SHOCK ASSESSMENT AND MANAGEMENT IN TRAUMA PATIENTS

dr. Prabowo Wicaksono Y.P., SpAn KMN., M. Biomed

A. BASIC SHOCK ASSESSMENT AND MANAGEMENT IN TRAUMA

PATIENT

1. DEFINITION OF SHOCK

Kegagalan sirkulasi akut: perfusi organ dan oksigenasi jaringan tidak adekuat:

disfungsi end organ.

Pengelolaan syok pada pasien trauma:

FIRST STEP:

RECOGNITION OF ITS PRESENCE !!!

Gejala dan tanda perfusi organ dan oksigenasi tidak adekuat

SECOND STEP:

IDENTIFY PROBABLE CAUSE

Pada kasus trauma: MECHANISM OF INJURY

90% syok in trauma: Hipovolemik syok karena perdarahan (hemoragik syok)

2. PRINCIPLES OF OXYGEN DELIVERY

Syok: penurunan pengiriman darah teroksigenasi ke jaringan (hipoperfusi)

RUMUS 1. PENGIRIMAN OKSIGEN KE JARINGAN TIAP MENIT (DO2) =

Jumlah oksigen dalam darah x Curah Jantung (CO)

Jumlah oksigen dalam darah =

[(Kapasitas pengikatan oksigen Hb x Konsentrasi Hb x Saturasi oksigen arteri) + jumlah

oksigen terlarut)] =

[[1,39 x Hb x SaO2) + (0.003x PaO2)] x CO

RUMUS 2. PENGARUH CURAH JANTUNG PADA TEKANAN DARAH

MAP = CO X SVR (systemic vascular resistance)

Penurunan MAP dibawah nilai kritis : penurunan CO; penurunan DO2

prabowo wicaksono 4

RUMUS 3. CURAH JANTUNG

CO = SV X HR

SV: dipengaruhi oleh PRELOAD, AFTERLOAD dan KONTRAKTILITAS

PRELOAD: STRECTH

Derajat peregangan serat otot miokard pada akhir fase diastolik.

Ditentukan oleh volume darah vena kembali ke jantung

Sistem vena : reservoir: 70% total volume darah

KONTRAKTILITAS

Kontraktilitas meningkat, CO meningkat.

Hukum Frank Starling: kekuatan kontraksi tergantung pada panjang serabut

miokard saat teregang

AFTERLOAD: SQUEZEE

Jumlah tekanan yang harus dilampaui jantung kiri untuk memompa darah ke

sirkulasi. Ditentukan oleh tekanan darah arteri dan tonus vaskular

prabowo wicaksono 6

KONSEP DASAR RESUSITASI CAIRAN :

PRELOAD mempengaruhi SV

SV mempengaruhi CO

CO mempengaruhi DO2

Perubahan PRELOAD, SV, SVR, CO : gangguan perfusi organ dan jaringan:

Metabolisme aerob anaerob

Metabolisme anaerob : piruvat laktat

Laktat : marker hipoksia jaringan dan beratnya shock

Kadar laktat ≥ 2 mmol/L: dihubungkan dengan peningkatan mortalitas

3. CLINICAL DIFFERENTIATION OF SHOCK AETIOLOGY

Klasifikasi: hemoragik dan non hemoragik

1. HAEMORRHAGIC SHOCK

THE MOST COMMON CAUSE OF SHOCK AFTER INJURY

Hampir semua pasien dengan multipel trauma akan menderita derajat tertentu

hipovolemia

If sign of shock are present, treatment should usually be initiated as if the

patient is hypovolaemic.

Once treatment is initiative other aetiologies should be identified and treated

accordingly

2. NON-HAEMORRHAGIC SHOCK

• Cardiogenic shock

• Tension Penumothorax

• Neurogenic shock

• Septic shock

prabowo wicaksono 11

4. PATOPHYSIOLOGY OF BLOOD LOSS

• Respon awal: kompensasi : vasokonstriksi progresif kulit, otot dan visceral

• Tujuan: alihkan aliran darah ke ginjal, jantung, otak

• Berkurangnya volume sirkulasi akut + cedera: TAKIKARDI

Tachycardia is usually the EARLIEST measurable circulatory sign of shock

• Mekanisme kompensasi: terbatas

• Cara paling efektif: volume repletion with isotonic electrolyte solutions in sufficient

quantities

• Initial management goal:

PROVIDING ADEQUATE OXYGENATION,

VENTILATION AND APPROPIATE

FLUID RESUSCITATION

5. INITIAL ASSESSMENT OF SHOCKED PATIENT

RECOGNITION OF SHOCKED

Pastikan airway dan breathing clear

Penilaian sirkulasi: identifikasi awal manifestasi syok: takikardi dan vasokonstriksi kulit

SYSTOLIC BLOOD PRESSURE SHOULD NOT BE USED AS SOLE INDICATOR OF SHOCK

DANGER OF DELAYED SHOCK RECOGNITION

Mekanisme kompensasi: TDS bisa normal sampai perdarahan 30% estimated blood

volume (EBV)

PERHATIKAN GEJALA DAN TANDA DINI SYOK:

• TAKIKARDI

• VASOKONSTRIKSI KULIT (LEMBAB, DINGIN, PUCAT)

• LAJU NAFAS MENINGKAT

• TEKANAN NADI (PULSE PRESSURE/ TDS-TDD) MENYEMPIT

ANY PATIENT WHO IS COOL AND TACHYCARDIC IS IN SHOCK UNTIL PROVEN

OHTERWISE

Tachycardia by age:

Infants >160

Preschool >140

School to puberty >120

Adult >100

BEWARE IN ELDERLY PATIENT !!

Bisa tidak terjadi takikardi:

• respon jantung terhadap katekolamin menurun

• obat beta blocker

• pace maker

6. INITIAL MANAGEMENT OF HAEMORRHAGIC SHOCK

Diagnosis dan pengelolaan harus dilakukan simultan:

THE BASIC PRINCIPLE IS STOP THE BLEEDING AND REPLACE THE VOLUME LOSS

A. PHYSICAL EXAMINATION

Immediately diagnosing life-threatening injuries

Airway and breathing: Priority

Circulation:

• haemorrhage control : direct pressure to bleeding site

• assessment of perfusion

• may require operative intervention to control internal bleeding

• Disability: neurologic exam: GCS, pupil: light reflect, pupil size

• Exposure: complete exam, prevent hypothermia

• Gastric dilation: decompression with NG tube

• Urinary catheter insertion: renal function and haematuria

B. VASCULAR ACCESS LINES

• Must be gained promptly

• With two 16 G (minimum) peripheral IV cannulae (short large cannulae)

• Withdrawn blood: for type, cross match, full blood count

prabowo wicaksono 21

C. INITIAL FLUID THERAPY

• Isotonic crystalloid solutions for initial resuscitation

• Initial fluid bolus is given as rapidly as possible

• Dose: 1-2 L (adult), 20 ml/kg (paediatric)

• “3 for 1 rule” : 3L of crystalloid fluid needed to replace each litre of blood lost

• Warming fluids –Plasma and Crystaloid

• Almost all trauma patient suffered from some degree of hypothermia

• Warming crystalloid fluid to 39 C

• Evaluate patient respons:

Evidence of adequate end organ perfusion and oxygenation:

• Urine output: adequate renal perfusion

• 0.5 ml/kg/hour (adult)

• 1 ml/kg/hour (paediatric)

• Level of consciousness

• Pulse rate

• Pulse pressure

• Blood pressure

Patient’s response to initial fluid therapy is the key to determining subsequent

therapy

7. BLOOD REPLACEMENT

A. PRC VS WB

• Either may be used in trauma patient

• Component therapy is usually used; maximise blood product available

• Purpose: to restore the O2 carrying capacity on the intravascular volume

• Crystalloid can be used for volume replacement itself

B. Crossmatched, Type-specific and Type O Blood

• Full crossmatched:

• Preferable.

• Availability: 1 hour

• For patient who stabilise rapidly (fast responder)

C. Type specific blood:

• Availability: 10 minutes,

• ABO and RH compatible

• For patient with transient response

D. O-neg blood

• Uses in exsanguinating haemorrhage

• Can not wait for type specific blood

• In multiple casualties; no risk of accidental wrong patient administration

B. RECENT DEVELOPMENT IN RESUSCITATIVE STRATEGIES FOR TRAUMATIC

HEMORRHAGIC SHOCK

• Perdarahan : masih merupakan penyebab utama kematian pada trauma

• Selama perdarahan belum dapat dikontrol, tujuan pengelolaan adalah:

Pertahankan oxygen delivery untuk membatasi hipoksia jaringan, inflamasi dan

disfungsi organ

1. CYRSTALLOIDS VS COLLOIDS

Berdasar EBM (Evidance Based Medicine):

Belum terbukti jenis cairan yang superior pada trauma

KOLOID:

Ekspansi plasma cepat dan persisten: peningkatan tekanan onkotik lebih cepat

Tujuan sirkulasi tercapai lebih cepat

KRISTALOID:

Lebih murah.

Resusitasi kristaloid jumlah besar: udem jaringan, asidosis hiperkloremik

Penelitian: meta analisis atau systematic review ??

Tidak terdapat bukti dari RCT’s bahwa resusitasi dengan koloid mengurangi resiko

kematian dibandingkan kristaloid

In light of shared pathophysiological pathway with inflammation activation between

sepsis and trauma, the use of HES raises serious concerns with respect to its safety in

trauma patient.

prabowo wicaksono 29

Crystalloids should be applied initially to treat the bleeding trauma patient and that

the addition of coloids should be considered in hemodynamically unstable patients

Use of the new HES: should be used within the prescribed limits because of the risk of

acute kidney injury and alteration of coagulation.

prabowo wicaksono 30

2. VASOPRESSOR AGENTS

• Resusitasi cairan: strategi pertama untuk pulihkan MAP pada syok hemoragik

• Agen vasopressor: USE WITH CAUTION !!!

• Dibutuhkan SEMENTARA untuk pertahankan tekanan arterial dan perfusi jaringan;

• Apabila terdapat hipotensi persisten, meski resusitasi cairan sedang berjalan dan

hipovolemi belum terkoreksi.

• MAP adalah penentu utama perfusi jaringan

prabowo wicaksono 31

• DOC: Norepinefrin (NE)

• Simpatomimetik, dominan vasokonstriktif.

• α-adrenergik stimulation: arterial and vena (splanchnic); alihkan volume darah vena

ke sirkulasi sistemik.

• β-adrenergik stimulation: menurunakan resistensi vena, meningkatkan venous

return.

• Rekomendasi target SBP (systolic blood pressure) : 80-90 mmHg

• Resusitasi cairan tetap dilanjutkan

prabowo wicaksono 32

3. HOW MUCH FLUID AND MAP TARGET

Mean arterial pressure (MAP): tekanan perfusi ke semua organ

MAP: target resusitasi cairan dini

Resusitasi cairan terlalu agresif: BAHAYA MENINGKATKAN PERDARAHAN

Penyebab:

• Koagulopati: dilusi faktor koagulasi dan sebabkan hipotermia

• MAP terlalu tinggi: cegah pembentukan clot

Konsep “ resusitasi hipotensif” atau “ resusitasi volume rendah”

prabowo wicaksono 33

• Resusitasi volume minimal lebih terpilih dibanding resusitasi cairan agresif sebelum

perdarahan aktif dapat dikontrol.

• Cegah hemodilusi dengan pembatasan cairan resusitasi dan tranfusi darah

• Hanya transfusi darah dapat memperbaiki oksigenasi jaringan

CONSIDER BLOOD TRANFUSION EARLY DURING THE MANAGEMENT OF

HEMORRHAGIC SHOCK TO IMPROVE MICROVASCULAR OXYGEN DELIVERY

prabowo wicaksono 34

Target SBP: 80-100 mmHg until major bleeding has stopped in the initial phase after

trauma for patients without brain injury.

For traumatic hemorrhagic shock associated with severe brian injury, cerebral

perfussion pressure must be maintained by increasing arterial pressure to prevent

secondary brain injury

prabowo wicaksono 35

prabowo wicaksono 36

4. TRANSFUSION AND PREVENTION OF ACUTE COAGULOPATHY OF TRAUMA (ACoT)

• Pencegahan koagulopati akut pada trauma telah menjadi tujuan utama pengelolaan

resusitasi awal syok hemoragik

• Pada traumatik hemoragik syok: 10-34 % alami koagulopati

• Penyebab : multifaktorial

prabowo wicaksono 37

prabowo wicaksono 38

• Hindari penundaan transfusi darah dan komponen darah

• Tranfusi dini packed red cell (PRC) dan fresh frozen plasma (FFP):

• Prioritas untuk pertahankan arterial oxygen delivery dan pulihkan koagulasi efektif

• The administration of PRC is considered indispensible when HB level is < 7 g/dl:

Recommendation from study by Transfusion Requirements in Critical Care (TRICC)

• Pada pasien cedera kepala: Hb minimal 10 gr % : improved local cerebral oxygenation.

• Transfusi FFP 10-15 ml/kg harus diberikan segera untuk kompensasi defisit faktor

koagulasi pada tranfusi dengan PRC.

• Idealnya FFP diberikan bersama PRC.

• FFP direkomendasikan pada PT atau APTT 1,5 kali normal.

prabowo wicaksono 39

C. SUMMARY

• Shock is acute circulatory failure leading to decrease organ perfusion

Management:

• First step: RECOGNITION OF ITS PRESENCE

• Second step: IDENTIFY THE PROBABLE CAUSE

• Tachycardia is usually the earliest measurable circulatory sign of shock

• Haemorrhagic shock: most common cause of shock in trauma

• Management of haemorrhagic shock: A – B – C – D – E

• C: STOP THE BLEEDING AND REPLACE VOLUME LOSS

• Crystalloids: First choice

• Colloids: consider in hemodynamically unstable patients: Gelatin, HES ( Caution: use

within prescribed limit)

prabowo wicaksono 41

• Vasopressor: use with CAUTION to transiently sustain MAP during persisten

hypotension, despite fluid resuscitation

• DOC: Norepinephrine

• Avoid excessive fluid resuscitation: danger of coagulopahty, hypothermia.

• Target SBP: 80-100 mmHg

• With Traumatic Brain Injury (TBI), GCS ≤ 8: Target SBP ≥ 120 mmHg

• Early tranfusion with PRC and FFP is a priority to maintain arterial oxgen delivery

and restore effective coagulation

prabowo wicaksono 42

1. Richards JB, Wilcox SR, Garvin R. Diagnosis and management of shock in the emergency departmen. Emergency Medicine Practice. 2014; 16 (3): 1-24

2. Bougie A, Harrois A, Duranteau J. Resuscitative strategies in traumatic hemorrhagic shock. Annals of Intensive Care. 2013; 3 (1): 1-9

3. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Mondejar EF, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Stahel PF, Vincent JL, Spahn DR. Management of bleeding following major trauma: an updated European guideline. Critical Care. 2010; 14: R52.

4. Hartog CS, Kohl M, Reinhart K. A systematic review of third-generation hydroxyethyl starch (HES 130/0.4) in resuscitation: safety not adequately addressed. Anesth Analg. 2011; 112 (3): 635-45.

5. Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2103; 28 (2).

6. Vincent JL. Understanding cardiac output. Critical Care. 2008; 12 (4): 1-3.7. Committee on Trauma American College of Surgeons. Shock. In: Committee on

Trauma American College of Surgeons. Advanced Trauma Life Support (ATLS) Student Course Manual. 9th edition. Chicago: American College of Surgeons; 2012.

prabowo wicaksono 43