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Prehospital Trauma Life Support

Lesson

6
Copyright © 2003, Elsevier Science (USA). All rights reserved.

Shock and Fluid Resuscitation

PROVIDER COURSE

Objectives
• Describe the pathophysiology of shock • Identify the types of shock • Differentiate between signs of compensated and decompensated shock • Discuss the role of hemorrhage control, hypothermia, PASG, and volume resuscitation in shock management

6-2
Copyright © 2003, Elsevier Science (USA). All rights reserved.

Shock

“The patient is in shock!”
What does this term mean?

6-3
Copyright © 2003, Elsevier Science (USA). All rights reserved.

. Elsevier Science (USA).Shock Lack of end-tissue perfusion What are the results of inadequate perfusion? 6-4 Copyright © 2003. All rights reserved.

Elsevier Science (USA). H2O. All rights reserved.Aerobic Metabolism • Normal process • With oxygen. . and energy (ATP) • Very efficient • Cells require ATP to function 6-5 Copyright © 2003. glucose metabolism produces CO2.

. All rights reserved.Anaerobic Metabolism • Abnormal process • Without oxygen. cell functions fail 6-6 Copyright © 2003. glucose metabolism produces lactic acid and less energy (ATP) • Very inefficient • Without ATP. Elsevier Science (USA).

Elsevier Science (USA).Staged Death Hypoperfusion Cellular hypoxia Anaerobic metabolism Cell death Organ failure Patient death 6-7 Copyright © 2003. . All rights reserved.

O2 Red blood cells O2 Kidney Capillaries Alveolus Capillaries What conditions can interfere with each component of the Fick Principle? 6-8 Copyright © 2003. . All rights reserved. Elsevier Science (USA).

The patient was unrestrained. All rights reserved. You see that the steering wheel is bent.Your patient is a 30-year-old woman who lost control of her vehicle and struck a light pole. . 6-9 Copyright © 2003. You find the patient slumped over in the driver’s seat. There is significant damage to the vehicle. Elsevier Science (USA). The scene is safe.

BP.No external hemorrhage.GCS score 14 (E-4.Bruising across abdomen and right thigh deformity Vitals: VR. cool and diaphoretic skin D . .Primary Survey A . weak and rapid radial pulse. V-4. Elsevier Science (USA). 24.Fast. 118. All rights reserved. M-6). 112/82 Is this patient in shock? Why? 6-10 Copyright © 2003.Patent B . BS clear C . pulse. anxious E .

.What is the most likely cause of the patient’s shock? Why is the patient’s BP normal? 6-11 Copyright © 2003. Elsevier Science (USA). All rights reserved.

Elsevier Science (USA).Blood Loss • External – Soft tissue wounds – Damage to major blood vessels • Internal – Body cavities/potential spaces • Pleural cavities • Peritoneal cavity • Retroperitoneal space • Interstitial blood loss from fractures 6-12 Copyright © 2003. All rights reserved. .

Elsevier Science (USA).Estimated Blood Loss 6-13 Copyright © 2003. All rights reserved. .

Hemorrhagic Shock 6-14 Copyright © 2003. Elsevier Science (USA). . All rights reserved.

Compensatory Mechanisms • Respiratory system – Tachypnea in response to hypoxia • Sympathetic nervous system ~ BP – HR x SV x SVR = • Peripheral and GI vasoconstriction (α) • Increased HR and strength of contraction (β) • Hormonal response – Retention of sodium and water 6-15 Copyright © 2003. . All rights reserved. Elsevier Science (USA).

what other types of shock are encountered in trauma patients? Can more than one type of shock occur in a trauma patient? 6-16 Copyright © 2003. . Elsevier Science (USA). All rights reserved.In addition to hypovolemia.

Elsevier Science (USA). All rights reserved. and dry below level of injury • Unopposed parasympathetic activity – Bradycardia Why are these patients hypotensive? 6-17 Copyright © 2003. .Neurogenic Shock • Disruption of sympathetic nervous system • Loss of tone vasodilation – “Relative” hypovolemia – Skin pink. warm.

Neurogenic Shock • HR x SV x SVR = BP • Hypotension due to: – Decreased HR due to bradycardia – Decreased SV due to relative hypovolemia – Decreased SVR due to vasodilation 6-18 Copyright © 2003. Elsevier Science (USA). All rights reserved. .

Septic Shock • Results from severe infection • Chemicals released during infection result in: – Vasodilation – Capillary leak • HR x SV x SVR = BP 6-19 Copyright © 2003. . Elsevier Science (USA). All rights reserved.

. flushed skin – Tachycardia – Hypotension • Early onset after trauma rare 6-20 Copyright © 2003. Elsevier Science (USA).Septic Shock • Signs include: – Fever – Warm. All rights reserved.

Cardiogenic Shock • Intrinsic causes: – Heart muscle damage ( SV) – Dysrhythmia ( HR or SV) – Valvular disruption ( SV) • Extrinsic causes: – Pericardial tamponade ( SV) – Tension pneumothorax ( SV) 6-21 Copyright © 2003. All rights reserved. Elsevier Science (USA). .

After a 45-minute extrication process. . Elsevier Science (USA). the fire department manages to release his mangled leg. All rights reserved.Your patient is a 27-yearold male who was working in a grain silo. His left leg became entrapped in an auger. 6-22 Copyright © 2003.

. V-3. cool.GCS score 12 (E-3. Elsevier Science (USA).Moderate hemorrhage from extensive soft tissue injury to lower left leg. pale.Patent B . diaphoretic skin D . 140.Primary Survey A . BP. 74/50 What stage of shock is the patient in? 6-23 Copyright © 2003. 38.Marked tachypnea C . no radial pulse. very fast. pulse. weak carotid pulse. All rights reserved. M-6) Vitals: VR.

Elsevier Science (USA).Decompensation • Late stage of shock – Compensatory mechanisms fail • Characterized by hypotension • Occurs when: – Insult is overwhelming – Delay in treatment – Inhibition of compensatory mechanisms 6-24 Copyright © 2003. . All rights reserved.

Elsevier Science (USA). . All rights reserved.Confounding Factors • • • • • • Age Athletes Pregnancy Preexisting medical conditions Medications Time from injury to treatment 6-25 Copyright © 2003.

. You are 25 minutes from the trauma center. the patient is lying supine on the ground complaining of severe lower abdominal pain. Elsevier Science (USA). The ambient temperature is 35° F (1° C). 6-26 Copyright © 2003.A 27-year-old male dock worker was pinned between a fork lift and a loading dock. All rights reserved. Upon your arrival.

rapid and weak radial pulse. Elsevier Science (USA). All rights reserved.Significant pain on palpation of lower abdomen and pelvis What are the principles of shock management? 6-27 Copyright © 2003. pale. . cool.Primary Survey A .VR fast C .GCS score 15 E . moist skin D .No external hemorrhage.Patent B .

All rights reserved. Elsevier Science (USA). .Airway/Oxygenation • Assess airway and intervene as necessary • Apply O2 to maintain SpO2 > 95% • Assess tidal volume/oxygenation as necessary and assist ventilations as needed 6-28 Copyright © 2003.

All rights reserved.External Hemorrhage Control • • • • Direct pressure Elevation Pressure points Tourniquet – Use as a last resort Focusing on other interventions instead of controlling hemorrhage 6-29 Copyright © 2003. . Elsevier Science (USA).

All rights reserved. . Elsevier Science (USA).Internal Hemorrhage Control • Limited options .only temporizing: – Splint fractures – PASG Delay in transport to surgical intervention 6-30 Copyright © 2003.

. All rights reserved. Elsevier Science (USA).PASG • Indications: – Suspected pelvic fractures with SBP < 90 mm Hg – Suspected intraperitoneal hemorrhage with SBP < 90 mm Hg – Suspected retroperitoneal hemorrhage with SBP < 90 mm Hg – SBP < 60 mm Hg What are contraindications for PASG? 6-31 Copyright © 2003.

. All rights reserved. Elsevier Science (USA).PASG • Contraindications: – – – – – – Penetrating thoracic trauma Splinting lower-extremity fractures Evisceration of abdominal organs Impaled objects in the abdomen Pregnancy Traumatic cardiopulmonary arrest 6-32 Copyright © 2003.

Volume Resuscitation • • • • Preferably two large-bore peripheral IVs Lactated Ringer’s Warmed fluid if possible (102° F/39 ° C) Initial bolus – Adults: 1 to 2 L – Pediatric: 20 mL/kg Delaying transport of critical patients to initiate IVs on scene 6-33 Copyright © 2003. . Elsevier Science (USA). All rights reserved.

Volume Resuscitation • Goal: Maintain perfusion of vital organs – Aim for MAP 60 to 65 mm Hg (SBP 80 to 90 mm Hg) Overaggressive resuscitation can result in increased internal hemorrhage and may lead to a worse patient outcome. 6-34 Copyright © 2003. . Elsevier Science (USA). All rights reserved.

All rights reserved.Complications • Prolonged shock can result in: – – – – – Acute Respiratory Distress Syndrome (ARDS) Acute Renal Failure (acute tubular necrosis) Coagulopathy Hepatic failure Multiple Organ Failure 6-35 Copyright © 2003. Elsevier Science (USA). .

aggressive treatment may prevent complications and death 6-36 Copyright © 2003. All rights reserved.Summary • Shock should be recognized in its early stages • Trauma patients may have more than one type of shock • Hemorrhage control is essential to management • Early. Elsevier Science (USA). .

.Prehospital Trauma Life Support Lesson Six is complete. Please make a selection from the menu below. Elsevier Science (USA). All rights reserved. Return to Main Menu Return to Provider Course Table of Contents Exit/Quit 6-37 Copyright © 2003.

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