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Advanced Emergency Trauma Course

GhanaEmergencyMedicineCollaborativePatrickCarter,MD∙DanielWachter,MD∙RockefellerOteng,MD∙CarlSeger,MD

Shock

Presenter:CarlSeger,MD

Overview   Introduction•  Definition•  Physiology

  InitialPatientAssessment•  Recognize

  TypesofShock  ClassesofHemorrhagicShock  TreatingHemorrhagicShock•  Fluid/BloodResuscitation•  EvaluatingtreatmentofShock

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Introduction

  Inordertotreatshockappropriately,itmustfirstberecognized,thenidentifythecause

  Inordertorecognizeit,itisimportanttounderstandsomeofthephysiologyofthediseaseprocess


Definition   Aphysiologicalstatethatresultsininadequateorganperfusionandtissueoxygenation  Downwardspiralofimpairedperfusionleadingtoimpairedfunction

  Resultsinmultipleorganfailureanddeath


Basic Physiology   OxygenDelivery=COxarterialcontentofO2  CardiacOutput=HRxStrokeVolume  StrokeVolumeisafunction•  Preload•  Afterload•  MyocardialContractility


Pathophysiology

  Bloodloss• Releaseofendogenouscatecholamines

  Increasecardiacoutput•  Increaseheartrate•  Vasoconstrictionoflessvitalorgans

  skin,muscle  ResultsinhigherdiastolicBP(narrowPP)

 Continuetoperfusevitalorgansaslongaspossible(brain,heart,kidney)


Initial Patient Assessment

  RecognitionofShock• Clinicalsignsandsymptomsdependsontheseverityoftheshock•  Earlymanifestationsincludetachycardiaandcutaneousvasoconstriction


Clinical Pathophysiology of Shock

  General/Vitalsigns  Cardiovascular-tachycardia  Skin-vasoconstrictionvs.vasodilation  Respiratory-increasedRR  Urinary-decreaseurineoutput  Neurologic-confusion,agitation  Extremities-coldvs.warm


Clinical Endpoints of Shock

END-STAGE SHOCK Bradycardia Arrythmias

Death

DECREASED BLOOD FLOW TO BRAIN AND HEART Restless, agitated, confused, lethargy

Hypotension Tachycardia Tachypnea


Classifying Shock   Hypovolemic•  Hemorrhagic

  Distributive/Vasogenic•  Sepsis,Anaphylactic

  Cardiogenic  Neurogenic•  Spinalcordinjury


SIRS   Systemic Inflammatory Response Syndrome -SIRS

•  Defined by the presence of two or more of the following:   Body temp < 36 °C (97 °F) or > 38 °C (100 °F)   Heart Rate > 90 bpm   RR > 20 bpm   WBC < 4,000 cells/mm3 or > 12,000 cells/mm3 (<

4 × 109 or > 12 × 109 cells/L), or greater than 10% band


Sepsis and Septic Shock

  Sepsis-DefinedasSIRSinresponsetoaconfirmedinfectiousprocess.

  Septicshock-Definedassepsiswithrefractoryarterialhypotensionorhypoperfusionabnormalitiesinspiteofadequatefluidresuscitation.

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Septic Shock   Abloodborneinfectionwidelydisseminatedtomanyareasofthebody

  Commonfeaturesarehighfever,vasodilatation(especiallyinaffectedtissues)

  Sludgingoftheblood,andRBCagglutinationresultinginDIC

http://en.wikipedia.org/wiki/File:Staphylococcus_aureus_Gram.jpg


Anaphylactic Shock   AnIgEmediatedeventthattriggersmassivereleaseofimmuneresponsemediators

  Resultsinwidespreadperipheralvasodilation,bronchialsmoothmusclecontraction,andlocalvasculardilatation

JustinBeck(flickr)


Cardiogenic Shock   Keyelementsarehypotension(SBP<90)andhypoperfusionwithpulmonarycongestion

  Mortalityis50-80%beforereperfusiontherapy  Acutemyocardialischemiaismostcommoncause

PatrickJ.Lynch,medicalillustrator;C.CarlJaffe,MD,cardiologist(Wikipedia)GhanaEmergencyMedicineCollaborative

AdvancedEmergencyTraumaCourse

Neurogenic Shock   Resultofspinalcordinjury  Lossofsympathetictone  Decreasedvasomotortone  Resultsinhypotensionandbradycardia

  Patientsmayremainalert,warm,anddrydespitethehypotension

PhotoofChristopherReevetakenbygunkyboy(Wikipedia)


Case 1   29y/omale,PVAwhilecrossingthestreet,awake,complainingofseverebackpain,andinabilitytomoveorfeelhislegs  HR45RR25BP100/45Sa0298%T34.0


What do we do next?

 Maintain ventilation

 Enhance perfusion

 Treat underlying cause


What studies or labs can help you immediately?

  X-rays  FASTexam  Frequentvitalsigns

  Continuouscardiacandoxygenmonitoring

http://en.wikipedia.org/wiki/File:Morrisons-with-fluid.jpg


X-rays from the trauma bay

SourceUndetermined

SourceUndeterminedGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Neurogenic Resuscitation

  Adequateoxygenation  Assessbreathing  Maximizecirculation•  IVfluidsorblood•  Pressorsifnecessary

  Supportheartrateifneeded•  Atropine

  PreparefortheOR


Hypovolemic

  Hemorrhagic•  Mostlytraumatic•  Focusoftoday

  Severeburn  GIlosses•  vomitinganddiarrhea

  Urinary•  DKA


Classes of Hypovolemic Shock CLASS I II III IV

BVL <15% 15-30% 30-40% >40%

AMOUNT 750cc 750-1500cc 1500-2000cc >2000cc

PULSE <100 >100 >120 >140

BP Nochange Narrowedpulsepressure

ConsistentdecreaseinSBP

DecreasedSBPandnarrowedpulsepressureornoDBP

RESP Nochange 20-30 30-40 >35

CNS Nochange Anxiety Anxious,confused Confused.lethargic

Urine >30ccperhr 20-30ccperhr 5-15ccperhr negligible

TX Replacefluidloss

2LNSIV 2LNSIV,usuallyrequiresbloodtransfusion

RapidtransfusionofbloodandNS,requiresimmediateinterventiontostophemorrhage


Treating Hemorrhagic Shock

  AsalwaysABC’s•  AirwayandBreathing

 WouldpreferO2satgreaterthan95% PlacingO2onthepatient

• Circulation HemorrhageControl VascularAccess,LargeboreIVx2


Monitoring   Continuousmonitoring  OxygenSaturation  Urineoutput

LRHopson,2005

SourceUndetermined


Treating Hemorrhagic Shock

 Identify&reversethecause Restoretissueperfusion Restoreorganfunction


Initial Fluid Therapy   AdultwithnormalCardiacFunction•  1to2LitersofLRorNSrapidly

  Pediatric•  20ml/kgofLRorNSrapidly

  Evaluatepatientsresponsetofluid


Evaluation of Treatment  Assessorganperfusion• Urinaryoutput• MentalStatus• Skinexam• Vitals


Response to Initial Fluid RapidResponse Transient

ResponseNoResponse

Vitals Returntonormal Transientimprovementwithreturntoprevious

RemainAbnormal

EstimatedBloodloss

10-20% 20-40%withongoinglikely

Severe>40%

NeedformoreFluid

Low High High

NeedforBlood Typeandcross Typespecific OnegNeedforsurgery Possible Likely Highlylikely


Case 2   25yearoldmaleinaheadonmotorvehicleaccident.HehassustainedobviouschestandabdominaltraumaandhasaGCSof13.

  VS:HR125RR28BP100/50T36.0Sa0293%on100%

  Patientisagitatedandconfused.


What class of Shock?  ClassIII ABC  IVAccess 2litersofNS


Case #2 cont

 PatientsVitalsafter2liters:• HR95RR25BP110/70


Case #3   17y/omalecutshisinnerthighwithasickle•  Presentshemorrhagingfromleftgroinarea•  AwakeandAlert•  VS:BP120/60HR120RR30Sat98%onRA•  PthaspulsedistallyinLtLeg


What to do?

 ABC• DirectPressuretobleedingarea•  IVAccess• 2LitersNS


Case #3   After2Liters• Havingdifficultycontrollingbleeding•  VitalSigns

 HR130BP85/60RR30Sat100%onNC


Case #3

 WhatNext?• MoreFluid• Blood• Surgeon?


Which Pressor should I choose?   Hypovolemicshock

•  Fluids and Blood

  Cardiogenicshock•  Dobutamine - Β1 agonist

  Increasessqueezeandheartrate

  Neurogenicshock•  Fluids, phenylephrine, Levophed,

look for another type of shock if it is persistent

  Anaphylacticshock•  Fluids and epinephrine

  Septicshock•  Neosynephrine - alpha agonist

  IncreasesSVRbyarteriolarconstriction

•  Norepinephrine/Levophed - alpha and beta agonists

  Dopamine•  Low Dose - increases renal blood

supply •  Medium Dose - beta effects

(increases heart rate and squeeze) •  High Dose - alpha effects

(arteriolar constriction)


Overview   Introduction•  Definition•  BasicPhysiology

  InitialPatientAssessment•  Recognize

  TypesofShock  ClassesofHemorrhagicShock  TreatingHemorrhagicShock•  Fluid/BloodResuscitation•  EvaluatingtreatmentofShock



Questions?

Dkscully(flickr)


References   Rivers,E.,Otero,R.,Nguyen,H.Approachtothepatientinshock,inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.219-225.

  Manning,J.FluidandBloodResuscitation,inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.225-231.

  Jui,J.SepticShock,inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.231-242.

  Peacock,W.,Weber,J.CardiogenicShock,inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.242-247.

  Rowe,B.,Carr,S.,AnaphylaxisandAcuteAllergicReactions,inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.242-252.

  Euerle,B.,Scalea,T.NeurogenicShock,inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.219-255.

  AmericanCollegeofSurgeons.Shock,inAdvancedTraumaLifeSupportforDoctors7thedition.2004.p.62-102.

  Mills,T.TraumaResuscitation,inEmergencyMedicine.Adams,Editor.2008,SaundersElsevier.p.77-84