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Shock: Ivan Mucharry Dalitan - PPDS Orthopaedi & Traumatologi Semester IV

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Shock is divided into haemorrhagic shock and non-haemorrhagic shock, which includes cardiogenic, cardiac tamponade, tension pneumothorax, neurogenic, and septic shock. The physical examination of a patient in shock focuses on the ABCDEs - Airway, Breathing, Circulation, Disability, and Exposure. Initial fluid resuscitation uses warmed isotonic fluids like lactated Ringer's solution, with a goal of restoring organ perfusion while avoiding excessive fluid that could exacerbate coagulopathy, acidosis, and hypothermia.

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Shock: Ivan Mucharry Dalitan - PPDS Orthopaedi & Traumatologi Semester IV

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71 views5 pages
Shock is divided into haemorrhagic shock and non-haemorrhagic shock, which includes cardiogenic, cardiac tamponade, tension pneumothorax, neurogenic, and septic shock. The physical examination of a patient in shock focuses on the ABCDEs - Airway, Breathing, Circulation, Disability, and Exposure. Initial fluid resuscitation uses warmed isotonic fluids like lactated Ringer's solution, with a goal of restoring organ perfusion while avoiding excessive fluid that could exacerbate coagulopathy, acidosis, and hypothermia.

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Shock is divided into haemorrhagic shock and non-haemorrhagic shock, which includes cardiogenic, cardiac tamponade, tension pneumothorax, neurogenic, and septic shock. The physical examination of a patient in shock focuses on the ABCDEs - Airway, Breathing, Circulation, Disability, and Exposure. Initial fluid resuscitation uses warmed isotonic fluids like lactated Ringer's solution, with a goal of restoring organ perfusion while avoiding excessive fluid that could exacerbate coagulopathy, acidosis, and hypothermia.

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Shock: Ivan Mucharry Dalitan - PPDS Orthopaedi & Traumatologi Semester IV

Uploaded by

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Shock is divided into haemorrhagic shock and non-haemorrhagic shock, which includes cardiogenic, cardiac tamponade, tension pneumothorax, neurogenic, and septic shock. The physical examination of a patient in shock focuses on the ABCDEs - Airway, Breathing, Circulation, Disability, and Exposure. Initial fluid resuscitation uses warmed isotonic fluids like lactated Ringer's solution, with a goal of restoring organ perfusion while avoiding excessive fluid that could exacerbate coagulopathy, acidosis, and hypothermia.

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Ivan Mucharry Dalitan PPDS Orthopaedi & Traumatologi Semester

IV

Shock
Shock is divided into:

Haemorrhagic Shock
Non Haemorrhagic Shock: Cardiogenic Shock, Cardiac tamponade, tension
pneumothorax, neurogenic shock, septic shock.
Haemorrhagic Shock

CLINICAL USEFULNESS OF CLASSIFICATION SCHEME


The clinical usefulness of this classification scheme is illustrated by the
following example: A 70-kg patient with hypotension who arrives at an ED or trauma
center has lost an estimated 1470 mL of blood (70 kg x 7% x 30% = 1.47 L, or 1470
mL). Resuscitation will likely require crystalloid, pRBCs, and blood products.
Nonresponse to fluid administration almost always indicates persistent blood loss
with the need for operative or angiographic control.
PHYSICAL EXAMINATION
The physical examination is directed toward the immediate diagnosis of life-
threatening injuries and includes assessment of the ABCDEs. Baseline recordings
are important to monitor the patients response to therapy, and measurements of
vital signs, urinary output, and level of consciousness are essential. A more detailed
examination of the patient follows as the situation permits.
AirwayandBreathing
Establishing a patent airway with adequate ventilation and oxygenation is the
first priority. Supplementary oxygen is provided to maintain oxygen saturation at
greater than 95%.

CirculationHemorrhageControl
Priorities for managing circulation include controlling obvious hemorrhage,
obtaining adequate intravenous access, and assessing tissue perfusion. Bleeding
from external wounds usually can be controlled by direct pressure to the bleeding
site, although massive blood loss from an extremity may require a tourniquet. A
sheet or pelvic binder from an extremity may be used to control bleeding from
pelvic fractures. The adequacy of tissue perfusion dictates the amount of fluid
resuscitation required. Surgical or angiographic control may be required to control
internal hemorrhage. The priority is to stop the bleeding, not to calculate the
volume of fluid lost.
DisabilityNeurologicExamination
A brief neurologic examination will determine the patients level of
consciousness, eye motion and pupillary response, best motor function, and degree
of sensation. This information is useful in assessing cerebral perfusion, following the
evolution of neurologic disability, and predicting future recovery. Alterations in CNS
function in patients who have hypotension as a result of hypovolemic shock do not
necessarily imply direct intracranial injury and may reflect inadequate brain
perfusion. Restoration of cerebral perfusion and oxygenation must be achieved
before ascribing these findings to intracranial injury. See Chapter 6: Head Trauma.
ExposureCompleteExamination
After lifesaving priorities are addressed, the patient must be completely
undressed and carefully examined from head to toe to search for associated
injuries.
GastricDilationDecompression
Gastric dilation often occurs in trauma patients, especially in children, which
can cause unexplained hypotension or cardiac dysrhythmia, usually bradycardia
from excessive vagal stimulation. In unconscious patients, gastric distention
increases the risk of aspiration of gastric contents, which is a potentially fatal
complication. Gastric decompression is accomplished by intubating the stomach
with a tube passed nasally or orally and attaching it to suction to evacuate gastric
contents. However, proper positioning of the tube does not completely obviate the
risk of aspiration.
UrinaryCatheterization
Urinary output is a sensitive indicator of the patients volume status and
reflects renal perfusion. Monitoring of urinary output is best accomplished by the
insertion of an indwelling bladder catheter. Transurethral bladder catheterization is
contraindicated in patients in whom urethral injury is suspected. Urethral injury
should be suspected in the presence of one of the following:
Blood at the urethral meatus
Perineal ecchymosis
High-riding or nonpalpable prostate
Accordingly, a urinary catheter should not be inserted before the rectum and
genitalia have been examined, if urethral injury is suspected. Urethral integrity
should be confirmed by a retrograde urethrogram before the catheter is inserted.
Within certain limits, urinary output is used to monitor renal blood flow.
Adequate resuscitation volume replacement should produce a urinary output of
approximately 0.5 mL/kg/hr in adults, whereas 1 mL/kg/ hr is an adequate urinary
output for pediatric patients. For children under 1 year of age, 2 mL/kg/hour should
be maintained. The inability to obtain urinary output at these levels or a decreasing
urinary output with an increasing specific gravity suggests inadequate resuscitation.
This situation should stimulate further volume replacement and diagnostic
endeavors.

VASCULAR ACCESS LINES


Access to the vascular system must be obtained promptly. This is best
accomplished by inserting two large-caliber (minimum of 16-gauge in an adult)
peripheral intravenous catheters before placement of a central venous line is
considered. The rate of flow is proportional to the fourth power of the radius of the
cannula and inversely related to its length (Poiseuilles law). Hence, short, large-
caliber peripheral intravenous lines are preferred for the rapid infusion of large
volumes of fluid. Fluid warmers and rapid infusion pumps are used in the presence
of massive hemorrhage and severe hypotension. The most desirable sites for
peripheral, percutaneous intravenous lines in adults are the forearms and
antecubital veins. If circumstances prevent the use of peripheral veins, large-
caliber, central venous (i.e., femoral, jugular, or subclavian vein) access using the
Seldinger technique or saphenous vein cutdown is indicated, depending on the
clinicians skill and experience.

INITIAL FLUID THERAPY


Warmed isotonic electrolyte solutions, such as lactated Ringers and normal
saline, are used for initial resuscitation. This type of fluid provides transient
intravascular expansion and further stabilizes the vascular volume by replacing
accompanying fluid losses into the interstitial and intracellular spaces. An initial,
warmed fluid bolus is given. The usual dose is 1 to 2 L for adults and 20 mL/kg for
pediatric patients. Absolute volumes of resuscitation fluids should be based on
patient response. It is important to remember that this initial fluid amount includes
any fluid given in the prehospital setting. The patients response is observed during
this initial fluid administration, and further therapeutic and diagnostic decisions are
based on this response. The amount of fluid and blood required for resuscitation is
difficult to predict on initial evaluation of the patient. The table provides general
guidelines for establishing the amount of fluid and blood likely required. It is most
important to assess the patients response to fluid resuscitation and identify
evidence of adequate end-organ perfusion and oxygenation (i.e., via urinary output,
level of consciousness, and peripheral perfusion). If, during resuscitation, the
amount of fluid required to restore or maintain adequate organ perfusion greatly
exceeds these estimates, a careful reassessment of the situation and search for
unrecognized injuries and other causes of shock are necessary. The goal of
resuscitation is to restore organ perfusion. This is accomplished by the use of
resuscitation fluids to replace lost intravascular volume. Note, however, that if blood
pressure is raised rapidly before the hemorrhage has been definitively controlled,
increased bleeding can occur. Persistent infusion of large volumes of fluid and blood
in an attempt to achieve a normal blood pressure is not a substitute for definitive
control of bleeding. Excessive fluid administration can exacerbate the lethal triad of
coagulopathy, acidosis, and hypothermia with activation of the inflammatory
cascade. Fluid resuscitation and avoidance of hypotension are important principles
in the initial management of blunt trauma patients, particularly those with traumatic
brain injury (TBI). In penetrating trauma with hemorrhage, delaying aggressive fluid
resuscitation until definitive control may prevent additional bleeding. Although
complications associated with resuscitation injury are undesirable, the alternative of
exsanguination is even less so. A careful, balanced approach with frequent
reevaluation is required. Balancing the goal of organ perfusion with the risks of
rebleeding by accepting a lower-than-normal blood pressure has been termed
controlled resuscitation, balanced resuscitation, hypotensive resuscitation,
and permissive hypotension. The goal is the balance, not the hypotension. Such a
resuscitation strategy may be a bridge to, but is not a substitute for, definitive
surgical control of bleeding.

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