3 Shock Tenth Edition

3 Shock

The first step in the initial management of shock is to recognize its

presence. The diagnosis of shock is based on clinical recognition of
the presence of inadequate tissue perfusion and oxygenation.

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Objectives
By the end of this interactive discussion, you will be able to:

1. Apply the ATLS principles to the management of a trauma patient with shock.
2. Recognize the signs and symptoms of shock.
3. Evaluate a patient case scenario to determine the possible causes of shock.
4. Discuss the changes that may be seen on initial investigations of a patient
with shock.
5. Evaluate the efficacy of initial fluid management of a patient in shock.
6. Discuss the impact of special patient factors on the management of shock.

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Case Scenario

M 80-year-old male, unrestrained

passenger in a low-speed MVC

I None reported

S Patient confused

T Brought to ED by paramedics

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Discussion Questions:
Case Details

1. What are the possible reasons for the 80-year-old male,

patient’s confusion? M
unrestrained
passenger in a low-
2. What additional scene information speed MVC
would be helpful to obtain from the
I None reported
prehospital providers that could help
you differentiate the causes of his S Patient confused
confusion? Brought to ED by
T
paramedics

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Case Scenario Progression

• Vital signs: BP 100/70; HR 100; RR 20

• Patient on a stretcher, receiving IV fluids

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Discussion Questions:
Case Details

1. Based on the information given, is • Vital signs: BP

100/70; HR 100; RR 20
this patient in shock? What
additional information is needed to • Patient on a stretcher,
receiving IV fluids
help determine this?
2. What vital signs and laboratory
studies support the diagnosis of
shock?
3. Can a single vital sign or laboratory
result diagnose shock?
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Discussion Questions:
Case Details

4. What is the most common • Vital signs: BP

100/70; HR 100; RR 20
cause of shock in a trauma
patient? • Patient on a stretcher,
receiving IV fluids
5. What types of soft tissue or
bony injuries might result in
shock?

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Case Scenario Progression

• Two large-bore IVs placed, 1 L crystalloid bolus given

• Vital signs post treatment: BP 98/77; HR 80
• The patient remains confused and unable to give his medical
history

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Discussion Questions:
1. What adjuncts should be
considered to determine the cause
of shock (if not already done)?
2. How should further resuscitation
proceed?
Case Details
• Two large-bore IVs
placed, 1 L crystalloid
bolus given
• Vital signs post
treatment: BP 98/77;
HR 80
• The patient remains
confused and unable to
give his medical history
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Discussion Questions:
3. How will you continue to monitor
this patient’s ongoing response to
fluid resuscitation?
Case Details
• Two large-bore IVs
placed, 1 L crystalloid
bolus given
• Vital signs post
treatment: BP 98/77;
HR 80
• The patient remains
confused and unable to
give his medical history
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Case Scenario Progression

• Chest x-ray shows multiple rib fractures, large R hemothorax

• The patient’s family arrives and provides history:
o coronary artery disease
o coronary artery stenting 1 year ago
o Meds: beta blocker, clopidogrel (Plavix), and aspirin

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Discussion Questions:
Case Details

• Chest x-ray shows multiple

1. How do the beta blockers affect this rib fractures, large R
patient’s presentation and response to hemothorax

interventions? • Patient history:

o coronary artery
2. What management concerns are disease
presented by the antiplatelet agents o coronary artery
stenting 1 year ago
the patient is taking?
o Meds: beta blocker,
3. What medical condition could further clopidogrel (Plavix),
and aspirin
impact the patient’s response to shock?
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Case Scenario Conclusion

• Platelet transfusion initiated.

• R chest tube is placed 750 mL of blood obtained
• Subsequent chest tube output is 50 mL/2 hours

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Any Questions?

?
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Review Objectives
By the end of this interactive discussion, you will be able to:

1. Apply the ATLS principles to the management of a trauma patient with shock.
2. Recognize the signs and symptoms of a trauma patient in shock.
3. Evaluate a patient case scenario to determine the possible causes of shock.
4. Discuss the changes that may be seen on initial investigations of a patient
with shock.
5. Evaluate the efficacy of initial fluid management of a patient in shock.
6. Discuss the impact of special patient factors on the management of shock.
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Key Learning Points

1. Hemorrhage is the most common cause of shock after injury.
2. No single laboratory test and no single vital sign on its own can diagnose shock.
3. Massive blood loss may produce only minimal acute decrease in hemoglobin or
hematocrit.
4. Major soft tissue injuries and fractures can be associated with significant
hemorrhage.
5. The patient’s response to initial fluid therapy will help guide subsequent
therapy.
6. A variety of special conditions may affect the patient’s response to shock and
the management of it (e.g., age, medication use).
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