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Trauma Surgery
N.B. Core Topics 1. 2. 3. 4. Shock Abdominal Trauma Crush Syndrome Burns

TUT 1: Shock [Dr Stark] A.


Definition: The inadequate delivery of oxygen and nutrients to maintain normal tissue and cellular function (leading to tissue hypoxia and anaerobic respiration) a. Circulation is composed of: i. Pump (heart) ii. Blood iii. Volume Classification (with examples) a. Hypovolaemic i. Loss Of Blood External Haemorrhage Trauma GI Bleeding Internal Haemorrhage Haematoma Haemothorax, Haemoperitoneum ii. Loss Of Plasma Burns iii. Loss Of Fluid and Electrolytes External Protein Loss Protein Losing Enteropathy Nephrotic Syndrome Vomiting, Diarrhoea Hyperosmolar States (DKA, HONK) Internal (third space) Pancreatitis Ascites Bowel Obstruction b. Cardiogenic i. Dysrhythmia Tachyarrhythmia/Bradyarrhythmia ii. Endocardium Acute Valvular Dysfunction (especially regurgitation) Papillary Muscle Dysfunction

B.

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iii. Myocardium Pump Failure Secondary to previous Myocardial Infarction or Cardiomyopathy c. Distributive i. Septic ii. Anaphylactic iii. Neurogenic iv. Spinal v. Endocrine Addisonian Crisis, Thyroid Storm vi. Drugs (Vasodilator) d. Obstructive i. Tension Pneumothorax ii. Pericardium Tamponade Constriction iii. Pulmonary Supply Pulmonary Embolism Pulmonary Hypertension iv. Atrial Myxoma v. Left Atrial Mural Thrombus vi. Obstructive Valvular Disease Aortic or Mitral Stenosis
Adapted from Current Emergency Diagnosis & Treatment, 5th ed. p. 193. McGraw-Hill, 2004

C.

Pathophysiology a. BP = = ( & ) b. SV is comprised of: i. Preload (Hypovolaemic shock) ii. Afterload (Distributive Shock) iii. Contractility (Cardiogenic Shock) c. 2 = 2 2 = 2

Microcirculatory Problems and Tissue Hypoxia In Shock, 2 is

decreased, meaning that management thereof is dependent on the component(s) impairing 2

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D.

Clinical Presentation Temperature Heart rate Systolic blood pressure Diastolic blood pressure Pulse pressure Pulsus paradoxus Mean arterial blood pressure Shock index Hyperthermia or hypothermia may be present. The treatment is obviously aggressive resuscitation in the former and exogenous heat application in the latter Usually elevated. However, paradoxical bradycardia can be seen in shock states such as haemorrhagic shock (up to 30%), hypoglycaemia, -blocker use, and pre-existing cardiac disease. May actually increase slightly when cardiac contractility increases in early shock and then fall as shock advances. Correlates with arteriolar vasoconstriction and may rise early in shock and then fall when cardiovascular compensation fails. Systolic minus diastolic pressure and related to stroke volume and rigidity of the aorta. Increases early in shock and decreases before systolic pressure. The change in systolic blood pressure with respiration. The rise and fall in intrathoracic pressure affects cardiac output. This can be seen in asthma, cardiac tamponade, and severe cardiac decompensation. Diastolic blood pressure + [pulse pressure/3]. The relationship between cardiac output and vascular resistance determines can be seen in asthma, cardiac tamponade, and severe cardiac decompensation. Shock index = heart rate/systolic blood pressure. Normal = 0.5 to 0.7. The shock index is related to left ventricular stroke work in acute circulatory failure. A persistent elevation of the shock index (>1.0) indicates an impaired left ventricular function (as a result of blood loss and/or cardiac depression) and carries a high mortality rate. Acute delirium or brain failure; restlessness, disorientation, confusion, and coma secondary to decrease in cerebral perfusion pressure (mean arterial pressure intracranial pressure). Patients with chronic hypertension may be symptomatic at normal blood pressures. Pallor, pale, dusky, clammy, cyanosis, sweating, altered temperature, and decreased capillary refill. Neck vein distension or flattening, tachycardia, and arrhythmias. An S3 may result from high-output states. Decreased coronary perfusion pressures can lead to ischemia, decreased ventricular compliance, increased left ventricular diastolic pressure, and pulmonary oedema Tachypnoea, increased minute ventilation, increased dead space, bronchospasm, hypocapnea with progression to respiratory failure, and adult respiratory distress syndrome. Ileus, gastrointestinal bleeding, pancreatitis, acalculous cholecystitis, and mesenteric ischemia can occur from low flow states. Reduced glomerular filtration rate, renal blood flow redistributes from the renal cortex toward the renal medulla leading to oliguria. Paradoxical polyuria can occur in sepsis, which may be confused with adequate hydration status. Respiratory alkalosis is the first acidbase abnormality, as shock progresses metabolic acidosis occurs. Hyperglycemia, hypoglycemia, and hyperkalemia.

Central nervous system Skin Cardiovascular

Respiratory Splanchnic organs Renal

Metabolic

Adapted from Tintinalli's Emergency Medicine > Section 4: Shock > Chapter 30. Approach to the Patient in Shock > Clinical Features > Physical Examination >Table 30-3

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E.

Management (ABCDE) a. Maintain Airway i. ETT and Oxygenation b. Decrease the Work of Breathing i. Mechanical Ventilation and Sedation (decreases the consumption of oxygen by respiratory muscles) c. Optimise Circulation i. IV access via Large Bore Peripheral Lines. ii. Keep patient supine, with legs raised. iii. CVP if possible iv. Fluid Resuscitation Isotonic Crystalloid Colloids Blood Adverse Effects Infection Metabolic K+ Fe3+ overload Allergy Clotting v. Vasopressor Agents -adrenergics -adrenergics Dopaminergics
See http://www.accessmedicine.com.ez.sun.ac.za/popup.aspx?aID=588366

d. Ensure adequate Oxygen Delivery i. Analgesia ii. Muscle relaxants iii. Warm covering iv. Anxiolytics e. Achieve The End Points Of Resuscitation i. Normalise BP, Pulse and Urine Output ii. Restore Circulating Volume iii. Restore All Fluid Compartments iv. Normalise Haemodynamics v. Maximise 2 vi. Restore Aerobic Metabolism and eliminate tissue Acidosis