PONGSASIT SINGHATAS, M.D.

Department of Surgery

Faculty of Medicine, Ramathibodi HospitalMahidol University

Resuscitation

in Hemorrhagic Shock

Shock

• Inadequate tissue perfusion

• Inadequate oxygen deliver to

tissue and cell

• Insufficient to maintain normal

aerobic metabolism

Objective Parameter

• MAP <60 mmHg

• SBP <90 mmHg or >40 mmHg

• MAP <65mmHg or >20% of baseline

• Not BP only

• Hypertensive patient ??

• Sign of poor tissue perfusion

ผู้ป่วยชายไทย อายุ 25 ปี กู้ชีพน าส่ง (รพช 30 เตียง) ขี่รถจักรยานยนต์ถูกรถยนต์ชน มีแผลฉีกขาดเลือดออกท่ีศีรษะ 5

cm, ต้นขาซ้ายผิดรูปกระดูกโผล,่ ปวดทอ้งท้องอดืแนน่, แขนซ้ายมีแผลเปิด10 cm เลือดออกตลอด พูดคยุได้ถามตอบสับสน

V/S BP 60/40, PR 150/min,

RR 22/min, BT 37.4

Lung clear , equal BS

E4V4M6, Pupil 3 mm RTL BE

1)Which of cause of shock in patient ?

2)How much of blood loss in patient ?

3)Initial shock management in patient ?

Hemorrhagic shock

• Most common cause in trauma

• Presumed hemorrhagic shock until

proven otherwise

• Fluid resuscitation in early signs

and symptoms of blood loss

Class I Class II Class III Class IV

For 70 kg male

• Principle is Stop the bleeding

and replace the volume loss

• ABCDE

• Vascular access line

• Fluid resuscitation

• Endpoints for resuscitation

Hemorrhagic shock

อุดรูรั่วและเติมน ้าให้ทัน ถ้าตุ่มแห้ง => เลือดหมดตัว => ตาย

Exsanguination = Extensive Hemorrhage

Vascular access line

• Peripheral intravenous catheter

- Is the best

- Use two large-caliber (minimal 16-gauge)

• Central venous catheter

- Femoral vein

- Jugular vein

- Subclavian veinCentral venous catheter

Vascular access line

• Peripheral

venous cutdown- Greater salphenous

vein at ankle

- Basilic vein at

antecubital

• Intraosseous

needle access

Fluid resuscitation

• Crystalloids

- NSS, RLS, Acetar

• Colloid

- Albumin, Gelatin, HES, Dextran

Fluid resuscitation

• Hypertonic saline

- 3%,5%,7% NaCl

• Blood product

- PRC, FFP, Plt, WB, Cryoprecipitate

• Blood subsitutes

- Hemoglobin-based

Oxygen carriers

Blood replacement

• Fully cross matched (1 hours)

• Type specific blood ABO and Rh, (10

min)

• If type specific blood is unavailable,

type O negative packed cell are

indicated

Blood replacement

• Whole blood is superior than

component therapy

• PRBC:FFP ratio of 1:1 or 2:1

• Platelet require in blood loss greater

than 1.5 blood volume

Blood replacement

Complication of blood

transfusion- Transfusion-Transmitted Disease

(TTD)

- Transfusion reaction

- Massive transfusion

- Transfusion-Related Acute Lung Injury (TRALI) => 1:5000,

pulmonary edema, treatment as a ARDS

Blood replacement

Massive blood transfusion• Replace total blood volume in 24 Hr

• Hyperkalemia

• Hypocalcemia from citrate intoxication

• Hypothermia

• Coagulopathy

Fluid resuscitation

• Warmed (39 c) isotonic electrolyte solution

• Lactated Ringer’s Solution, normal saline

• 1 to 2 L for adult or 20 mL/Kg for pediatric

Fluid resuscitation

• Give as rapidly as possible

• Require application of pumping

devices

• Replace each 1 mL of blood loss by 3 mL of crystalloid fluid (3:1 rule)

ผู้ป่วยชายไทย อายุ 25 ปี กู้ชีพน าส่ง (รพช 30 เตียง) ขี่รถจักรยานยนต์ถูกรถยนต์ชน มีแผลฉีกขาดเลือดออกท่ีศีรษะ 5

cm, ต้นขาซ้ายผิดรูปกระดูกโผล,่ ปวดทอ้งท้องอดืแนน่, แขนซ้ายมีแผลเปิด10 cm เลือดออกตลอด

หลัง Load NSS 2000 ml ผู้ปว่ยตื่นขึน้ถามตอบรู้เรื่องV/S BP 80/40, PR 130/min,

RR 20/min

E4V5M6, Pupil 3 mm RTL BE

1)Which of fluid response in patient ?

2)Next step of Management ?

Responses to Initial Fluid Resuscitation

2000 mLof isotonic solution in adult; 20 mL/Kg in children

• Continuous large volume infusion to maintain BP => not definite bleeding control

• To late, if wait to make sure bleeding can not stop

Fluid resuscitation

• Rapid response may still be necessary to operative intervention

• Transient response - Continued fluid administration and initial blood

transfusion

- Require rapid surgical intervention

Fluid resuscitation

• No response - Need for immediate definite intervention

- Operation or angioembolization

- Control exsanguinating hemorrhage

Fluid resuscitation

- Large syringe connect to pressure source (human hand)

- IV pressure bag

- Pneumatic external pressurized intravenous infusion system

Increasing hematocrit and decreasing temperature => Increase blood viscosity

Increase intravascular flow rate

ผู้ป่วยชายไทย อายุ 25 ปี กู้ชีพน าส่ง (รพช 30 เตียง) ขี่รถจักรยานยนต์ถูกรถยนต์ชน มีแผลฉีกขาดเลือดออกท่ีศีรษะ 5

cm, ต้นขาซ้ายผิดรูปกระดูกโผล,่ ปวดทอ้งท้องอดืแน่น, แขนซ้ายมีแผลเปิด10 cm เลือดออกตลอด

หลัง Load NSS 2000 ml ผู้ปว่ยตื่นขึน้ถามตอบรู้เรื่องV/S BP 80/40, PR 130/min,

RR 20/min

E4V5M6, Pupil 3 mmRTL BE

Push blood component

FAST – Positive, Film pelvis – Untable Fx pelvis

CxR - WNL Film C-spine – no Fx

1)How to control bleeding in patient ?

2)How many BP do you accept ?

Where are sites of bleeding

Site Treatment

Intrathoracic Thoracotomy

Intraabdomen Laparotomy

Pelvic fracture Pelvic binder, External fixation, C-clamp

Long bone Fx Splint or traction

External bleeding Pressure then repair

pelvic binder pelvic external fixation

Skin traction Skeleton traction

Foley catheter balloon tamponade

Foley catheter balloon tamponade

• Controlled resuscitation, balance

resuscitation, permissive hypotension

• Keep SBP 80-90 mmHg or 100 mmHg if head injury is suspected

• Penetrating trauma with hemorrhage

• No evidence in blunt trauma

Hypotensive resuscitation

Hypotensive resuscitation

• Delay aggressive fluid resuscitation

until definitive control

• Prevent additional bleeding

Balance of organ perfusion

and

Risk of rebleeding

(accept a low normal blood pressure)

ผู้ป่วยชายไทย อายุ 25 ปี กู้ชีพน าส่ง (รพช 30 เตียง) ขี่รถจักรยานยนต์ถูกรถยนต์ชน

LW at scalp => Continuous suture by Nylon 2/0

Open Fx Lt femur => Pressure dressing by gauze and elastic bandage then splint

Large LW Lt forearm => Pressure dressing

by gauze and elastic bandage

Unstable pelvic Fx => Pelvic binderV/S BP 90/60, PR 110/min,

RR 20/min E4V5M6, Pupil 3 mmRTL BE

How to manage between referring to

trauma center ?

Endpoints for resuscitation

Macrocirculation

• Blood pressure

• End-organ perfusion

- Mental status

- Urine output

- Pulse oxymeter

• CVP and Pulmonary Artery pressure

• Echocardiogram assess ventricular volume

Microcirculation

• Lactate and base deficit

• Gastric tonometry

• SCVO2

Parameter Early Late

SBP 90 mmHg >100 mmHg

Pulse <120 <100

Hematocrit >25% >20%

Serum lactate Less than first observe

normal

Cardiac output

Adequate to maintain

Maximized

Blood gas No Resp acido, Met acid tolerated

Normal

Goals for resuscitation

Table 30-8 Hemodynamic Resuscitation End Points

Modality Goals

CVP 10–12 mm Hg Preload

PAOP 12–18 mm Hg

MAP 90–100 mm Hg Afterload

SVR = (MAP –

CVP/CO)(80)

800–1400 dyne s/cm5

CO 5.0 L/min

CI 2.5–4.5 L per min m2

Contractility

SV = CO/heart rate 50–60 mL per min

Heart rate 60–100 bpm Avoid >100 bpm; this will decrease SV

and

increase myocardial oxygen

consumption

Coronary perfusion

pressure

CPP = DBP – CVP (or

PAOP)

>60 mm Hg

ScvO2 or SmvO2

>70% Tissue oxygenation

Serum lactate <2mM/L

Lethal triad: Bloody vicious cycle

Factors contributing to the Coagulopathy

of Trauma

Acidosis

• Decrease coagulation factor activity

• Decrease thrombin generation

• Decrease platelet aggregation

Hypothermia

• Platelet dysfunction

• Reduced clotting factor activity

Factors contributing to the Coagulopathy

of Trauma

Dilutional Coagulopathy

• Factor deficiency

• Thrombocytopenia

• Anaemia

Damage control

• Desire to reassess the intra-abdominal content (directed re-look)

• Evidence of decline of physiology reverse

1)Initial body temperature < 34 C

2)Initial acid-base status- Arterial pH <7.2

- Serum lactate > 5 mmol/L

- Base deficit <-15 mmol/L in patient <55 years

or <-6 mmol/L in patient >55 years

Damage control

3)Onset coagulopathy

PT >16 sec or PTT >60 sec

>50% of normal

4)Other condition

- >10 unit blood

- SBP <90 mmHg more than 60 min

- Operating time >60 min

Control

1. Bleeding2. Contamination

Reversible cause

5H

• Hypovolemia

• Hypoxia

• Hydrogen iron

• Hypo-hyprekalemia

• Hypothermia

5T

• Tension

pneumothorax

• Temponade cadiac

• Toxins

• Thrombosis

pulmonary

• Thrombosis coronary

Take Home Message

• Recognized shock present

• Hemorrhagic shock common in

trauma

• Principle of hemorrhagic shock is

Stop the bleeding and replace the volume loss

Thank you