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