ShockCritical Concepts - Surgery

SHOCK

“Rude unhinging of the machinery of life”

-Gross

“A momentary pause in the act of death”

-Dr. Cowley

SHOCK

Inadequate delivery of oxygen and nutrients necessary for normal tissue and cellular

function.

Types of Shock

Hypovolemic

Cardiogenic

Neurogenic (distributive)

Septic (distributive)

Obstructive

Types of Shock

CVP CO SVR other

Hypovolemic Cold and clammy

Cardiogenic

Neurogenic Warm and rosy

Septic

Obstructive Clinical exam

Types of Shock

Hypovolemic

Cardiogenic

Neurogenic (distributive)

Septic (distributive)

Obstructive

How to Resuscitate

ABC’sChoice of line?What to use?Rate of administration?How much?When to stop?

ABCDE’s

AirwayBreathing

Tension ptx?Circulation

Tamponade?Disability

Neurogenic shock?Exposure

Signs of hemorrhage/trauma?

Intravenous Access

Intravenous Access

Hagen-Poiseuile Law

Which fluid?

CrystalloidLactated ringersNormal Saline

ColloidSyntheticAlbuminBlood plasma

Rate?

How much?

Class Blood Loss(ml)

Blood Loss(%)

HR BP UOP Mental Status

I <750 <15% <100 NL >30 NL

II 750-1500

15-30% >100 20-30 anxious

III 1500-2000

30-40% >120 5-15 confused

IV >2000 >40% >140 None lethargic

How much?

Bolus1 liter

Blood1:1

Massive Transfusion>10 PRBCs in 24 hrs

When to stop?

Vital signsUOPBase deficitLactate

HEMOSTASIS METHODS

Objectives

Review general concepts about achieving hemostasis in a bleeding subject

Discuss non-surgical compression and tourniquet methods

Discuss surgical methods using sutures, ligatures, and other devices

Understand the application and use of pelvic binders for pelvic fractures

GENERAL CONCEPTS

Direct controlBe as specific (pinpoint) as possible

Avoid collateral damageInjury to tissue around point of controlDistal ischemia

Temporary versus permanent

Types of Control

Non-SurgicalCompressionTourniquetsPro-coagulant products

SurgicalLigationSuturing/StaplingCautery

Non-Surgical Control- Compression

Applying direct pressure to the source o bleeding

Usually the best first step

Usually done wrong

Keys to Success

1- Pinpoint Source of Bleeding

a- Use minimal surface area

- Concentrate pressure to exact source of bleeding

b- Use minimal gauze

-Gauze is for ABSORPTION

- Fold minimal amount of gauze into minimal size of square

Keys to Success

2- Apply consistent pressure

A- Get into a comfortable position

B- Apply bandage/device whenever possible

Pressure Dressing

Non-Surgical Control- Tourniquet

Circumferential compression cutting of blood flow to distal limb/appendage

Generally frowned uponOnly when direct pressure cannot be

applied due to the nature of the injuryAmputationsNear-amputations

a

Keys to Success

Complete cessation of arterial blood flowNon-elastic bandageTight enough to cause pain

Dress the open wound

Surgical Hemostasis

Bleeding Skin/Tissue EdgesSutureStapleDressing/Adhesive

Severed vesselSutureLigationClip

a

Bleeding Skin/Tissue Edges

Wash out wound whenever possible Suture

Simple interruptedSimple runningLocking runningHorizontal mattress

StapleFaster but less available

Dressing/AdhesiveOnly if able to temporarily staunch the blood low