TRAUMATIC SHOCK Do Ngoc Son MD., PhD. Emergency Department Bach Mai Hospital, Hanoi 1

TRAUMATIC SHOCKTRAUMATIC SHOCKDo Ngoc Son MD., PhD. Emergency DepartmentBach Mai Hospital, HanoiDo Ngoc Son MD., PhD. Emergency DepartmentBach Mai Hospital, Hanoi

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ObjectivesObjectives

• Definition of traumatic shock

• Recognition of shock stages and severity

• Management of shock according to stages and severity

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DEFINITION AND PATHOPHISIOLOGY OF

SHOCK

DEFINITION AND PATHOPHISIOLOGY OF

SHOCK 3

DEFINITION OF SHOCKDEFINITION OF SHOCK

• Inadequate organ perfusion and tissue oxygenation.

• Circulatory system failed to meet the metabolic demand of the body

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HUMAN CIRCULATORY SYSTEMHUMAN CIRCULATORY SYSTEM

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ARTERIAL BLOOD PRESSURE

ARTERIAL BLOOD PRESSURE

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Blood pressure

Cardiac output

Stroke volume

Preload

Systemic vascular resistance

Heart rate

Cardiac contractility

Afterload

BOOD PRESSURE REGULATION(ROLE OF NEURO-ENDOCRINE SYSTEM)

BOOD PRESSURE REGULATION(ROLE OF NEURO-ENDOCRINE SYSTEM)

• Pressure receptors located at the aortic arch and carotids

• Sympathoadrenal axis regulate the release of catecholamine

• Renin-angiotensin-aldosteron system blood vessel tone and urine secretion

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VOLUME STATUSVOLUME STATUS

67%

8%

25%

ECF

ICF

Intravascularvolume

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BLOOD VOLUME

PHYSIOLOGICAL RESPONSES DURING SHOCK


• In normal condition, the body can compensate for the reduction of tissue perfusion

• When the compensated capabilities are

overloaded SHOCK irreversible shock if undetected and untreated

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• Systemic vascular constriction• Increased blood flow primarily to important

organs (brain, heart) • Increased cardiac output• Increased respiratory rate and tidal volume• Decreased urine output• Decreased gastroenterological activity

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COMPENSATED SHOCKCOMPENSATED SHOCK

• Defense mechanism try to maintain the blood perfusion to main organs by:

– Constrict the pre-capillary sphincter, blood bypasses capillary through shunt

– Increased heart rate and cardiac muscle contractility

– Increased respiratory activity, bronchial dilation

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COMPENSATED SHOCKCOMPENSATED SHOCK

• Progresses until causes of shock are treated or continues to next stage

• Difficult to diagnose due to obscure symptoms

– Tachycardia

– Signs of reduced skin perfusion

– Altered mental status• Some medication (B- blockers) could

undermine the symptoms by preventing the tachycardia.

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UNCOMPENSATED SHOCK

UNCOMPENSATED SHOCK

• Physiological responses– Pre-capillary sphincter opens

– Hypotension

– Reduced cardiac output

– Blood accumulate in capillary bed

– Aggregation of the erythrocytes

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UNCOMPENSATED SHOCKUNCOMPENSATED SHOCK

• Easier to diagnose than compensated shock:– Longer capillary refill time

– Marked increased heart rate

– Increased and thready pulses

– Agitated, disorientated and confused

– Hypotension

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IRIVERSIBLE SHOCKIRIVERSIBLE SHOCK

• Failed compensated mechanism

• Sometimes difficult to distinguish• Resuscitatable but high mortality (ARDS,

ARF, hepatic failure, sepsis)• Prolonged organ ischemia, cellular death,

MODS: brain, lung, heart and kidney• Coagulation disorders (DIC)

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Cellular O2 deficiency

Anaerobicmetabolism

Cellular energy

starvation

Metabolic disorders

A. Lacticproduction

Metabolicacidosis

CELLDEATH

CELULAR O2 DIFFICENCY

INITIAL ASSESSMENT AND MANGAGEMENT OF SHOCKINITIAL ASSESSMENT AND

MANGAGEMENT OF SHOCK

• Initial clinical manifestation may be poor• Identification of the causes is not so as

important as prompt treatment for shock• Aim of treatment is recover the circulatory

volume and shock management• It is important to exam shock patient regularly

to assess their response

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ETIOLOGIESETIOLOGIES

• Blood lost

• Trauma

• Fracture of long bone or opened fracture

• Plasma lost due to burn

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ETIOLOGIESETIOLOGIES

• Fluid lost to third compartment

• Causes:– Peritonitis

– Burn

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INTERNAL HEMORRHAGE INTERNAL HEMORRHAGE

• Hematemesis, black or bloody stools

• Hemoptysis

• Pleural effusion of blood (Hemothorax)

• Peritoneal effusion of blood (Hemoperitoneum)

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STAGES OF HEMORRHAGIC SHOCK

STAGES OF HEMORRHAGIC SHOCKSTAGES OF HEMORRHAGIC SHOCK

• Stage 1: blood lost < 15% total blood volume

• Stage 2: 15-30% total blood volume

• Stage 3: 30-40% total blood volume

• Stage 4: > 40% total blood volume

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Blood lost

(ml)

% blood

volume

Clinical signs

SBP DBP Resp

Rate

Heart

Rate

Urine volume

(ml) Treatment

1 <750 0-15 Slightly anxious

Normal

Normal

14-20 <100 >30 Crystalloid solution

2 750-1500

15-30 Mildly anxious

Normal

20-30 >100 20-30 Crystalloid solution or blood products

3 1500-2000

30-40 Anxious, confused

30-40 >120 5-15 Colloid and blood

4 >2000 >40 Confused Lethargic

>40 >140 None Colloid and surgery

STAGES OF HEMORRHAGIC SHOCKSTAGES OF HEMORRHAGIC SHOCK

STAGE 1STAGE 1

• Blood lost < 750 mL• Total blood volume (%): 0-15%• Central nervous manifestation: slightly anxious• Systolic BP: normal• Diastolic BP: normal• Respiratory rate: 14 - 20 BPM• Pulse < 100• Urine output: > 30 ml/h• Treatment : Crystalloid infusion (ratio 3/1)

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STAGE 2STAGE 2

• Blood lost : 750 – 1500 mL• Total blood volume (% ): 15 – 30%• Central nervous manifestation: mild anxious • Systolic BP: normal• Diastolic BP: increased• Respiratory rate: 20 - 30 BPM• Pulse > 100• Urine output: 20 - 30 ml/h• Treatment: Crystalloid or blood transfusion

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STAGE 3STAGE 3

• Blood lost: 1500 - 2000 mL• Total blood volume (%): 30 – 40%• Central nervous manifestation: Anxious and

confused• Systolic BP: decreased• Diastolic BP: decreased• Respiratory rate: 30 – 40 BPM• Pulse > 120• Urine output: 5 - 15 ml/h• Treatment: Crystalloid or blood transfusion31

STAGE 4STAGE 4

• Blood lost > 2000 mL• Total blood volume (%) > 40%• Central nervous manifestation: Confused

Lethargic• Systolic BP: decreased• Diastolic BP: decreased• Respiratory rate > 40 BPM• Pulse > 140• Urine output: Negligible• Treatment: colloid, blood and surgery

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PITFALLSPITFALLS

• Not all traumatic shock patients go through all 4 stages

• In healthy young adults, the heart rate may be normal even patients are on stage 2 or 3

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DIAGNOSISDIAGNOSIS34

SEQUENCES OF EXAMINATIONSEQUENCES OF EXAMINATION

Order of ABC• A = Airway• B = Breathing:

+ O2 supply

+ Assisted ventilation

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SEQUENCES OF EXAMINATIONSEQUENCES OF EXAMINATION

Order of ABC• C = Circulation:

+ Hemostasis by local bandage

+ Blood volume replacement by fluid infusion

+ Identification of obstructive shock: - Tension pneumothorax: prompt thoracocentesis

- Cardiac tamponade: prompt Pericardiocentesis

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Symptoms and diagnosisSymptoms and diagnosis

• Hemorrhagic shock:• Manifestations:

– Obvious blood lost: Hematemesis, black or bloody stools.

– Tachycardia, hypotension, low CVP.

– Thirsty, dizziness, vertigo, agitation, LOC.

– Pale, cold, sweating, cyanosis.

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• Hemorrhagic shock:• Respiratory disorders: tachypnea, cyanosis• Oliguria, anuria• Monitor, assessment of the severity of blood

lost:– Orthostatic hypotension: BP > 20 mmHg, pulse >

20 BPM: 10-20% blood lost

– Supine hypotension: >20% blood lost

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• Non-hemorrhagic shock (Hypovolemia):• Causes: dehydration or electrolyte

disturbance• Manifestation: mainly symptoms of

dehydration and electrolyte disturbance– ECF dehydration

– ICF dehydration

– Others: oliguria, cold

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Consequences of shockConsequences of shock

Consequences of shock:• Kidney: acute renal failure • Lungs: ARDS• Heart: hypoxic heart failure, metabolic

acidosis, cardiac muscle stress• GE: gastric ulcers or bleeding• Liver: failure• Pancreas: edema, necrosis• Endocrinological glands: pituitary gland is

most vulnerable in bleeding necrosis (Sheehan syndrome)

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MANAGEMENTMANAGEMENT41

Emergency treatmentEmergency treatment

Emergency treatment• Position: head down, open the airway• Breathing: O2 4-8 LPM. Ambu bag or

endotracheal intubation for ARF• Monitoring for heart rate, blood pressure,

SpO2, EKG• Basic labs: CBC, hematocrit, platelets, blood

group, fibrinogen, prothrombin.

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• Large venous access:• 500-1000ml Ringer lactate (NaCl 0.9%)/15-20

min. Continue infusion until BP increase and heart rate slow down infusion rate

• Fluid infusion helps to replace the blood lost until blood arrival

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• Large venous access: Blood transfusion should be started after 3

liters of fluid infusion

If blood is not available, fluid infusion should be continued

It should be remembered that fluid is not able to carry O2

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• Blood transfusion: for hemorrhagic shock• Packed red blood cells: targeted Ht 25 - 30%• Fresh plasma or packed platelet if platelet

<50.000/mm3 or Prothrombin < 50%– Many trauma centers now resuscitate patients with a

1:1:1 strategy. For every unit of red blood cells, a unit of platelets and a unit of fresh plasma is given:

• 1 unit blood cell : 1 unit plasma : 1 unit platelets

• Consider auto transfusion

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• Urinary catheter placement

• If fluid infusion and blood transfusion is adequate, CVP >7 but still hypotension: – Dopamine: 5- 20 g/kg/min

– If failed: add Dobutamine

– If failed: add Norepinephrine

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• Ventilatory support if respiratory failure is detected

• Identify and treat the causes

• Trauma operate

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FLUID MANAGEMENTFLUID MANAGEMENT

• Large venous access> 18 F if possible

• 2 lines in case of stage 3-4 of shock

• Vasopressors are not indicated if circulatory volume is not adequate

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FLUID MANAGEMENTFLUID MANAGEMENT

• Start with large bore venous access: + Can use compressor bag + Ringers lactate is common - Choose NS 0.9% if suspected hyperkalemia - NS 0.9% can be used for the line of blood

transfusion.

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POSITION OF INFUSIONPOSITION OF INFUSION

• Upper extremity peripheral vein: preferred precaution in case of upper extremity

fracture

• Central veins: sub-clavian and internal jugular vein: best choice even at stage 4 risk of pneumothorax (chest X ray is needed after procedure)

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POSITION OF INFUSIONPOSITION OF INFUSION

• Femoral vein: easy and safePrecaution in case of abdominal trauma due to

coincidental hemoperitoneum

• Intraosseous infusion: easiest; especially in children; may also use in adult

• Peritoneal infusion

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CENTRAL VENOUS PRESSURECENTRAL VENOUS PRESSURE

• CVP assesses the preload of right ventricle• CVP Catheters are not necessity in most

trauma patients• CVP is more useful in trauma patients who

have: + Predisposed heart failure + Intra ventricle pacemaker + Neurogenic shock + Myocardial contusion + Suspected tamponade

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CVP IN TRAUMATIC PATIENTSCVP IN TRAUMATIC PATIENTS

• Low CVP (< 6 mmHg) hypovolemia - continue infusion or blood transfusion• High CVP (> 15 mmHg):

+ Cardiac overload (over blood transfusion) + Right heart failure (AMI) + Cardiac tamponade + Lung disease + Tension pneumothorax + Dislocation of catheter + Hypocalcemia

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CVP IN TRAUMATIC PATIENTSCVP IN TRAUMATIC PATIENTS

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Initial CVP Change in CVP

Causes Solution

Low No Consistent with blood loss

Increase infusion rate

Low Increase Good resuscitation Slow down infusion rate

Low or moderate

Decrease Continued blood loss Continue rapid infusion

High No overload or predisposed condition

Slow down infusion rate

CONTROVERSAL ISSUESCONTROVERSAL ISSUES

• Fluid type?

• When?

• Rate?

• Targets of hemorrhagic shock?

• Opened of blunt trauma?

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FLUID TYPE?FLUID TYPE?

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COLLOIDSCOLLOIDS

• Albumin, hydroxyethylstarch, pentastarch, gelatin, dextran

• Advantages: smaller volume, more intravascular volume, stronger fluid shift from extravascular to intravascular spaces

• Disadvantages: expensive, allergic reaction and coagulation disorders

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COLLOIDSCOLLOIDS

• Cochrane. BMJ 1998: 317:235-40.– Objectives: effect of albumin on mortality rate

– Study: multiple analysis of 30 trials (total number of patients: 1419)

– Conclusion: albumin increased mortality rate in trauma patients

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COLLOIDSCOLLOIDS

• Cochrane 2003. – Objectives: compare the effectiveness between

crystalloid and colloids

– Study: albumin (18 trials); HES (7 trials); Gelatin (4 trials); Dextran (8 trials)

– Conclusion: no difference in mortality on trauma, burn and surgery patients

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HYPERTONIC SALINEHYPERTONIC SALINE

• Advantages: less volume, longer intravascular half life, stronger water shift

• Disadvantages: hypernatremia, hyperosmolarity, convulsion, coagulation disorders

• Fluid types– Hypertonic salt (7.5% NaCl) +/- 6% dextran– Bolus 250 cc (~ 4ml/kg) in 5-10 min

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HYPERTONIC SALINEHYPERTONIC SALINE

• Cochrane 2003 – Objectives: evaluate the effect of hypertonic salt on

mortality rate

– Study: 25 trials

– Conclusion: tendency of reduced mortality rate on hypertonic salt group

• ROC Trial– Very large USA multicenter trial

– No benefit of hypertonic saline (and perhaps harm)

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CONTROLLED INFUSIONCONTROLLED INFUSION

• Also called permissive hypotension• Increase of BP before successful hemostasis

may be harmful• Reasons:

– Increased hydrostatic pressure– Dislodge the clot– Dilute the coagulation factors

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CONTROLLED INFUSIONCONTROLLED INFUSION

• Excess and early infusion in blunt trauma increased the mortality

• Controlled infusion seem to be better (targeted systolic BP 70 – 90)

• Delayed infusion (until successful hemostasis) may be better

• More research required on blunt trauma

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OTHER MANAGEMENTOTHER MANAGEMENT

• Blood transfusion:

+ Blood group O (-): immediately available

+ Type and screen (if needed within < 15min)

+ Type and complete cross-matched: 45-60 min• Emergency thoracostomy, Pericardiocentesis,

aortic cross-clamping• Auto transfusion: blood from chest tubes

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INDICATION FOR EMERGENCY BLOOD TRANSFUSION GROUP O (-)

INDICATION FOR EMERGENCY BLOOD TRANSFUSION GROUP O (-)

• No blood pressure on arrival

• Many patients need transfusion at the same time

• Blood group is not available

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TRANSFUSION THE TYPE AND SCREEN & COMPLETE CROSS-

MATCHED

TRANSFUSION THE TYPE AND SCREEN & COMPLETE CROSS-

MATCHED

• Type and screen blood: (5-10 minutes delay from blood bank)

emergency transfusion but can wait > 10 minutes but less than 1 hour

• Complete cross matched (45-60 minutes delay)

stable patient who can wait 45-60 minutes

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NON-HEMORRAGIC SHOCKNON-HEMORRAGIC SHOCK

• Hypovolemic shock (non-hemorrhage) + vomiting, diarrhea, water lost to “third

compartment”

+ treated by Ringer’s lactate or normal saline

+ no need hemostasis

• Anaphylactic shock + allergic reaction to anaphylactic agents

+ treated by epinephrine, anti-histamine and fluid infusion

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• Septic shock

+ May be late complication of trauma

+ Patient may have fever or hypothermia

+ Treated by fluid transfusion and isotopes

+ Identify and treat the causes of infection plays important role in trauma patients (initiate antibiotics and abscess drainage)

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• Obstructive shock: main symptom is cervical vein enlargement

+ Tension pneumothorax - Emergency decompression + Acute cardiac tamponade - Fluid infusion - Pericardiocentesis + Pulmonary embolism - Need definitive diagnosis - Fibrinolysis or surgery

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• Cardiac shock: pumping dysfunction

+ Acute myocardial infarction

+ Myocardial contusion

- very rare even among blunt chest trauma

+ Treated by inotropes

- Dopamine

- Dobutamine

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• Neurologic shock: spinal cord injury

+ Due to peripheral blood vessel dilation

+ Usually coincide with relative bradycardia

+ Treated by fluid infusion and then inotropes• Spinal cord shock

+ paralysis and lost of reflexes

+ Can be totally recovered (within 24 hours)

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HEMOSTASIS TECHNIQUESHEMOSTASIS TECHNIQUES

• Direct pressure on the bleeding site

• Temporary tourniquets

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MONITORINGMONITORING

• Mental status • Heart rate, blood pressure, respiratory rate• Urine output (target > 30 cc/h)• Capillary refill time• CVP• Laboratory (less important)

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LABORATORYLABORATORY

• Hematocrit+ may be normal at the beginning even though

patients are in severe blood lost+ lower at the beginning indicating that patients

are in very severe blood lost• BUN+ may be elevated if there is reduced blood

volume to the kidney (functional renal insufficiency) or GI bleeding

+ Slightly elevated in children who are dehydrated

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LABORATORYLABORATORY

• Blood sugar: may be elevated due to stress• WBC: less value for diagnosis

– Elevates following stress

• Hypocalcaemia if transfused blood containing citrate, treatment is not necessary

• Hypokalemia: temporary shift of potassium into cells from stress. Patients do not need potassium replacement.

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CAUSES OF COAGULATORY DISORDERS


• Hypothermia (temperature < 35.5oC)+ most common reason

+ warm patient as quick as possible

• Massive blood transfusion+ lost of coagulation factors and platelet

+ transfuse 1 unit of frozen fresh plasma and 1 unit of packed platelet for every 6-8 units of packed RBC

(note: many trauma centers now using a 1:1:1 ratio of prbc:plasma:platelets)

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• Infection

• Coagulopathy or predisposed hepatic failure

• Adverse effects of medications or toxins

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IRRIVERSIBLE SHOCKIRRIVERSIBLE SHOCK

• Invisible dehydration• Ventilatory problem• Gastric distension• Cardiac tamponade• AMI• Acute adrenal insufficiency• Neurologic shock• Hypothermia• Medication or toxins

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HYPOTHERMIA IN TRAUMAHYPOTHERMIA IN TRAUMA

• Trauma patients at risk for hypothermia due to a variety of causes

• Hypothermia results in increased blood loss (clotting disorders), increased risk of infection and increased cardiac dysfuntion/events

• Prevent Hypothermia:– Warm all fluids being given to the severely injured

trauma patients– Keep warm blankets on patient once unclothed– Frequently check patient’s temperature

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BLOOD LOST IN BONE FRACTUREBLOOD LOST IN BONE FRACTURE

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Position of fracture Amount of blood lost (mL)

Tibia (closed) 500-1000

Femur (closed) 500-2500

Femur (opened) 1000->2500

Arm (closed) 500-750

Vertebral column (closed) 500-1500

Pelvic (closed) 1000->3000

Pelvic (opened) >2500

THANK YOU FOR YOUR ATTENTIONTHANK YOU FOR YOUR ATTENTION83

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TRAUMATIC SHOCK Do Ngoc Son MD., PhD. Emergency Department Bach Mai Hospital, Hanoi 1