The Hemodynamic

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Shock and Fluid therapy

Text of The Hemodynamic

  • 1. The hemodynamicallyunstable patient Jeannouel van Leeuwen MD Trauma in the Caribbean II November 6-8, 2009

2. 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)

3. 4. 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 5. 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)

6. 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% = tachycardia
    • III: 40% = decreased SBP, confusion
    • IV: >40% = lethargy, no UOP

It is not the blood loss you can see that will get you, its the blood loss you cant see 7. 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

8. Identification of the Site of Bleeding

  • External Hemorrhage
  • Pleural Space
  • Peritoneal Cavity
  • Extremity Fracture
  • Retroperitoneal Space

One set of vital signs isnt hemodynamically stable 9. 10. External Bleeding

  • Significant blood loss
    • 1 liter- adult
    • 1/2 liter- child
    • 100 to 200 ml- infant
  • Result may beHYPOVOLEMICshock

Ventilate, perfuse , and piss is all that it is about 11. Bleeding Control

  • Direct local pressure
    • Most effective

12. 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 dont resuscitate it with water

Even a dead patients vital signs are stable 13. Resuscitation from Hemorrhagic Shock

  • Reversal of hypovolemia
  • Control of hemorrhage

The most important clotting factor is the surgeon 14. 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

15.

  • The major cause of shock is decreased circulatory volume. Replace body fluids by the best means at hand.-Alfred Blalock, 1899-1964

16. Fluid resuscitation practice

  • The rate of ARDS and MOFS are decreasing due to change in fluid resuscitation practice

One set of vital signs isnt hemodynamically stable 17. 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

18. 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 dont panic 19. 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 6 thunit, FFP followed by platelets and cryoprecipitate.

20. Acute Coagulopathy of Trauma (ACoTS) Hess et al. J Trauma 2008 21. 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

22. Risks of Aggressive Volume Resuscitation

  • hemorrhage + excessive hemodilution due toBP,blood viscosity,hematocrit,clotting factor concentration

23. 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

24. 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

25. Degree of Hemorrhagic Shock

  • Moderate Hemorrhagic Shock:
    • 20 40% blood loss
    • & low urine output
      • Due to aldosteron and ADH

26. 27. Compensatory Mechanism

  • Adrenergic discharge
  • Hyperventilation:
    • with spontaneous deep breathing there is a decreased intra-thoracic ----> increase ventricular end diastolic volume ----> increase cardiac output.
  • Collapse:
    • Displaced blood from extremity to the heart and the brain

28.

  • Monitoring:
  • Management:
    • resuscitate patient and control blood lost and correct dehydration
    • give balance salt solution (crystalloid)
    • disadvantage of giving colloid resuscitation.
      • Increase intravascular volume at the expense of necessary interstitial fluid
      • Depression of albumin synthesis
      • Depression of circulating immunoglobulin
      • More expensive and less easier to titrate

29.

  • Causes of Refractory Shock:
    • Continuing blood loss from primary injury or another source
    • Inadequate replacement of fluids
    • Massive trauma or other derangement
    • Myocardial infarction
    • Concomitant septic shock

30. Traumatic Shock

  • Traumatized tissue activates coagulation system forming:
    • Microthrombi:
      • Occludes pulmonary vasculature ---> increase pulmonary vascular resistance ----> increase right arterial pressure
    • Humoral products of microthrombi :
      • cytoxines
      • Increases vascular permeability ---> loss of plasma

31. 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

32. 33. Beware

  • More bloodloss if restoration of volume due to increased bloodpressure

Patients bleed whole blood-not components 34. SBP &