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TRAUMATIC SHOCK

This article discusses the definition of traumatic shock, the recognition of different stages and severity, and the management of shock based on these factors.

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TRAUMATIC SHOCK

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  1. TRAUMATIC SHOCK Do Ngoc Son MD., PhD.Emergency DepartmentBach Mai Hospital, Hanoi

  2. Objectives • Definition of traumatic shock • Recognition of shock stages and severity • Management of shock according to stages and severity

  3. DEFINITION AND PATHOPHISIOLOGY OF SHOCK

  4. DEFINITION OF SHOCK • Inadequate organ perfusion and tissue oxygenation. • Circulatory system failed to meet the metabolic demand of the body

  5. HUMAN CIRCULATORY SYSTEM

  6. Preload Stroke volume Cardiac output Blood pressure ARTERIAL BLOOD PRESSURE Cardiac contractility Afterload Heart rate Systemic vascular resistance

  7. BOOD PRESSURE REGULATION(ROLE OF NEURO-ENDOCRINE SYSTEM) • Pressure receptors located at the aortic arch and carotids • Sympathoadrenal axis  regulate the relieve of catecholamine • Renin-angiotensin-aldosteron system  blood vessel tone and urine secretion

  8. BLOOD VOLUME BLOOD VOLUME

  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 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 bypass capillary through shunt • Increased heart rate and cardiac muscle contractility • Increased respiratory activity, bronchial dilation

  12. COMPENSATED SHOCK • Progress until causes of shock are treated or continue to next stage • Difficult to diagnose due to obscure symptoms • Tachycardia • Signs of reduced skin perfusion • Altered mental status • Some medication such as propranolol could undermine the symptoms (B- blocker)

  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 thread pulses • Agitated, disorientated and confused • Hypotension

  15. IRIVERSIBLE SHOCK • Failed compensated mechanism • Sometimes difficult to distinguish • Resuscitable but high mortality (ARDS, ARF, hepatic failure, sepsis) • Prolonged organ ischemia, cellular death, MODS: brain, lung, heart and kidney • Coagulation disorders (DIC)

  16. Cellular O2 deficiency A. Lactic production Cellular energy starvation Anaerobic metabolism Metabolic disorders Metabolic acidosis CELL DEATH CELULAR O2 DIFFICENCY

  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. ITIOLOGIES • Blood lost • Trauma • Fracture of long bone or opened fracture • Plasma lost due to burn

  19. ITIOLOGIES • Fluid lost to third compartment • Causes: • Peritonitis • Burn

  20. INTERNAL HEMORRHAGE • Hematemesis, black or bloody stools • Hemoptysis • Pleural effusion of blood • Peritoneal effusion of blood 22

  21. STAGES OF HEMORRHAGIC SHOCK

  22. 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

  23. 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)

  24. 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

  25. 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 • Treatment: Crystalloid or blood transfusion

  26. 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

  27. 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

  28. DIAGNOSIS

  29. SEQUENCES OF EXAMINATION Order of ABC • A = Airway • B = Breathing: + O2 supply + Assisted ventilation

  30. 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

  31. 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.

  32. 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

  33. Symptoms and diagnosis • Non-hemorrhagic shock: • Causes: dehydration or electrolyte disturbance • Manifestation: mainly symptoms of dehydration and electrolyte disturbance • ECF dehydration • ICF dehydration • Others: oliguria, cold

  34. 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 • Pancreas: edema, necrosis • Endocrinological glands: pituitary gland is most vulnerable in bleeding  necrosis (Sheehan syndrome)

  35. MANAGEMENT

  36. Emergency treatment Emergency treatment • Position: head down, open the airway • Breathing: O2 4-8 LPM. Ambu bag or intracheal intubation for ARF • Monitoring for heart rate, blood pressure, SpO2, EKG • Basic labs: CBC, hematocrit, platelets, blood group, fibrinogen, prothrombin

  37. 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

  38. 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

  39. 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% • Consider auto transfusion

  40. 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

  41. Emergency treatment • Ventilatory support if respiratory failure is detected • Identify and treat the causes • Trauma  operate

  42. 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

  43. FLUID MANAGEMENT • Start with large bore venous access: + Use with Peggy bag + Can use compressor bag + Ringer lactate is common - Choose NaCl 0.9% if suspected hyperkalemia - NaCl 0.9% can be used for the line of blood transfusion

  44. POSITION OF INFUSION • Upper extremity peripheral vein: preferred  precaution in case of upper extremity fracture • Central veins: sub-clavicle and carotid vein: best choice even at stage 4  risk of pneumothorax (chest X ray is needed after procedure)

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