Fluid management 14 พค.58

Advanced Management in Shocks

ผศ.นพ.เรวตั ชุณหสุวรรณกลุ

สาขาวิชาศลัยศาสตร์อุบติัเหตุ

คณะแพทยศาสตร์ศิริราชพยาบาล

Shocks

“ Inadequate tissue perfusion and oxygenation “

Autoresuscitation

1. Peripheral and splanchnic vasoconstriction

(epinephrine, norepinephrine and vasopressin)

increases peripheral resistance and reduces intravascular plasma loss 2. Hormonal response

(vasopressin, Renin-Angiotensin II, Cortisol)

Clinical signs of shock

CNS : anxiety , confuse , drowsy ,coma CVS : tachycardia , vasoconstriction RS : tachypnea KUB : decreased urine output GI : decreased movement Skin : pale , cool MS : decreased blood supply

Shock What is the cause of the shock ?

● Blood loss

● Fluid loss

● Tension pneumothorax

● Cardiac tamponade

● Cardiogenic

● Septic

● Neurogenic

● Anaphylactic

● Hypoadrenal

Hypovolemic

Nonhemorrhagic

vs

Presenter

Presentation Notes

3-7Shock: What is the cause of the shock state? Explain that cardiogenic shock may be caused by myocardial infarction, dysrhythmia, and cardiac failure. Remind the students that bradycardia is not a constant finding in neurogenic shock. Explain that cord lesions below the T4 level may lead to shock with a well perfused periphery and reflex tachycardia. Shock can be caused by “medical” conditions, such as adrenal insufficiency or diabetes.

Tension pneumothorax

High pressure pneumothorax causing cardiovascular compromised status

* chest injury * dyspnea & tachypnea * distended neck vein * deviated trachea * hypotension * tympanic on percussion * absent breath sound

Cardiac Tamponade

Obstructive shock Beck’s triad : Hypotension : Distant heart sound : Engorged neck vein Pericardiocentesis Thoracotomy

Hemorrhagic shock Source of bleeding

External bleeding Internal bleeding

Chest

Abdomen

Pelvis

Long bone not intracranial hemorrhage

Save Life and Save Limb Stop bleeding

Direct pressure Tourniquet

Splinting

Rudge WBJ, Rudge BCJ, Rudge CJ. Ann R Coll Surg Engl. 2010 January;92(1):77-78

Classes of Shock

class I class II class III class IV Blood loss <15% 15-30% 30-40% >40% BP normal normal SBP<90 SBP<70 Pulse <100 100-120 120-140 >140 Mental anxiety anxiety confused lethargic Urine >30 20-30 <20 negligible Fluid crystalloid crystalloid+blood • Adult blood : 70ml/kg • Child blood : 80ml/kg

Class I Hemorrhage

● Slightly anxious ● Normal blood pressure ● Heart rate < 100 / min ● Respirations 14-20 / min ● Urinary output 30 ml / hour

BVL (15%) ; adult 70ml/kg , child 80mi/kg

Crystalloid

Presenter

Presentation Notes

3-16Class I Hemorrhage Use this slide to summarize the type of physical findings associated with a blood loss of up to 15% or 750mL. Emphasize that normal vital signs, urinary output, and mild tachycardia are associated with this class of hemorrhage.

Class II Hemorrhage

● Anxious ● Normal blood pressure ● Heart rate > 100 / min ● Decreased pulse pressure ● Respirations 20-30 / min ● Urinary output 20-30 ml / hour

BVL (15-30%) ; adult 70ml/kg , child 80ml/kg

Crystalloid, ? blood

Presenter

Presentation Notes

3-17Class II Hemorrhage Use this slide to summarize the type of physical findings associated with a blood loss of up to 30% or 1500 mL. Summarize this class of hemorrhage by noting an increase in tachycardia, confusion, beginning oliguria, and maintenance of the systolic blood pressure while pulse pressure is decreased.

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

BVL (30-40%) ; adult 70ml/kg , child 80ml/kg

Crystalloid, blood components,

operation

Presenter

Presentation Notes

3-18Class III Hemorrhage Use this slide to summarize the type of physical findings associated with a blood loss of up to 40% or 2000 mL. Summarize this class of hemorrhage by noting increasingly somnolent, worsening renal perfusion with oliguria, increased respiratory rate, increased heart rate, and decreased blood pressure with a further decrease in pulse pressure.

Class IV Hemorrhage

● Confused, lethargic ● Profound hypotension ● Heart rate > 140 / min ● Decreased pulse pressure ● Respirations >35 / min ● Urinary output negligible

BVL (>40%) ; adult 70ml/kg , child 80ml/kg

Definitive control, blood

components

Presenter

Presentation Notes

3-19Class IV Hemorrhage Use this slide to summarize the type of physical findings associated with a blood loss of greater than 40% or 2000 mL. Summarize the changes in clinical signs, including unconsciousness, oliguria and hypotension, and the need for blood and an operation.

Fluid Resuscitation

Fluid challenge test : 2000ml I.V. in 15 min : 20ml/kg in 15 min Warm fluid and patient Blood for lab test Cross-match 2 x estimated blood loss Uncross matched blood : gr.O ,Rh +ve PRC

Response 1. Rapid response : <20% , cease 2. Transient response : 20-40% , on going 3. Unresponsive : >40% , active bleeding

Fluid Resuscitation

Adjuncts

• Monitors : V/S , O2 sat , EKG , urine output : GCS , ABG • Catheters : N-G , Foley catheter • Investigations : FAST , DPL , CT , Angiogram : CXR , Film pelvis & limb

Fracture Pelvis

Associated injuries : Head injury 51% Extremity fracture 48% Abdominal injury 28% Peripheral nerve injury 26% KUB injury 23% Chest injury 22%

Fracture Pelvis

High mortality and morbidity rate * 39% from hemorrhage * 31% from associated injuries * 30% from complications Causes : traffic accident 84% : falling from height 9% : others 7%

Anatomy

Volume of Pelvis : ¶H( R² + 2Rr + r² )/3 R or r ↑ 2cm → vol. ↑ 1.3 litre R or r ↑ 5cm → vol. ↑ 5.0 litre

Diagnosis

1. History of injury * car accident * motorcycle accident * pedestrian accident * falling from height * crush injury

Diagnosis

2. Physical examination * marks at pelvis and perineum * leg deformity or length discrepancy * signs of ruptured urethra or bladder * anorectal or vaginal lacerations * pelvic compression test ???

Diagnosis

3. Investigations * pelvic film : AP , Inlet , Outlet , Judet * FAST * DPL * CT scan * Angiography

Interventions

Direct pressure / tourniquet

STOP the

bleeding! Reduce pelvic volume

Angio-embolization

Splint fractures

Operation

What can I do about it?

Presenter

Presentation Notes

3-11Interventions: What can I do about it? Ask a student to recall the most common cause of shock in the injured patient, emphasizing the need to identify and stop the hemorrhage by the most direct and simplest means available while avoiding blind clamping. These might include direct pressure to control external hemorrhage, reducing pelvic volume, and splinting fractures. In civilian circumstances, applying a tourniquet is a matter of last resort (things may be different in the military arena). Emphasize that fractures of the “smaller” long bones are also accompanied by, albeit smaller, blood loss. Students’ responses to this question also should include controlling hemorrhage with operative intervention, such as laparotomy and/or thoracotomy.

Hypotensive Resuscitation

“ Delivery of limited volumes of intravenous fluids to sustain blood pressure lower than normal until control of hemorrhage has been established “

“ Rapid resuscitation can exacerbate bleeding by dislodging fragile clots , decreasing blood viscosity and creating compartment syndrome of cranial vault, abdomen, extremities and it also exacerbate the Lethal Triad of hypothermia, acidosis and coagulopathy “

Trauma Induced Coagulopathy

Lethal triad Dilutional coagulopathy Consumptive coagulopathy Hyperfibrinolysis Anemia Electrolyte imbalance

Hypocalcemia

Sorensen B, Fries D. British Journal of Surgery 2012; 99(Suppl 1): 40–50

Hypothermia

Acidosis

Coagulopathy


“ Tissue injury from regional hypoperfusion is a risk “

“ Early control of hemorrhage was paramount and attempts at fluid resuscitation prior to this would result in increased bleeding and mortality “


“ In penetrating injury an SBP of 80-90 mmHg may be adequate “

“ Currently, patients with blunt injury should be managed with traditional strategies ”

“ A significant association exists between prehospital hypotension (SBP<90) and worse outcomes in severe traumatic brain injury “


“ Early identification of bleeding sources and control of hemorrhage will lead to more rapid replacement of intravascular volume and decreased morbidity and mortality “

Neurogenic Shock Circulatory shock

Spinal shock: neurological shock

Bradycardia

May not present if injury occur below T4

Vasopressor usually needed

Clinical recognition

Decreased sensation

Motor impairment

Loose sphincter tone

Choices of Fluids

“ Extracellular fluid redistributed into both intravascular and intracellular spaces during shock and rapid correction of this extracellular deficit required an infusion of a 3:1 ratio of crystalloid fluid to blood loss “

Crystalloids

: replace interstitial and intravascular fluid loss

: do not cause allergic reaction : inexpensive : limited intravascular expansion : tissue edema ( pulmonary edema , bowel

edema and compartment syndrome )

Colloids

: longer intravascular half-life : may improve organ perfusion and cause less tissue

edema in early phase : allergic reaction , impaired blood cross-matching ,

altered platelet function , hyperchloremic acidosis

: greater expense “ There is no clear basis to give colloid products over

crystalloid solutions for fluid resuscitation “

RLS VS NSS

: large volume of NSS can lead to hyperchloremic metabolic acidosis

: large volume of RLS can increase lactate level but not cause acidosis

: RLS does not increase clots when giving blood : no literature supporting the use of NSS over

RLS for the treatment of severe head injury to reduce intracerebral swelling

Hypertonic Saline

“ causes influx of fluid into intravascular space

with small volume” “ In head trauma patients, it can limit cerebral

edema , lower intracranial pressure and improve cerebral perfusion “

“ 3% hypertonic saline plus 6% dextran showed the greatest benefit in shock patients with concomitant severe closed head injury “

Artificial Oxygen-Carrying Blood Substitutes

“ improve oxygen-carrying capacity without the storage, availability, immune suppression, transfusion reaction, compatibility, disease transmission problems associated with standard transfusions”

“ fail to restore coagulation components causing hemorrhage “

Blood Transfusion

“ Patient in shock who fails to response adequately to 2 liters of crystalloid is in need of blood transfusion “

“ Hemoglobin levels of 10g/dl were optimal for shock resuscitation but recent studies show that hemoglobin levels of 7-9g/dl do well “

Massive Blood Transfusion

“ Blood transfusion of total blood volume in 24 hours or 50% of blood volume in 1 hours “

“ Bleeding > 150ml/min or > half of blood

volume in 20 minutes “ “ PRC : FFP : PLT = 1:1:1 “

Complications of Transfusion

Hypothermia : mild = 32-35 degrees Celsius : mod = 28-32 degrees Celsius : sev = < 28 degrees Celsius Trauma victims with core temperature < 32 degrees Celsius have 100% mortality

Complications of Resuscitation

Coagulopathy : dilutional ( one blood volume replacement ) : hypothermia : INR >2 : PTT >1.5 times : plt < 50000/mcl : fibrinogen level < 100mg/dl : head injury ( release of thromboplastin )


Acidosis : NSS >> RLS : pH < 7.1 independently predicted coagulopathy

: decreases fibrinogen and platelet

: increases PTT and bleeding time


Compartment Syndromes “ tissue edema is a frequent result of large

volume resuscitation , in restricted body compartments , the resulting increase in pressure can lead to ischemia and subsequent tissue necrosis “

“ The three affected areas are the extremities, abdomen and cranial vault “

Inotropes and Vasopressors

1. Dopamine 2-3ug/kg/min เพิ่ม urine output 3-5 เพิ่ม heart rate 5-10 เพิ่ม blood pressure 2. Dobutamine 5-20ug/kg/min เพิ่ม myocardial contractility vasodilatation เหมาะกบั heart failure จาก M.I.

3. Epinephrine 0.01-0.05 ug/kg/min เพิ่ม stroke volume และ heart rate ขนาดมากกวา่น้ี เพิ่ม BP และ vascular resistance 4. Norepinephrine เหมาะสาํหรับเพิ่ม BP จากการเพิ่ม

vascular resistance ในผูป่้วยท่ีได ้volume เพียงพอ

แลว้


5. Phenylephrine เพิ่ม vascular resistance เหมาะเป็น first line drug ในผูป่้วย neurogenic

shock ท่ีได ้fluid resuscitation เพียงพอแลว้

6. Vasopressin เพิ่ม vascular resistance และ

arterial pressure ในผูป่้วย septic shock แต่อาจทาํ

ใหเ้กิด M.I. และ ischemic bowel ได ้


7. Amrinone and Milrinone เพิ่ม cardiac contractility โดยไม่มีผลกบั oxygen consumption

เหมาะกบัผูป่้วย cardiogenic shock


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Fluid management 14 พค.58