the hemodynamic
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The hemodynamically
unstable patient
Jeannouel van Leeuwen MDTrauma in the Caribbean II November 6-8, 2009
Causes of Shock
• Severe bleeding• Severe burns• Heart failure• Heart attack• Head or spinal
injuries• Allergic reactions
• Dehydration• Electrocution• Serious infection• Extreme emotional
reactions (temporary/less dangerous)
Signs and Symptoms of Shock
• Restlessness, anxiety• Extreme thirst• Rapid, weak pulse• Rapid, shallow
respirations
• Mental status changes• Pale, cool, moist skin• Decreased blood
pressure (late sign)
All bleeding eventually ceases
Shock (Hypoperfusion)
• Results from the inadequate delivery of oxygenated blood to body tissues
• May result from any condition involving: – Failure of the heart to provide oxygenated
blood (pump failure)– Abnormal dilation of the vessels (pipe
failure)– Blood volume loss (fluid failure)
Hypovolemic Shock
• CNS response to hypovolemia – Rapid: peripheral vasoconstriction, increased
cardiac activity– Sustained: arterial vasoconstriction, Na/water
retention, increased cortisol Hemorrhage or fluid loss • Classes of hemorrhage:
I: 15% II: 30% = tachycardiaIII: 40% = decreased SBP, confusionIV: >40% = lethargy, no UOP
It is not the blood loss you can see that will get you, it’s the blood loss you can’t see
Signs and Symptoms of Internal Bleeding• Discolored, tender, swollen or hard skin, rigid
abdomen• Absence of distal pulse• Increased respiratory and pulse rates• Pale, cool, moist skin • Nausea and vomiting• Thirst• Mental status changes• Bleeding from body orifices
Identification of the Site of Bleeding
• External Hemorrhage• Pleural Space• Peritoneal Cavity• Extremity Fracture• Retroperitoneal Space
One set of vital signs isn’t “hemodynamically stable”
External BleedingExternal Bleeding
Significant blood lossSignificant blood loss– 1 liter - adult– 1/2 liter - child– 100 to 200 ml 100 to 200 ml - infant- infant
Result may be HYPOVOLEMIC shock
Significant blood lossSignificant blood loss– 1 liter - adult– 1/2 liter - child– 100 to 200 ml 100 to 200 ml - infant- infant
Result may be HYPOVOLEMIC shock
Ventilate, perfuse , and piss is all that it is about
Bleeding ControlBleeding ControlBleeding ControlBleeding Control
Direct local pressureDirect local pressure
Most effective
Direct local pressureDirect local pressure
Most effective
What is the optimal fluid strategy?
• In trauma you only need “resuscitation” if you are bleeding
• The best fluid is the fresh whole blood from your identical twin
• If your car leaks gasoline, we don’t resuscitate it with water
Even a dead patient’s vital signs are stable
Resuscitation from Hemorrhagic Shock
• Reversal of hypovolemia
• Control of hemorrhage
The most important clotting factor is the surgeon
Priorities in initial resuscitation of the trauma patient
• Secure the airway
• Control of hemorrhage ASAP :generally operative control
• Fluid resuscitation : restore volume status and sufficient red cells
• Endpoints in resuscitation :restore bloodpressure, adequate urine output
• The major cause of shock is decreased circulatory volume. Replace body fluids by the best means at hand. -Alfred Blalock, 1899-1964
Fluid resuscitation practice
• The rate of ARDS and MOFS are decreasing due to change in fluid resuscitation practice
One set of vital signs isn’t “hemodynamically stable”
Fluid Resuscitation Practice
• Permissive hypotension is :• not to infuse fluids when a casualty is awake
and alert, and • to infuse fluids to keep a casualty alive if they
get hypotensive.• The main goal is • not fluid resuscitation but hemorrhage control
In the emergency department
• No fluid resuscitation in majority only IV for medication
• Fluids (saline/RL or colloids) only if there is suspected bleeding and they are hypotensive. To keep alive until you get them to the operating room.
If you can feel a pulse don’t panic
In the operating room
• In majority no fluid resuscitation for patients without major blood loss, such as orthopedic injuries or hollow viscus injuries.Crystalloids to maintain adequate urine output.
• For bleeding patients crystalloids followed by Packed Red Blood Cells. After the 6th unit, FFP followed by platelets and cryoprecipitate.
Acute Coagulopathy of Trauma (ACoTS)
Hess et al. J Trauma 2008
Goals for Early Resuscitation
• Systolic BP 80-100 mmHg • Hematocrit 25-30%• PT, PTT, INR in normal range• Platelet count > 50,000• Normal ionized calcium• Prevent acidosis from worsening• Core temp > 36 C
Risks of Aggressive Volume Resuscitation
• ↑ hemorrhage + excessive hemodilution due to ↑ BP, ↓ blood viscosity, ↓ hematocrit, ↓ clotting factor concentration
Pathophysiology
Hypovolemic Shock: Most common Most of the blood is lost from systemic and small
veins (50%) ----> decrease cardiac return ----> low cardiac output ----> decrease blood pressure
Degree of Hemorrhagic Shock
Mild Hemorrhagic Shock: < 20% blood lost adrenergic constriction of blood vessels in the
skin thirsty, feels cold normal BP, PR and urine output
Degree of Hemorrhagic Shock
Moderate Hemorrhagic Shock: 20 – 40% blood loss
& low urine output Due to aldosteron and ADH
Compensatory Mechanism
1. Adrenergic discharge
2. Hyperventilation: with spontaneous deep breathing there is a
decreased intra-thoracic ----> increase ventricular end diastolic volume ----> increase cardiac output.
3. Collapse: Displaced blood from extremity to the heart
and the brain
Monitoring:
Management: resuscitate patient and control blood lost and
correct dehydration give balance salt solution (crystalloid) disadvantage of giving colloid resuscitation.
1. Increase intravascular volume at the expense of necessary interstitial fluid
2. Depression of albumin synthesis
3. Depression of circulating immunoglobulin
4. More expensive and less easier to titrate
Causes of Refractory Shock:
1. Continuing blood loss from primary injury or another source
2. Inadequate replacement of fluids
3. Massive trauma or other derangement
4. Myocardial infarction
5. Concomitant septic shock
Traumatic Shock
Traumatized tissue activates coagulation system forming:
1. Microthrombi: Occludes pulmonary vasculature ---> increase
pulmonary vascular resistance ----> increase right arterial pressure
2. Humoral products of microthrombi: cytoxines Increases vascular permeability ---> loss of
plasma
Degree of Hemorrhagic Shock
Severe Hemorrhagic Shock: 40% blood lost In addition to above s/sx pt has low BP and
rapid pulse rate signs of M.I. ---> Q waves and depressed
St-T segments
Beware
• More bloodloss if restoration of volume due to increased bloodpressure
Patients bleed whole blood-not components
SBP > 100 vs. SBP > 70 led to no difference in mortality
Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries
William H. Bickell, Matthew J. Wall, Paul E. Pepe, R. Russell Martin, Victoria F. Ginger, Mary K. Allen, and Kenneth L. Mattox
Volume 331:1105-1109
October 27, 1994
Number 17
The New England Journal of Medicine
Methods: We conducted a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a prehospital systolic blood pressure ≤ 90 mm Hg.
Results: Among the 289 patients who received delayed fluid resuscitation, 203 (70 percent) survived and were discharged from the hospital, as compared with 193 of the 309 patients (62 percent) who received immediate fluid resuscitation (P = 0.04).
Does ATLS work?
• Most patients do fine with just the crystalloid fluid
• Rates of renal failure and multiple organ failure are going down.
Breaking the “Bloody Vicious Cycle”
• Prevent hemodilution• Treat coagulopathy• Control hemorrhage• Use best possible
resuscitation products• Prevent hypothermia
Hemorrhage
Resuscitation
Hemodilution and Hypothermia
Coagulopathy
•THANK YOU
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