Prehospital Trauma Life Support: Shock and Fluid Resuscitation

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
Shock
The patient is in shock!

What does this term mean?
6-3
Shock
Lack of end-tissue perfusion What are the results of inadequate perfusion?
6-4
Aerobic Metabolism
Normal process With oxygen, glucose metabolism produces CO2, H2O, and energy (ATP) Very efficient Cells require ATP to function
6-5
Anaerobic Metabolism
Abnormal process Without oxygen, glucose metabolism produces lactic acid and less energy (ATP) Very inefficient Without ATP, cell functions fail
6-6
Staged Death
Hypoperfusion Cellular hypoxia Anaerobic metabolism Cell death
Organ failure
Patient death
6-7
O2
Red blood cells O2
Kidney Capillaries Alveolus Capillaries
What conditions can interfere with each component of the Fick Principle?
6-8
Your patient is a 30-year-old woman who lost control of her vehicle and struck a light pole. The patient was unrestrained. There is significant damage to the vehicle. You find the patient slumped over in the drivers seat. You see that the steering wheel is bent. The scene is safe.
6-9
Primary Survey
A - Patent B - Fast; BS clear C - No external hemorrhage; weak and rapid radial pulse; cool and diaphoretic skin D - GCS score 14 (E-4, V-4, M-6); anxious E - Bruising across abdomen and right thigh deformity
Vitals: VR, 24; pulse, 118; BP, 112/82
Is this patient in shock? Why?

6-10
What is the most likely cause of the patients shock? Why is the patients BP normal?
6-11
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
Estimated Blood Loss
6-13
Hemorrhagic Shock
6-14
Compensatory Mechanisms
Respiratory system
Tachypnea in response to hypoxia
Sympathetic nervous system

~ BP HR x SV x SVR =
Peripheral and GI vasoconstriction () Increased HR and strength of contraction ()
Hormonal response
Retention of sodium and water
6-15
In addition to hypovolemia, what other types of shock are encountered in trauma patients?
Can more than one type of shock occur in a trauma patient?
6-16
Neurogenic Shock
Disruption of sympathetic nervous system
Loss of tone vasodilation
Relative hypovolemia Skin pink, warm, and dry below level of injury
Unopposed parasympathetic activity

Bradycardia
Why are these patients hypotensive?
6-17
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
Septic Shock
Results from severe infection Chemicals released during infection result in:
Vasodilation Capillary leak
HR x SV x SVR = BP
6-19
Septic Shock
Signs include:
Fever Warm, flushed skin Tachycardia Hypotension
Early onset after trauma rare
6-20
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
Your patient is a 27-yearold male who was working in a grain silo. His left leg became entrapped in an auger. After a 45-minute extrication process, the fire department manages to release his mangled leg.
6-22
Primary Survey
A - Patent
B - Marked tachypnea C - Moderate hemorrhage from extensive soft tissue injury to lower left leg; no radial pulse; very fast, weak carotid pulse; pale, cool, diaphoretic skin D - GCS score 12 (E-3, V-3, M-6) Vitals: VR, 38; pulse, 140; BP, 74/50
What stage of shock is the patient in?
6-23
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
Confounding Factors
Age Athletes Pregnancy Preexisting medical conditions Medications Time from injury to treatment
6-25
A 27-year-old male dock worker was pinned between a fork lift and a loading dock. Upon your arrival, the patient is lying supine on the ground complaining of severe lower abdominal pain.
The ambient temperature is 35 F (1 C). You are 25 minutes from the trauma center.
6-26
Primary Survey
A - Patent
B - VR fast C - No external hemorrhage; rapid and weak radial pulse; pale, cool, moist skin D - GCS score 15 E - Significant pain on palpation of lower abdomen and pelvis
What are the principles of shock management?
6-27
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
External Hemorrhage Control

Direct pressure Elevation Pressure points Tourniquet
Use as a last resort
Focusing on other interventions instead of controlling hemorrhage

6-29
Internal Hemorrhage Control

Limited options - only temporizing:
Splint fractures
PASG
Delay in transport to surgical intervention
6-30
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
PASG
Contraindications:
Penetrating thoracic trauma Splinting lower-extremity fractures Evisceration of abdominal organs Impaled objects in the abdomen Pregnancy Traumatic cardiopulmonary arrest
6-32
Volume Resuscitation
Preferably two large-bore peripheral IVs Lactated Ringers 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
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
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
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, aggressive treatment may prevent complications and death
6-36
Prehospital Trauma Life Support

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6-37

Prehospital Trauma Life Support: Shock and Fluid Resuscitation

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Prehospital Trauma Life Support

Shock and Fluid Resuscitation

The patient is in shock!

Red blood cells O2

Kidney Capillaries Alveolus Capillaries

Vitals: VR, 24; pulse, 118; BP, 112/82

Is this patient in shock? Why?

Estimated Blood Loss

Sympathetic nervous system

Peripheral and GI vasoconstriction () Increased HR and strength of contraction ()

Can more than one type of shock occur in a trauma patient?

Unopposed parasympathetic activity

Why are these patients hypotensive?

Early onset after trauma rare

What stage of shock is the patient in?

Characterized by hypotension Occurs when:

What are the principles of shock management?

External Hemorrhage Control

Focusing on other interventions instead of controlling hemorrhage

Internal Hemorrhage Control

Delay in transport to surgical intervention

What are contraindications for PASG?

Prehospital Trauma Life Support

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