Professional Documents
Culture Documents
Definition of shock
Where a circulatory abnormality results in inadequate organ perfusion and tissue
oxygenation.
Initial management steps:
The first step in managing shock in an injured patient is the recognition of its
presence. This is based on recognising the presence of inadequate organ
perfusion and tissue oxygenation.
The second step is to identify the probable cause of shock. In trauma cases this is
directly related to the mechanism of injury and usually takes the form of
hypovolaemic shock (due to haemorrhage) .
Management involves simultaneous recognition of the shock state, identification of
probable cause and initiating treatment.
PRINCIPLES
Cardiac output (CO) = Heart Rate (HR) x Stroke Volume (SV)
The venous system acts as a reservoir or capacitor for the blood volume and
contains nearly 70% of the total blood volume. The volume of venous blood returning
to the heart determines the myocardial muscle fibre length at end-diastole. Muscle
fibre length is related to contractility of myocardial muscle according to Starlings law.
Pathophysiology of blood loss
Early circulatory responses to blood loss are: compensatory i.e. progressive
vasoconstriction of cutaneous, muscle and visceral circulation to preserve blood flow
to the kidneys, heart, and brain.
Acute circulatory volume depletion together with the injury results in an increased
HR to attempt to preserve CO. Tachycardia is usually the earliest measurable
circulatory sign of shock.
92
93
Any patient who is cool and tachycardic is in shock until proven otherwise.
Normal heart rate varies with age. Tachycardia by age is classified as:
Infants
Preschool
School to puberty
Adult
>160
>140
>120
>100
Elderly patients may not exhibit tachycardia due to the limited cardiac response to
catecholamine stimulation, concurrent use of -blockers or the presence of a pace
maker. A narrowed pulse pressure suggests significant blood loss and involvement
of compensatory mechanisms.
Clinical Differentiation of Shock Aetiology
Shock in trauma patients may be classified as haemorrhagic or non-haemorrhagic.
1.
Haemorrhagic shock is the most common cause of shock after injury. Virtually
all multiply injured patients will have some degree of hypovolaemia. Most cases
of non-haemorrhagic shock will respond partially or briefly to volume
resuscitation.
Therefore, if signs of shock are present, treatment should usually be
initiated as if the patient is hypovolaemic. NB once treatment is initiative
other aetiologies should be identified and treated accordingly
2.
Non-haemorrhagic shock
a.
b.
c.
d.
Cardiogenic shock
Tension pneumothorax
Neurogenic shock
Septic shock
94
Class II
750-1500
Class III
1500-2000
Class IV
>2000
Blood loss
(% blood
volume)
Pulse rate
Up to 15%
15-30%
30-40%
>40%
<100
>100
>120
>140
Blood
pressure
Pulse
pressure
(mmHg)
Respiratory
rate
Urine output
(mL/Hr)
CNS/Mental
status
Fluid
replacement
(3:1 Rule)
Normal
Normal
Decreased
Decreased
Normal or
Increased
Decreased
Decreased
Decreased
14-20
20-30
30-40
>35
>30
20-30
5-15
Negligible
Slightly
anxious
Crystalloid
Mildly
anxious
Crystalloid
Anxious,
confused
Crystalloid
and blood
Confused,
lethargic
Crystalloid
and blood
Blood loss
ml
Physical examination
Isotonic crystalloid solutions are used for initial resuscitation provides transient
intravascular expansion and further stabilises vascular volume by replacing
accompanying fluid losses into interstitial and intracellular spaces.
An initial fluid bolus is given as rapidly as possible. The usual dose is 1 to 2 L
(adults) and 20mL/kg (paediatric). The patients response is then used to judge
further therapeutic and diagnostic decisions.
The amount of fluid and blood required for resuscitation is difficult to predict
during the initial patient evaluation. Table 1 is used to provide general guidelines
for establishing the amount of fluid and blood the patient is likely to require.
The 3 for 1 rule is used based on 3L of crystalloid fluid needed to replace each
litre of blood lost (including loss to the interstitial and intracellular spaces). It is also
essential to look for evidence of adequate end-organ perfusion and oxygenation
based upon urine output, level of consciousness, and peripheral perfusion.
Reassessment is needed if fluids needed greatly exceed estimates of fluid
anticipated.
EVALUATION OF FLUID RESUSCITATION AND ORGAN PERFUSION
A.
General
Signs and symptoms of inadequate perfusion are the same as those used for shock
in assessing patient response i.e. normal BP, pulse pressure, pulse rate. NB they do
not indicate organ perfusion, which requires us to look at CNS status and skin
circulation (difficult to quantitate).
96
Urine output is a good indicator of adequate renal perfusion and is a prime monitor of
resuscitation and patient response. Consideration should be given to measurement
of central venous pressure via a Swan-Ganz catheter (NB associate risks).
B.
Urine Output
Within limits used to monitor renal blood flow. Adequate volume replacement
generates approximately 0.5mL/kg/hr in adults (1mL/kg/hr for paediatric
patients)
C.
Acid/Base Balance
Should also be monitored but routine use of Sodium bicarbonate is not indicated to
treat metabolic acidosis secondary to hypovolaemic shock.
THERAPEUTIC DECISIONS BASED UPON RESPONSE TO INITIAL FLUID
RESUSCIATION
The patients response to initial fluid therapy is the key to determining
subsequent therapy. It is particularly important to distinguish the patient who is
haemodynamically stable (may have persistent tachycardia, tachypnoeic, and
oliguric still underresuscitated) compared with haemodynamically normal
(adequate signs of tissue perfusion).
Response patterns may be rapid response, transient response and minimal or no
response to initial fluid therapy (see table 2).
Table 2
RESPONSES TO INTIAL FLUID RESUSCITATION
Rapid response
Transient
response
Transient
improvement;
recurrence of BP
& HR
Moderate and
ongoing (20-40%)
High
No Response
Low
Type and
crossmatch
Possibly
Moderate to high
Type-specific
Likely
Immediate
Emergency blood
release (O-neg)
Highly likely
Yes
Yes
Yes
Vital signs
Return to normal
Estimated
blood loss
Need more
crystalloid
Need for blood
Blood
preparation
Need for
operative
intervention
Early presence
of surgeon
Minimal (10-20%)
Low
Remain abnormal
Severe (>40%)
High
Table base upon 2000mL Ringers lactate solution in adults, 20mL/kg Ringers
lactate bolus in children
97
BLOOD REPLACEMENT
The decision to give blood is based on the patients response, as illustrated in table
2.
A.
98