forensic Considerations
 Identify, store, and properly transfer potential evidence
 Clothing removed, placed in breathable container
 Bullets, knives labeled and given to proper authorities
 Holes in clothing should not be disturbed.
 In case of death, paper bags placed over hands if presence of evidence suspected
 Evidence collected by nail clippings
 Identify all wounds, document
 Chain of custody maintained
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Health Promotion
 Motor vehicle safety
 Environment safety
 Abuse and neglect
Treatment Priorities
 Ensure adequate treatment of underlying injury while providing oxygenation and perfusion
 Teach patient, caregivers strategies to prevent injuries and optimize home and work environments
 Focus on promoting comfort and maintaining asepsis for all interruptions of integument
(Real ER) 911: The Bronx - Episode One https://youtu.be/KZQ0HUpb9zs
 Diagnoses, Outcomes, and Interventions
 Ineffective Airway Clearance
 Risk for Infection
 Impaired Physical Mobility
 Spiritual Distress
 Post-Traumatic Stress Disorder
The Patient Experiencing Shock
 Shock
o Clinical syndrome characterized by systemic imbalance between oxygen supply and demand
o Inadequate blood flow to body organs and tissues
What is Shock? https://youtu.be/9a7N9AU1GiQ?list=PLdVvae0BQcKztVN9VICTi25bXgmseXc0I
Cellular homeostasis
 Four physiologic components
o Sufficient cardiac output
o Uncompromised vascular system
o Sufficient blood volume and blood pressure
o Tissues that are able to extract and use oxygen
Basic hemodynamics
 Five components
o Stroke volume (SV)
o Cardiac output (CO): CO= SV × HR
o Systemic vascular resistance (SVR)
o Mean arterial pressure (MAP)
o Sympathetic tone
Pathophysiology
 Triggered by sustained drop in MAP
 Stage I: Early, reversible, and compensatory shock
o Body reacts to decrease in arterial pressure
o Compensatory after MAP falls 10–15 mmHg below normal levels
o No permanent damage if effective treatment provided
Stage II: Intermediate or progressive shock
 Sustained decrease in MAP of 20 mmHg or more below normal levels
 Vasoconstriction response eventually limits blood flow and cells become oxygen deficient
 Generalized state of acidosis and hyperkalemia
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Stage III: Refractory or irreversible shock
 Tissue anoxia generalized
 Cellular death so widespread that no treatment can reverse
 Death of cells, then tissues, then organs
Shock: Systemic Effects
 Respiratory system
o Acid-base balance disturbance
 Tachypnea
 Respiratory alkalosis, hypoxemia
 Neuroendocrine system
o Sympathetic and adrenal response
 Vasoconstrict
 HR and BP increase
o Pituitary response
 Water, sodium retention
 Hyperglycemia
Effects of shock on body systems
 Cardiovascular system
o Hypoxic myocardial cells
o Sympathetic stimulation increases heart rate
o Rapid, weak palpated pulse
o Tachycardia
o Cardiovascular system
 Progressive shock
 Damage to heart’s electrical systems and contractility
 Decreased cardiac output, fall in blood pressure
 Decrease in systolic and diastolic pressures. Decrease in pulse pressure.
Respiratory system
 Impaired oxygen delivery to cells
 Respiratory rate increases
 Decrease in perfused alveoli
 Gas exchange impaired
 Oxygen levels in blood decrease, carbon dioxide levels increase
 Respiratory acidosis
 Hypoxemia, hyperventilation trying to compensate (respiratory alkalosis)
 Acute respiratory distress syndrome (ARDS)
Cardiovascular Effects
 Myocardial deterioration
 Disseminated intravascular coagulation (DIC)
 Vasoconstriction
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Gastrointestinal and hepatic systems
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Splanchnic arterioles constricts, arterial blood flow redirected to heart, brain
Ischemic gastrointestinal organs
Gastric and duodenal mucosa lesions
Permeability of damaged mucosa increases, may result in sepsis
Gastric, intestinal motility impaired, may result in paralytic ileus
Necrosis of the bowel
Increase in gluconeogenesis and glycogenolysis
Liver functions impaired
Metabolic acidosis develops
Liver’s reticuloendothelial Kupffer cells destroyed
Neurologic system
 Changes in mental status, orientation
 Dizzy, faint, anxiety, irritability, drowsy, confusion
 Cerebral hypoxia
 Ischemia of brain cells
 Cerebral edema
 Neurotransmitter failure
 Loss of sympathetic tone
Renal system
 Renal hypoperfusion
 Drop in renal perfusion
 Decrease in glomerular filtration rate
 Reduced urine output
 Acute tubular necrosis
 Renal failure
 Need urine minimum of 0.5ml/kg/hour to prevent failure.
Effects on skin, temperature, thirst
 Vasoconstricted blood vessels
 Pale skin color, lips, oral mucous membranes, nail beds, conjunctiva
 Skin is cool, moist
 Decrease in body temperature
 Thirst increases
Shock: Classifications
 Hypovolemic
 Cardiogenic
 Distributive (vasogenic shock)
o Anaphylactic shock
o Neurogenic shock
o Septic shock
Shock Types of shock https://youtu.be/rOADTgtWuD4?list=PLdVvae0BQcKztVN9VICTi25bXgmseXc0I
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Types of Shock: Hypovolemic
 A decrease in intravascular volume of 15% or more
 Causes
o Loss of blood volume and body fluid
o Loss of intravascular fluid
o Loss of intravascular volume
o Renal losses of fluid
o Third spacing
Hypovolemic Shock Pathophysiology
 Initially, blood pressure decreases
 Decreased blood flow to skin, skeletal muscles, kidneys, and abdominal organs
 Eventual loss of the cell’s physical integrity
 Untreated, multiple organ failure and death
o Older adults experiencing hypovolemia
 Relative decrease in sympathetic activity in cardiovascular system
 Secondary volume depletion due to chronic diuretic use, malnutrition
 Those prescribed beta-blockers may not present with tachycardia as an early indicator.
Cardiogenic shock
 Compromised pumping ability of the heart
 Causes
o Myocardial infarction
o Cardiac tamponade and arrest
o Restrictive pericarditis
o Cardiac arrest
o Dysrhythmias
o Pathologic changes in valves
o Cardiomyopathies
o Complications of cardiac surgery
o Electrolyte imbalances
o Drugs
o Head injuries
Cardiogenic Shock Pathophysiology
 Decrease in cardiac output and MAP
 Increased myocardial oxygen consumption and decreased perfusion
 Myocardial ischemia and necrosis
 Cyanosis
Obstructive shock
 Obstruction in the heart or great vessels
 Causes
o Impaired diastolic filling
o Increased right ventricular afterload
o Increased left ventricular afterload
Vasogenic Shock
 Widespread vasodilatation and decreased peripheral resistance
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Septic Shock
 Caused by gram-negative or gram-positive bacterial infections
 Risk factors include hospitalization, debilitating chronic illnesses, poor nutrition, old age, and being
immunocompromised.
 Stages of septic shock
o Early (warm) phase
o Late (cold) phase
 Toxic shock syndrome
 Disseminated intravascular coagulation (DIC)
Neurogenic shock
 Caused by imbalance between parasympathetic and sympathetic stimulation of vascular smooth muscle
 Risk factors include head injuries, spinal cord trauma, insulin reactions, CNS depressant drugs, anesthesia,
severe pain, and prolonged exposure to heat.
Anaphylactic shock
 Widespread humorally mediated hypersensitivity reaction (anaphylaxis)
 Cause
o Allergens
 Pathophysiology
o Vasodilatation
o Pooling of blood in periphery
o Hypovolemia with altered cellular metabolism
Shock Diagnosis
 Blood hemoglobin and hematocrit
 Arterial blood gas (ABG)
 Serum electrolytes
 Blood urea nitrogen (BUN), serum creatinine levels, urine specific gravity, and osmolality
 Blood cultures
 White blood cell count and differential
 Serum cardiac enzymes
 Other tests to determine injury or locate internal hemorrhage
 Diagnostic methods for hypoperfusion
o Gastric tonometry
Sublingual PaCO2
o
Shock: Diagnostic Testing
 Respiratory and Metabolic acidosis
 Cardiac
o 12 lead EKG
 Fluid balance assessment
o Heart pressures measured in ICU
 Lab
o CBC
o Blood chemistry
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Prevent complications
 Renal failure
 Gastric bleeding
 ARDS, respiratory failure
 Disseminated Intravascular Coagulation
 Cardiac dysrhythmias
Shock Interventions
 Treat the underlying cause
 Increase arterial oxygenation
o Improve tissue perfusion: Modified Trendelenburg
o Central venous catheter: Aids in differential diagnosis, provides information about preload of the
heart
Oxygen Therapy
 Establish and maintain airway
 Required for all shock patients
 Ventilatory assistance might be necessary
 Maintain PaO2 at greater than 80 mmHg for first 4–6 hours
Replace fluid volume
 Use rapid infuser machines such as Belmont.
 0.9% NaCl, LR crystalloid solutions for trauma
 Colloids: Albumin, dextran
 Blood: Goal to keep hematocrit at 30% to 35% and hemoglobin level between 12.5–14.5 g/100mL
o Packed RBCs for hemoglobin: Donor: O neg or pos, then type specific if no time for crossmatch
o Fresh frozen plasma and platelets for clotting factors
o Autotransfusion (autologous): blood of patient
The Belmont Rapid Infuser - Setup and Operation https://youtu.be/GtOFejrQCNs
Evaluate fluid replacement
 Lung sounds clear, no crackles early, gurgles late
 Tachycardia decreases
 BP increases
 Urine output increases
 Heart pressure changes
 More alert
Medications
 Vasoactive, inotropic drugs when fluid replacement not sufficient
 Diuretics
 Sodium bicarbonate
 Calcium
 Antiarrhythmic agents
 Broad-spectrum antibiotics
 Epinephrine
 Antihistamines
 Inhaled beta-2 agonists
 Morphine
 PPIs