Approaches of Shock In Trauma

By Asmamaw A
Session outlines
Case senario
Introduction
Definition of shock
Physiology of ABP
Pathophysiology of shock
Classification of H.shock
Assessment parameters of shock
Management of Hemorrhagic shock
Case scenario
Discussion
Female patient aged 32 years, with polytrauma resulting
from car crash against truck, who was brought to the
emergency department of Black lion Hospital

On arrival, the patient was unconscious and she presented

with tachycardia(144),hypotension(MAP=40mmHg)
RR=35,T=35.7 , anisocoria; GCS= 3; and he has pelvic,
humerus, and left jaw fractures; in addition to active
bleeding in the right frontoparietal region and large
hematoma in the pelvic and hypogastric region.
Case scenario cont….
A. How do you approach this pt?

B.What are the promlems the pt does have?

Introduction
• Uncontrolled hemorrhage accounts for 30-40% of early
mortality in trauma and more than 80% mortality in the
operating room, reported as the leading cause of
potentially preventable death.

• The patients often progress to varying degrees of

coagulopathy, hypothermia, and metabolic acidosis,
considered the lethal triad of trauma and major predictive
of morbidity and mortality in polytraumatized patient

• Unrecognized bleeding or delayed resuscitation remain

causes of preventable death.
Introduction cont….
50% deaths occur at scene within minutes:
 CNS injury 40-50%
 Hemorrhage 30-40%

50% after hospital arrival:

 60% die within first 4 hrs
 The rests died beyond 12-24 hours

Hemorrhage accounts for a significant portion of deaths at the scene and in the hospital

Immediate and early deaths account for the majority of trauma deaths, with
<10% of deaths occurring late in the ICU.
Introduction cont….
The trimodal death distribution of trauma

Immediate deaths occur within minutes and consist of major

lacerations to the brain, brainstem, aorta, spinal cord, and heart.

Early deaths occurred within the first few hours and consist of
potentially survivable injuries such as epidurals, subdurals,
hemopneumothorax, pelvic fractures, long bone fracture, and
abdominal injuries

Late deaths can occur up to weeks later in the intensive care

unit and include deaths from sepsis and multiple organ failure
Trauma
Trimodal Death Distribution
50%

30%
DEATH

20%

Minutes Hours Days Weeks

Immediate Early Late

Hemorrhage is responsible for 40% of civilian trauma
deaths,and 50% of military trauma deaths.

Up to half of the civilian deaths occur in the prehospital

phase.
Shock
Shock is a physiologic state characterized by a systemic
reduction in tissue perfusion below that necessary to
meet the metabolic needs of tissues and organs.

Hypoperfusion results in oxygen deficiet, occurring as

oxygen delivery becomes unable to meet metabolic
requirements.

Hypoperfusion is a time-dependent emergency

Shock cont….
Shock

Is inadequate organ perfusion to meet the tissue’s

oxygenation demand
An imbalance between O2 delivery and demand

Inadequate perfusion and oxygenation of cells

leads to
- Cellular dysfunction and damage
- Organ dysfunction and damage
 Hypotension

In adults
- Systolic BP  90 mm Hg
- Mean arterial pressure  60 mm Hg
 Reduction of systolic BP > 40 mm Hg from the
patient’s baseline pressure
Shock cont…
When the body is healthy, three conditions are needed to
keep the right amount of blood flowing

1. Heart must be working well

2. Adequate amount of oxygen rich blood must be
circulating in the body
3. Blood vessels must be intact and able to adjust blood
flow
Shock cont…
Why do we worry about shock?

High mortality : 20 - 90%

Early on the effects of O2 deprivation on the cell are
reversible
Early intervention reduces mortality
- Can prevent the detrimental effects of O2 deprivation
Shock cont…
Physiology of ABP

ABP CO (cardiac out put) and

peripheral vascular resistance
CO = SV (Stroke volume) * HR(heart rate)
SV EDV(depends on venous return)
, myocardial contractility and after load
Shock cont…
Mean Arterial Pressure (MAP)

It describes the average blood pressure of an

individual
MAP = CO x SVR
MAP = 2DBP + SBP
3
= 1/3 pulse pressure + DBP
where : pulse pressure = SBP - DBP
*The normal range is b/n 60 – 100 mmHg
*It indicates adequate perfusion of the organs
Shock cont…
Pre load
Is the ability of the myocardial muscle to stretch
and contract at the end diastole
Dependent on intravascular volume
. If intravascular volume is depleted (due
to increased endothelial permeability),
Preload decreases
•
•CVP is used to measure it

( normal = 8 - 12cm H2O )

Shock cont…
Afterload
Is the amount of vascular resistance or
pressure the heart needs to exert to push the
blood out of the ventricular chambers into the
pulmonary or systemic vascular system

Afterload determines tissue perfusion

MAP is used as a surrogate measure

- Keep between 60 - 100 mm Hg
Shock cont…
CO
Amount of blood pumped by the heart per
minute
Normal = 4 - 8 lt
SV
 Amount of blood ejected by each ventricles
per single beat
Normal = 70ml/beat
Shock cont…
Myocardial contractility

Is the force of ventricular contraction

Dependent on the amount of stretch of the
ventricular fibers
 Heart Stroke Cardiac
Rate
(beats/min)
X Volume
(cc/beat)
= Output
(L/min)

Myocardial
Preload Contractilit Afterload
y
Cardiac Output
Other ABP determinants

Systemic Vascular Resistance (SVR)

- Vessel length
- Blood viscosity
- Vessel diameter
 Shock cont…
Stages of shock

Pre-shock
Shock
End-organ dysfunction
Stages of shock
Pre shock

 Hemostatic compensation for decreased

perfusion
MAP= ↓CO (↑ HR*↓SV) * ↑ SVR
Decrease CO is compensated by ↑HR and
↑SVR
 MAP is maintained
 HR will be increased
 Extremities will be cool due to vasoconstriction
Stages of shock cont…..
Shock

Compensatory mechanisms become overwhelmed, resulting

in
- Tachycardia
- Tachypnea
- Metabolic acidosis
- Oliguria
- Cool, clammy skin
Decrease MAP
( Usually occur with Loss of 30 - 40% of
effective blood volume)
Stages of shock cont…..
End organ dysfunction

 Cell death and organ failure

 Decreased renal function (ARF)
 Liver failure
 DIC
 Death
Pathophysiology of shock
Cellular Response to Shock

Blood
Loss
Inadequate
Acidosis
Perfusion

Cellular Cellular
Edema Hypoxia

Lactic Aerobic
Acid Metabolism
Anaerobic
Metabolism
 Injuries Prone to Hemorrhage

Vascular Solid Organ Bones

Aorta Spleen Pelvis
Vena Cava Liver Femur

Quickly Rule Out Blood Loss

Chest – CXR / FAST
Abdomen - FAST
Pelvis – Xray
Femur – exam / Xray
The 3 primary areas to look for blood loss are the
 Chest,
 Abdomen
 Pelvis.

Isolated head injuries are not the cause of hemorrhagic

shock.
Fracture associated with blood
Femur and pelvic fractures are most often associated
with large blood loss.

Pelvic fractures can run from stable with minimal blood

loss to catastrophic hemorrhage of the entire blood
supply.

Edema occurs in injured soft tissues. Tissue injury

results in activation of systemic inflammatory response
and production and release of multiple cytokines.
 Fracture associated with blood
ture Associated Blood Loss
• Humerus 750 ml
• Tibia 750 ml
• Femur 1500 ml
• Pelvis >3L
Associated Soft Tissue Trauma
Release of Cytokines
• Increased permeability
• Magnify fluid loss
Confounding Factors In Response
To Hemorrhage
 Patients age
 Pre-existing disease / meds
 Severity of injury

 Access to care

 Duration of shock
 Amount prehospital fluid

 Presence of hypothermia
 Assessment parameters

Skin perfussion
Pulse
Blood PressuresBloo
Pulse pressure
Shock index
Urine output
Assessment parameters cont….
Skin Perfusion
Pale, cool, mottled
• Vasoconstriction

Most sensitive in
pediatrics
• Starts distal extremities
• Ascends towards trunk

 Capillary Refill
• Normal <3 seconds
Rough BP Estimation from Pulse
• If you can palpate
this pulse, you
60
know the SBP is
roughly this number

80

70

80
 Assessment parameters cont
• Blood PressuresBl

• BP response to volume loss

• Non-linear due to compensatory mechanisms
• Insensitive sign of early shock

• Infrequently & or inadequately monitored

• First BP should always be manual
• Automated BP overestimated by 10 mm Hg
 Pressure
Pulse PressurePuls
• Narrowed pulse pressure suggests significant
blood loss
• Result of increasing diastolic pressure from
compensatory catecholamine release

100/66 100/74 100/77 100/84

.
• Normal pulse pressure is around 25-40.
Shock Index (SI)
Shock index (SI) is the ratio of heart rate in bpm to
systolic blood pressure in mm Hg.

SI = HR / SBP
Elevated early in shock
SI > 0.9 predicts:
Acute hypovolemia in presence of normal HR & BP
Marker of injury severity & mortality
Urine out put
Urine Output

Adult 0.5 ml / kg / hour

Child 1.0 ml / kg / hour

Toddler 1.5 ml / kg /
hour

Infant 2.0 ml / kg / hour

 Class I Hemorrhage

750 mL BVL (15%)

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

Crystalloid
 Class II Hemorrhage

750-1500 mL BVL (15-30%)

● Anxious
● Normal blood pressure
● Heart rate > 100 / min
● Decreased pulse pressure
● Respirations 20-30 / min
● Urinary output 20-30 mL / hour
Crystalloid,
? blood
 Class III Hemorrhage
1500-2000 mL BVL (30-40%)

● Confused, anxious
● Decreased blood pressure
● Heart rate > 120 / min
● Decreased pulse pressure
● Respirations 30-40 / min
Crystalloid, blood
● Urinary output 5-15 mL / hour components,
operation
 Class IV Hemorrhage
>2000 mL BVL (>40%)

● Confused, lethargic
● Hypotension
● Heart rate > 140 / min
● Decreased pulse pressure
● Respirations >35 / min Definitive
● Urinary output negligible control, blood
components
Classic Signs & Symptoms of Shock

Changing mentation
Tachycardia
Cool, clammy, skin
Prolonged capillary refill
Narrowed pulse pressure
Decreased urine output
Hypotension
 Shock
What is the cause of the shock state?
Hypovolemic vs Nonhemorrhagic
● Blood loss ● Tension
● Fluid loss pneumothorax
● Cardiac tamponade
● Cardiogenic
● Septic
● Neurogenic
 Shock

How do I locate the bleeding?

● Physical examination
● Diagnostic adjuncts to
primary survey
● Chest X-ray
● Pelvic X-ray
● FAST / DPL
● CBC
● Blood group and Rh factor
 Causes of traumatic shock

Hemorrhagic
Non hemorrhagic

Initial determination of the causes is depends on

taking appropriate Hx, careful P/E, monitoring
CVP, Chest/pelvic x-ray and ultrasonography, but
shouldn’t delay appropriate resuscitation
 Hemorrhagic shock

Most common cause of shock after injury and all

patients with multiple injuries have an element of
hypovolemia
The primary focus in hemorrhagic shock is to
promptly identify and stop hemorrhage
Sources of potential blood loss: chest, abdomen,
pelvis, retroperitonium, extremities, and external
bleeding must be quickly assessed by physical
examination and appropriate adjunctive studies ….
 such as chest x-ray, pelvic x-ray, abdominal
assessment with either FAST or DPL, and bladder
catheterization

Nonhemorrhagic Shock
Non hemorrhagic shock includes cardiogenic
shock, cardiac tamponade, tension pneumothorax,
neurogenic shock, and septic shock
Initial management of hemorrhagic shock

For most trauma patients, treatment is instituted

as if the patient has hypovolemic shock
The basic management principle is to stop the
bleeding and replace the volume loss
* P/E
- Immediate DX of life threatening
injury and assessment of ABCDE
 Airway and breathing
Patent air way with adequate ventilation and
oxygenation (supplemental oxygen to make sao2 >
93%)

Circulation—Hemorrhage Control
Controlling obvious hemorrhage, obtaining
adequate intravenous access, and assessing tissue
perfusion
Interventions

What can I do about it?

Direct pressure / Angio-
tourniquet embolization
STOP
the
bleeding!
Reduce Splint
pelvic fractures
volume
Operation
 Interventions

What can I do about it?

● Fluid resuscitation
● Vascular access?
● Type?
● Volume?
● Monitor response
● Prevent hypothermia!
Mechanical Means of
Stopping Hemorrhage

Pelvic Binders
Reduce pelvis volume

Tourniquets
Studied extensively
in war
Good outcomes
Safe and effective
 Patient Response
Identify improved organ
function
● Skin: warm, capillary refill
● Renal: increased urinary output
● Vital signs
● CNS: improved level of
consciousness
 Disability
Determine the patient’s level of consciousness, eye
motion and pupillary response, best motor
function, and degree of sensation
Alterations in CNS function in patients who have
hypotension as a result of hypovolemic shock do
not necessarily imply direct intracranial injury

Exposure
Completely undress the patient, examine from
head to toe to search for associated injuries
(Prevent hypothermia)
 Urinary Catheterization
Asses urine for hematuria – may indicate
retroperitoneal bleed
Monitor UOP - evaluates renal perfusion

Initial fluid therapy

Warmed isotonic electrolyte solutions, such as

lactated Ringer’s and normal saline are used for
initial resuscitation
- Dose : 1 to 2 lt. for adults and 20 mL/kg for
pediatric patients
The amount of fluid and blood required for
resuscitation is difficult to predict on initial
evaluation of the patient

It is most important to assess the patient’s

response to fluid resuscitation and identify
evidence of adequate end-organ perfusion and
oxygenation (i.e., via urinary output, level of
consciousness, and peripheral perfusion)
Persistent infusion of large volumes of fluid and blood
in an attempt to achieve a normal blood
pressure is not a substitute for definitive control of

bleeding (triads of coagulopathy, acidosis and

hypothermia)
NB
Hemostatic resuscitation involves early
administration of blood products in order to restore
both perfusion and coagulation and minimize the use of
large volumes of crystalloid and their dilutive effect on
coagulation
Evaluation of fluid resuscitation and organ
perfusion

Normal BP, pulse pressure, pulse rate

Improvement in CVP and skin circulation
Adequate UOP
Improvement in mental status
Therapeutic Decisions Based on Response to
Initial Fluid Resuscitation

The patient’s response to initial fluid resuscitation

is the key to determining subsequent therapy
Observing the response to the initial resuscitation
identifies patients whose blood loss was greater
than estimated and those with ongoing bleeding
who require operative control of internal
hemorrhage
The potential patterns of response to initial fluid
administration can be divided into three groups:
rapid response, transient response, and minimal or
no response

Rapid Response
Patients usually respond to initial fluid
resuscitation and remain hemodynamically normal
Patients usually have lost minimal (less than 20%)
blood volume
Typed and cross matched blood should be kept
available ( as reserve )
Surgical consultation and evaluation are
necessary during initial assessment and treatment,
as operative intervention may still be necessary

Transient Response
Patients respond to the initial fluid bolus.
However, they begin to show deterioration of
perfusion indices as the initial fluids are slowed to
maintenance levels
Most of these patients initially have lost an
estimated 20% to 40% of their blood volume
Transfusion of blood and blood products is
indicated
Patients may require operative or angiographic
control of hemorrhage

Minimal or No response
Failure to respond to crystalloid and blood
administration in the ED dictates the need for
immediate, definitive intervention (e.g., operation
or angioembolization) to control exsanguinating
hemorrhage
Reference
Advance Trama Life support book 9th edition
Internet
Bailey and Love’s short practice of surgery
Update
Thank You!