Haemorrhagic Shock and mx

7/23/2019 Haemorrhagic Shock and mx

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APPROACH TO THEPATIENT IN SHOCK ANDIT’S MANAGEMENT

(HAEMORRHAGE)

FOO HONG ZHI



Defnition

Shock is circulatory insufciency thatcreates an imbaance bet!een tissueoxygen supply "#ei$er%& an# oxygendemand "cons'm(tion&)



Defnition "cont)&

Car#iacInotro(%* s(ee# an# shortenin+ ca(acit%o, m%ocar#i'm-

Chronotro(%* heart contraction rate- an#.'sitro(%* abiit% to rea/ an# f heartchambers



Ho! is o'r bo#% res(onse toshock0

Shock acti$ates autonomic responses- man%o, !hich ser$e to maintain (er,'sion (ress're to$ita or+ans) Stim'ation o, the caroti#

barorece(tor stretch re1e/ acti$ates thes%m(athetic ner$o's s%stem ea#in+ to*



Ho! is o'r bo#% res(onse to shock0 "cont)&

2) Arterioar $asoconstriction- res'tin+ inre#istrib'tion o, boo# 1o! ,rom the skin-skeeta m'sce- ki#ne%s- an# s(anchnic $iscera3

4) An increase in heart rate an# contractiit% thatincreases CO3

5) Constriction o, $eno's ca(acitance $esses-!hich a'+ments $eno's ret'rn3

6) Reease o, the $asoacti$e hormonese(ine(hrine- nore(ine(hrine- #o(amine- an#

cortiso to increase arterioar an# $eno's tone3an#

7) Reease o, ADH an# acti$ation o, the renin8an+iotensin a/is to enhance !ater an# so#i'm

conser$ation to maintain intra$asc'ar $o'me)



Ho! is o'r bo#% res(onse to shock0 "cont)&

The ce'ar res(onse to shock initiates acasca#e o, (athoo+ic e$ents that res't in

hemoconcentration-

h%(erkaemia-

h%(onatremia-

Prerena a9otemia-

h%(er8 or h%(o+%cemia-

actic aci#osis)



Cassifcation o, shock

H%(o$oaemicCar#io+enic

Obstr'cti$e

Distrib'ti$eEn#ocrine



Cassifcation o, shock "cont)&

HypovolaemicA re#'ce# cic'atin+ $o'meHaemorha+ic or non haemorha+ic "#eh%#ration-e/cessi$e 1'i# oss in #iarrho(ea or $omitin+- 'rinar%oss in #iabetes- e$a(oration an# thir# s(ace&

Car#io+enicPrimar% ,ai're o, the heart to ('m( boo# to thetiss'eMI- #%srh%tmias- $a$'ar heart #isease- b'ntm%ocar#ia in:'r%- an# car#iom%o(ath%

Obstr'cti$eRe#'ction in (reoa# beca'se o, obstr'ction o,car#iac fin+Car#iac tam(ona#e- tension (ne'mothora/-

massi$e ('monar% emboism- air emboism)



Cassifcation o, shock "cont)&

Distrib'ti$e

The (attern o, car#io$asc'ar res(onsescharacteri9in+ a $ariet% o, con#ition inc'#in+*se(tic shock- ana(h%a/is- s(ina cor# in:'r%)

Ina#e;'ate or+an (er,'sion is accom(anie# b%$asc'ar #iatation !ith h%(otension- o! s%stemic$asc'ar resistance- ina#e;'ate a,teroa# an# ares'tin+ abnorma% hi+h car#iac o't('t)

En#ocrine

Combination o, h%(o$oaemiccar#io+enic an##istrib'ti$e shock)

H%(o<h%(erth%roi#ism- a#rena ins'=cienc%



Car#io$asc'ar an# metaboiccharacteristics o, shock

Hypovalaemia

Cardiogenic

Obstructive

Distributive

CO .o! .o! .o! Hi+h

>asc'ar

resistance

Hi+h Hi+h Hi+h .o!

>eno's(ress're

.o! Hi+h Hi+h .o!

Mi/e# $eno'ssat'ration

.o! .o! .o! Hi+h

?ase #efcit Hi+h Hi+h Hi+h Hi+h



Conse;'ences o, Shock

1. Unresuscitatable shock Pro,o'n# shock ,or a (roon+e# (erio# o, time)Ce #eath ,rom ce'ar ischaemia- an# the abiit%

o, the bo#% to com(ensate is ost)M%ocar#ia #e(ression- not res(onse to 1'i# or

inotro(ic thera(%- (eri(hera% oss abiit% tomaintain s%stemic $asc'ar resistance) Death isine$itabe)

2. ulti!organ "ailure2 or more ,aie# or+an s%stems) S'((orti$e care).'n+s* ARDSKi#ne%* AKI.i$er* Ac'te i$er ins'=cienc%Coa+'o(ath%Car#iac ,ai're



Haemorrha+e

#o recognise$ to manage a++ressi$e%to re#'ce the se$erit% an# #'ration o,shock an# a$oi# #eath an#<or m'ti(eor+an ,ai're)

Haemorrha+e is treate# b% arrestingthe bleeding- an# not b% 1'i#res'scitation or boo# trans,'sion)



Patho(h%sioo+%



Defnitions%evealed haemorrhage* ob$io's e/terna haemorrha+e)

E+ e/an+'ination ,rom an o(en arteria !o'n# or massi$ehaematemesis ,rom #'#ena 'cer)

Concealed haemorrhage is containe# !ithin the bo#%ca$it% an# m'st be s's(ecte#- acti$e% in$esti+ate# an#controe#)

&rimary haemorrha+e* imme#iate% as a res't o, an in:'r%)

%eactionary haemorrha+e* #ea%e# haemorrha+e "!ithin46 ho'rs& an# is 's'a% ca'se# b% #iso#+ement o, cot b%res'scitation- normai9ation o, ?P an# $aso#iatation)

'econdary haemorrha+e* is ca'se# b% so'+hin+ o, the!a o, a $esse- occ'rs @826 #a%s a,ter in:'r% an# is(reci(itate# b% ,actors s'ch as in,ection- (ress're necrosis"#rain& or mai+nanc%)

'urgical haemorrhage is the res't o, a #irect in:'r% an#is amenabe to s'r+ica contro)

(on!surgical haemorrhage is the +enera oo9e ,rom ara! s'r,aces #'e to coa+'o(ath%- it cannot be sto((e# b%

s'r+ica means "e/ce(t (ackin+& b't re;'ires correction o,coa+'ation abnormaities)



Cassifcation o, Haemorrha+ic shockC)*'' + C)*'' ++ C)*'' +++ C)*'' +,

?oo# oss

- m.

B27-

B@7

2785-

@7827

586-

2784

6-

4

?P 'nchan+e# Norma-raise#

%educed >er% o! orrecor#abe

HR< PR norma #achycardia

1--!12-

tach%car#ia

24

tach%car#ia24

CRT norma so! so! 'n#etecte#

RR norma norma tach%(noeic

tach%(noeic

rineo't('tM<ho'r

5 485 284 82

E/tremitie norma (ae (ae Pae an# co#



Mana+ement

AIRFA- s(ine stabii9ation an# ?REATHING*HM- i, s(ontaneo's $entiation nota#e;'ate- int'bation an# $entiation isnee#e#)

CIRC.ATION an# sec're bee#in+*4 I> access "orJ& to c'bita ,ossa or ,emora

$eins

?P- HR- CRT- menta stat's- 'rine o't('t

I#entife# haemorrha+e

Haemorrha+e contro* Dama+e contro s'r+er%

DISA?I.IT* GCS- ('(is

EPOSRE an# co$er



Mana+ement "cont)&

Histor% takin+Aer+ies

Me#ications

Past me#ica histor%.ast mea

E$ents s'rro'n#in+ in:'r%



Permissi$e H%(otension

L Aso kno!n as hypotensive resuscitationis the 'se o, restricti$e 1'i# thera(%s(ecifca% in the tra'ma (atient- thatincreases S?P !itho't reachin+

normotension)L To achie$e '& /-!0-mmHg "s'=cient to

maintain critica or+an (er,'sion& in non8T?I)

L Res'scitatin+ JmmH+ r'ns the risk o,cot #iso#+ement an# $icio's circe,ormation)

L Transient res(on#er or non8res(on#er



'i# res'scitation

L There is no #ierence in s'r$i$a com(arin+ cr%staoi#

!ith cooi# res'scitation)L Cr%staoi# so'tions remain recommen#e# beca'se o,

the increase# cost o, cooi# a+ents)L Isotonic cr%staoi# so'tions- norma saine "NS&- or

actate# Rin+er’s ".R& so'tion are the (re,erre#

res'scitation 1'i#s)L Cr%staoi# so'tions are h%(o8oncotic) .o! oncotic

(ress're res'ts in s'bstantia shi,ts o, cr%staoi# to thee/tra$asc'ar s(ace corres(on#in+ to the reati$e si9e o,the intra$asc'ar an# interstitia 1'i# com(artments)

L 1 ratio "or isotonic crystalloid volumereplacementL "or every amount o" blood lost$ three times that

amount o" isotonic crystalloid is re3uired to storeintravascular volume because$ at best$ about -4o" the in"used 5uid stays intravascular



?oo# trans,'sion

In#ications*LAc'te boo# oss- to re(ace circ'atin+$o'me an# maintain o4 #eman#)

LPerio(erati$e anaemia- to ens'rea#e;'ate o4 #ei$er% #'rin+ (erio(erati$e(hase)

LS%m(tomatic chronic anaemia !itho'thaemorrha+e or im(en#in+ s'r+er%)

LO ne+ati$e- sa,e O



Scenario 2

L A 67 %ear o# +enteman com(aint*Im (assin+ back stoo !ith boo# an#i+hthea#e#ness ,or 5 #a%s)

A((roach in emer+enc% settin+)



Scenario 2 "cont)&

L O<E* aert- orientate#- o$er!ei+ht mae-

an/io's an# restessL ?P 24<- HR 22<min- RR 4- T 5@

L acia (aor- coo moist skin- :a'n#ice-

fn+er c'bbin+- coate# ton+'e

L .'n+s cear- C>S s%stoic m'rm'r ataortic area

L Ab#omen #isten#e# !ith #iate# $ein-#i=c't to eicit he(atos(enome+a%-1'i# tris (ositi$e) H%(eracti$e bo!e)

L PR* maaenae !ith ,resh boo#)



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Haemorrhagic Shock and mx