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TRAUMATIC SHOCK
Do Ngoc Son MD., PhD. Emergency Department
1
Bach Mai Hospital, Hanoi
Objectives
• Definition of traumatic shock
• Recognition of shock stages and severity
• Management of shock according to stages and
severity
2
DEFINITION AND
PATHOPHISIOLOGY OF
SHOCK
3
DEFINITION OF SHOCK
• Inadequate organ perfusion and tissue
oxygenation.
• Circulatory system failed to meet the
metabolic demand of the body
4
HUMAN CIRCULATORY SYSTEM
5
ARTERIAL BLOOD
PRESSURE
Preload
Cardiac
output
Blood pressure
Stroke
volume
Heart
rate
Cardiac
contractility
Afterload
Systemic
vascular
resistance
6
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
7
8
VOLUME STATUS
BLOOD
VOLUME
8%
25%
ECF
ICF
Intravascular
volume
67%
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
CELULAR O2
DIFFICENCY
Cellular
energy
starvation
Metabolic
disorders
Cellular O2
deficiency
Anaerobic
metabolism
CELL
DEATH
A. Lactic
production
Metabolic
acidosis
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
21
INTERNAL HEMORRHAGE
• Hematemesis, black or bloody stools
• Hemoptysis
• Pleural effusion of blood (Hemothorax)
• Peritoneal effusion of blood
(Hemoperitoneum)
22
22
23
24
25
STAGES OF
HEMORRHAGIC SHOCK
26
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
27
STAGES OF HEMORRHAGIC SHOCK
Blood
lost
(ml)
%
blood
volume
Clinical
signs
SBP
DBP
Resp
Rate
Heart
Rate
Urine
volume
(ml)
Treatment
1
<750
0-15
Slightly
anxious
Nor
mal
Nor
mal
14-20
<100
>30
Crystalloid
solution
2
7501500
15-30
Mildly
anxious
Nor
mal

20-30
>100
20-30
Crystalloid
solution or
blood products
3
15002000
30-40
Anxious,
confused


30-40
>120
5-15
Colloid and
blood
4
>2000
>40
Confused
Lethargic


>40
>140
None
Colloid and
surgery
28
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)
29
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
30
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
31
• Treatment: Crystalloid or blood transfusion
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
32
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
33
DIAGNOSIS
34
SEQUENCES OF EXAMINATION
Order of ABC
• A = Airway
• B = Breathing:
+ O2 supply
+ Assisted ventilation
35
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
36
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.
37
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
38
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
39
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)
40
MANAGEMENT
41
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.
42
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
43
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
44
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
45
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
46
Emergency treatment
• Ventilatory support if respiratory
failure is detected
• Identify and treat the causes
• Trauma  operate
47
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
48
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.
49
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)
50
POSITION OF INFUSION
• Femoral vein: easy and safe
Precaution in case of abdominal trauma due to
coincidental hemoperitoneum
• Intraosseous infusion: easiest; especially in
children; may also use in adult
• Peritoneal infusion
51
CENTRAL VENOUS PRESSURE
• CVP assesses the preload of right ventricle
• CVP Catheters are not necessity in most
trauma patients
• CVP is more useful in trauma patients who
have:
+ Predisposed heart failure
+ Intra ventricle pacemaker
+ Neurogenic shock
+ Myocardial contusion
+ Suspected tamponade
52
CVP IN TRAUMATIC PATIENTS
• Low CVP (< 6 mmHg)  hypovolemia
- continue infusion or blood transfusion
• High CVP (> 15 mmHg):
+ Cardiac overload (over blood transfusion)
+ Right heart failure (AMI)
+ Cardiac tamponade
+ Lung disease
+ Tension pneumothorax
+ Dislocation of catheter
+ Hypocalcemia
53
CVP IN TRAUMATIC PATIENTS
Initial CVP Change in
CVP
Low
No
Low
Increase
Low or
moderate
High
Decrease
No
Causes
Solution
Consistent with blood Increase infusion
loss
rate
Good resuscitation
Slow down infusion
rate
Continued blood loss Continue rapid
infusion
overload or
Slow down infusion
predisposed condition rate
54
CONTROVERSAL ISSUES
• Fluid type?
• When?
• Rate?
• Targets of hemorrhagic shock?
• Opened of blunt trauma?
55
FLUID TYPE?
56
COLLOIDS
• Albumin, hydroxyethylstarch, pentastarch,
gelatin, dextran
• Advantages: smaller volume, more
intravascular volume, stronger fluid shift from
extravascular to intravascular spaces
• Disadvantages: expensive, allergic reaction
and coagulation disorders
57
COLLOIDS
• Cochrane. BMJ 1998: 317:235-40.
– Objectives: effect of albumin on mortality rate
– Study: multiple analysis of 30 trials (total number
of patients: 1419)
– Conclusion: albumin increased mortality rate in
trauma patients
58
COLLOIDS
• Cochrane 2003.
– Objectives: compare the effectiveness between
crystalloid and colloids
– Study: albumin (18 trials); HES (7 trials); Gelatin
(4 trials); Dextran (8 trials)
– Conclusion: no difference in mortality on trauma,
burn and surgery patients
59
HYPERTONIC SALINE
• Advantages: less volume, longer intravascular
half life, stronger water shift
• Disadvantages: hypernatremia,
hyperosmolarity, convulsion, coagulation
disorders
• Fluid types
– Hypertonic salt (7.5% NaCl) +/- 6% dextran
– Bolus 250 cc (~ 4ml/kg) in 5-10 min
60
HYPERTONIC SALINE
• Cochrane 2003
– Objectives: evaluate the effect of hypertonic salt on
mortality rate
– Study: 25 trials
– Conclusion: tendency of reduced mortality rate on
hypertonic salt group
• ROC Trial
– Very large USA multicenter trial
– No benefit of hypertonic saline (and perhaps harm)
61
CONTROLLED INFUSION
• Also called permissive hypotension
• Increase of BP before successful hemostasis
may be harmful
• Reasons:
– Increased hydrostatic pressure
– Dislodge the clot
– Dilute the coagulation factors
62
CONTROLLED INFUSION
• Excess and early infusion in blunt trauma
increased the mortality
• Controlled infusion seem to be better (targeted
systolic BP 70 – 90)
• Delayed infusion (until successful hemostasis)
may be better
• More research required on blunt trauma
63
OTHER MANAGEMENT
• Blood transfusion:
+ Blood group O (-): immediately available
+ Type and screen (if needed within < 15min)
+ Type and complete cross-matched: 45-60 min
• Emergency thoracostomy, Pericardiocentesis,
aortic cross-clamping
• Auto transfusion: blood from chest tubes
64
INDICATION FOR EMERGENCY
BLOOD TRANSFUSION GROUP O (-)
• No blood pressure on arrival
• Many patients need transfusion at the same
time
• Blood group is not available
65
TRANSFUSION THE TYPE AND
SCREEN & COMPLETE CROSSMATCHED
• Type and screen blood: (5-10 minutes delay
from blood bank)
 emergency transfusion but can wait > 10
minutes but less than 1 hour
• Complete cross matched (45-60 minutes delay)
 stable patient who can wait 45-60 minutes
66
NON-HEMORRAGIC SHOCK
• Hypovolemic shock (non-hemorrhage)
+ vomiting, diarrhea, water lost to “third
compartment”
+ treated by Ringer’s lactate or normal saline
+ no need hemostasis
• Anaphylactic shock
+ allergic reaction to anaphylactic agents
+ treated by epinephrine, anti-histamine and fluid
infusion
67
NON-HEMORRAGIC SHOCK
• Septic shock
+ May be late complication of trauma
+ Patient may have fever or hypothermia
+ Treated by fluid transfusion and isotopes
+ Identify and treat the causes of infection plays
important role in trauma patients (initiate
antibiotics and abscess drainage)
68
NON-HEMORRAGIC SHOCK
• Obstructive shock: main symptom is cervical
vein enlargement
+ Tension pneumothorax
- Emergency decompression
+ Acute cardiac tamponade
- Fluid infusion
- Pericardiocentesis
+ Pulmonary embolism
- Need definitive diagnosis
- Fibrinolysis or surgery
69
NON-HEMORRAGIC SHOCK
• Cardiac shock: pumping dysfunction
+ Acute myocardial infarction
+ Myocardial contusion
- very rare even among blunt chest trauma
+ Treated by inotropes
- Dopamine
- Dobutamine
70
NON-HEMORRAGIC SHOCK
• Neurologic shock: spinal cord injury
+ Due to peripheral blood vessel dilation
+ Usually coincide with relative bradycardia
+ Treated by fluid infusion and then inotropes
• Spinal cord shock
+ paralysis and lost of reflexes
+ Can be totally recovered (within 24 hours)
71
HEMOSTASIS TECHNIQUES
• Direct pressure on the bleeding site
• Temporary tourniquets
72
73
74
MONITORING
•
•
•
•
•
•
Mental status
Heart rate, blood pressure, respiratory rate
Urine output (target > 30 cc/h)
Capillary refill time
CVP
Laboratory (less important)
75
LABORATORY
• Hematocrit
+ may be normal at the beginning even though
patients are in severe blood lost
+ lower at the beginning indicating that patients
are in very severe blood lost
• BUN
+ may be elevated if there is reduced blood
volume to the kidney (functional renal
insufficiency) or GI bleeding
+ Slightly elevated in children who are
dehydrated
76
LABORATORY
• Blood sugar: may be elevated due to stress
• WBC: less value for diagnosis
– Elevates following stress
• Hypocalcaemia if transfused blood containing
citrate, treatment is not necessary
• Hypokalemia: temporary shift of potassium
into cells from stress. Patients do not need
potassium replacement.
77
CAUSES OF COAGULATORY
DISORDERS
• Hypothermia (temperature < 35.5oC)
+ most common reason
+ warm patient as quick as possible
• Massive blood transfusion
+ lost of coagulation factors and platelet
+ transfuse 1 unit of frozen fresh plasma and 1 unit of
packed platelet for every 6-8 units of packed RBC
(note: many trauma centers now using a 1:1:1 ratio
of prbc:plasma:platelets)
78
CAUSES OF COAGULATORY
DISORDERS
• Infection
• Coagulopathy or predisposed hepatic failure
• Adverse effects of medications or toxins
79
IRRIVERSIBLE SHOCK
•
•
•
•
•
•
•
•
•
Invisible dehydration
Ventilatory problem
Gastric distension
Cardiac tamponade
AMI
Acute adrenal insufficiency
Neurologic shock
Hypothermia
Medication or toxins
80
HYPOTHERMIA IN TRAUMA
• Trauma patients at risk for hypothermia due
to a variety of causes
• Hypothermia results in increased blood loss
(clotting disorders), increased risk of infection
and increased cardiac dysfuntion/events
• Prevent Hypothermia:
– Warm all fluids being given to the severely injured
trauma patients
– Keep warm blankets on patient once unclothed
– Frequently check patient’s temperature
81
BLOOD LOST IN BONE FRACTURE
Position of fracture
Amount of blood lost
(mL)
Tibia (closed)
500-1000
Femur (closed)
500-2500
Femur (opened)
1000->2500
Arm (closed)
500-750
Vertebral column (closed) 500-1500
Pelvic (closed)
1000->3000
Pelvic (opened)
>2500
82
THANK YOU FOR YOUR ATTENTION
83