Emergency lectures - Shock
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Transcript of Emergency lectures - Shock
Initial Assessment and Management
Committee on Trauma Presents
Shock
Case Scenario
● 28-year-old female in MVC
● Pulse: 126; BP: 96/70; RR: 28
● Confused and anxious
How would you manage this patient?
Is this patient in shock? If so, what type?
Objectives
● Define shock.
● Recognize the shock state.
● Determine the cause of shock.
● Discuss treatment principles.
● Recognize the importance of early identification and control of hemorrhage.
What is shock?
Cell death
Inadequate oxygen delivery
Catecholamines and other responses
Anaerobic metabolism
Cellular dysfunction
Generalized State of Hypoperfusion
Shock
●Alteration in level of consciousness, anxiety
●Cold, diaphoretic skin
●Tachycardia
●Tachypnea, shallow respirations
●Hypotension
●Decreased urinary output
Is the patient in shock?
Shock
●Scene information / mechanism of injury
●AMPLE history
Inadequate perfusion
Organ dysfunction
How do I recognize shock?
Shock
What is the cause of the shock state?
●Blood loss
●Fluid loss
●Tension pneumothorax
●Cardiac tamponade
●Cardiogenic
●Septic
●Neurogenic
Hypovolemic
Nonhemorrhagic
vs
Shock
How do I locate the bleeding?
Shock
●Physical examination
●Diagnostic adjuncts to primary survey
● Chest X-ray
● Pelvic X-ray
● FAST / DPL
How do I locate the bleeding?
What is the cause of the shock state?
In the vast majority of trauma patients, shock is due to blood loss.
Shock
Interventions
Direct pressure / tourniquet STOP
thebleeding!
Reduce pelvic volume
Angio-embolization
Splint fractures
Operation
What can I do about it?
Interventions
●Fluid resuscitation
● Vascular access?
● Type?
● Volume?
●Monitor response
●Prevent hypothermia!
What can I do about it?
Patient Response
●Skin: warm, capillary refill
●Renal: increased urinary output
●Vital signs
●CNS: improved level of consciousness
Identify improved organ function
How do I evaluate the patient’s response?
Patient Response
What is the patient’s response?
Patient Response
●Rapid responder
●Transient responder
●Nonresponder
Related to volume or persistence of hemorrhage
Operation
What is the patient’s response?
Class I Hemorrhage
●Slightly anxious
●Normal blood pressure
●Heart rate < 100 / min
●Respirations 14-20 / min
●Urinary output 30 mL / hour
750 mL BVL (15%)
Crystalloid
Class II Hemorrhage
●Anxious
●Normal blood pressure
●Heart rate > 100 / min
●Decreased pulse pressure
●Respirations 20-30 / min
●Urinary output 20-30 mL / hour
750-1500 mL BVL (15-30%)
Crystalloid,? blood
Class III Hemorrhage
●Confused, anxious
●Decreased blood pressure
●Heart rate > 120 / min
●Decreased pulse pressure
●Respirations 30-40 / min
●Urinary output 5-15 mL / hour
1500-2000 mL BVL (30-40%)
Crystalloid, blood
components, operation
Class IV Hemorrhage
●Confused, lethargic
●Hypotension
●Heart rate > 140 / min
●Decreased pulse pressure
●Respirations >35 / min
●Urinary output negligible
>2000 mL BVL (>40%)
Definitive control, blood components
Pitfalls
●Age extremes
●Athletes
●Pregnancy
●Medications
●Pacemaker
Complications of Shock – Patient Factors
Pitfalls
●Hypothermia
●Early coagulopathy
Pitfalls
Pitfalls
Complications of Shock and Shock Management
●Equating BP with cardiac output
●Misleading hemoglobin and hematocrit levels
Pitfalls
Pitfalls
Complications of Shock
Summary
●Shock is inadequate organ perfusion and tissue oxygenation.
●Hypovolemia is the cause of shock in most trauma patients.
●Patients may present with mild to severe shock.
Summary
●Conduct a rapid initial assessment and resuscitation.
●Determine cause of shock.
●Stop the bleeding.
●Reevaluate.