8/10/2019 2. Shock on trauma.ppt
1/36
Shock on trauma
Tatat A. Agustian
8/10/2019 2. Shock on trauma.ppt
2/36
ObjectivesDefine shockRecognize the shock state
Determine the causeApply treatment principlesApply principles of fluid managementMonitor patients response Employ options for vasculer accessRecognize complications of vascular access
8/10/2019 2. Shock on trauma.ppt
3/36
Key Issues : Shock Management
Recognize inadequate organ perfusionIdentify the cause Hemorrhagic vs nonhemorrhagic
Treatment
Stop the bleeding! Restore volume
8/10/2019 2. Shock on trauma.ppt
4/36
Cardiac Physiology
CO = SV X HR
Preload Contractility Afterload
Venous
Capacitance
dp / dtVascular
Tone
8/10/2019 2. Shock on trauma.ppt
5/36
Cardiac PhysiologyCO = stroke volume x heart rate
Stroke volume is determined by: Preload
Volume of venous return to the heart Venous capacitance , volume status , differencebetween mean venous systemic pressure and right
atrial pressure. Myocardial contractility Starlings Law
Afterload Systemic vascular resistance
8/10/2019 2. Shock on trauma.ppt
6/36
Pathophysiology
8/10/2019 2. Shock on trauma.ppt
7/36
Cellular Alteration in shock
8/10/2019 2. Shock on trauma.ppt
8/36
Recognition of Shock State
1. Tachycardia2. Vasoconstriction
2. Cardiac outputNarrow pulse pressure 3. Map
3. Blood Flow
Caution : Compensatory mechanisms
8/10/2019 2. Shock on trauma.ppt
9/36
Pitfalls in shock Recognition
Extremes of ageAthletesPregnancyMedications
Hematocrit/hemoglobin concentration
8/10/2019 2. Shock on trauma.ppt
10/36
Etiology of Shock
HemorrhagicMost commonClinical clues History & Physical
examination Selected
diagnostic tests
NonhermorrhagicTension
pneumothoraxCardiogenic
NeurogenicSeptic
8/10/2019 2. Shock on trauma.ppt
11/36
Hemorrhagic ShockLoss of circulating blood volume
Normal blood volume
Adult 7% of ideal weight Child: 9 % of ideal weight
8/10/2019 2. Shock on trauma.ppt
12/36
Classification of HemorrhageClass I-IV
Not absolute
Only A clinical guideSubsequent treatment determined by
patient response
8/10/2019 2. Shock on trauma.ppt
13/36
Class I Hemorrhage
750 mL BVL
8/10/2019 2. Shock on trauma.ppt
14/36
Class II Hemorrhage
750 1500 ml BVL
8/10/2019 2. Shock on trauma.ppt
15/36
Class III Hemorrhage1500 2000 ml BVL
8/10/2019 2. Shock on trauma.ppt
16/36
Class IV Hemorrhage : 2000 ml 2000 ML BVL
8/10/2019 2. Shock on trauma.ppt
17/36
Fluid Shifts : Soft tissue Injury
Blood loss intoinjury site
Compoundsintravascular loss.
Tissueedema
8/10/2019 2. Shock on trauma.ppt
18/36
Assessment and ManagementRecognize shockStop the bleeding !
Replenish intravascular volumeRestore organ perfusion
8/10/2019 2. Shock on trauma.ppt
19/36
Assessment and Management
Airway and Breathing Oxygenate and ventilate Pao > 80 mm hg (10,6 kpa)
C irculation Assess
C ontrol T reat
8/10/2019 2. Shock on trauma.ppt
20/36
Assessment and Management
Disability cerebral perfusionE xposure/ E nvironment
Associated injuries Prevent hypothermia
Gastric and bladder decompression
Urinary output
8/10/2019 2. Shock on trauma.ppt
21/36
Management : Vascular Access
2 large caliber, peripheral IV sCentral access Femoral Jugular Subclavian
IntraosseousObtain blood for croossmatch
8/10/2019 2. Shock on trauma.ppt
22/36
Management : Fluid Therapy
Warmed crystalloid solutionRapid fluid bolus ringer,s lactate Adult: 2 Liters, Ringers Lactate Child :20 ml /kg Ringers lactate
Monitor response to initial therapy
8/10/2019 2. Shock on trauma.ppt
23/36
Reevaluate Organ perfusion
MonitorVital signsCNS statusSkin perfusionUrinary outputPulse oximetry
8/10/2019 2. Shock on trauma.ppt
24/36
Resuscitation Evaluation
Hourly Urinary Output Inadequate output suggests
inadequate resuscitation
8/10/2019 2. Shock on trauma.ppt
25/36
Acid Base Abnormalities
Monitor with ABGsUsual etiology
Adult : Acidosis due to inadequateperfusion
Child : Acidosis due to inadequateventilation
8/10/2019 2. Shock on trauma.ppt
26/36
8/10/2019 2. Shock on trauma.ppt
27/36
Therapeutic Decisions
Patient response determinessubsequent therapyHemodynamically normal vshemodynamically stable
Recognize need to resuscitate inoperating room
8/10/2019 2. Shock on trauma.ppt
28/36
Therapeutic Decisions
Rapid Response
8/10/2019 2. Shock on trauma.ppt
29/36
Therapeutic Decisions
Transient Response20% -40% blood lossDeteriorates after initial fluidsSurgical consultation evaluation
Continued fluid plus bloodContinued hemorrhage : Operation
8/10/2019 2. Shock on trauma.ppt
30/36
Therapeutic DecisionsMinimal to No Response
> 40% Blood loss
No Response to fluid resuscitationImmediate surgical consultation
Exclude nonhemorrhagic ShockImmediate operation
8/10/2019 2. Shock on trauma.ppt
31/36
Volume Replacement
Warmed fluids Crossmatched PRBCs
Type specificType O, Rh negativeAutotransfusionCoagulopathy
8/10/2019 2. Shock on trauma.ppt
32/36
Pitfalls
Equating Bp withcardiac output
Extremes of ageHypothermia
AthletesPregnancy
MedicationsPacemaker
8/10/2019 2. Shock on trauma.ppt
33/36
Avoiding Complications
Continued hemorrhageFluid overload
Invasive monitoring (ICU) CVP Pulmonary artery catheter
Other problems
8/10/2019 2. Shock on trauma.ppt
34/36
Keys to Successful Treatment
Early control of hemorrhageEuvolemiaContinuous reevaluation
8/10/2019 2. Shock on trauma.ppt
35/36
Questions
8/10/2019 2. Shock on trauma.ppt
36/36
Summary
Restore organ perfusion Early recognition of the shock stateOxygenate and ventilateStop the bleedingRestore volume
Continuous monitoring of responseAnticipate pitfalls
Top Related