Shock 848th Forward Surgical Team - PowerPoint PPT Presentation


PPT – Shock 848th Forward Surgical Team PowerPoint presentation | free to view - id: c6285-MWJjN


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

Shock 848th Forward Surgical Team


Early recognition, control of the hemorrhage source by effective first ... There is an in-line air vent to prevent an air embolus when fluid bag is pressurized ... – PowerPoint PPT presentation

Number of Views:218
Avg rating:3.0/5.0
Slides: 27
Provided by: christoph97


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Shock 848th Forward Surgical Team

Shock 848th Forward Surgical Team
  • Combat-Related trauma may present with classical
    symptoms of hemorrhagic shock following rapid
    exsanguination from major vascular structures
  • Hemorrhagic shock is the most common cause of
    death among combat casualties
  • Early recognition, control of the hemorrhage
    source by effective first aid, and rapid volume
    resuscitation with IV fluids are the ideal
    preparation for definitive surgical repair

Physiological Consequences of Hemorrhage
  • Adverse effects of hemorrhage on young, healthy
    soldiers are directly related to two primary
  • 1.)     Decreased intravascular volume
  • 2.)     Inadequate oxygen-carrying

Cardiovascular Response
  • The immediate response to the fall in venous
    return to the heart, and decrease in pressure to
    the aortic arch and carotid baro-receptors is a
    diffuse activation of the sympathetic nervous
  • Release of catecholamines from adrenal medulla
  • Increase in heart rate and contractility
  • Increase in systematic vascular resistance due to
    vasoconstriction of skeletal muscles and viscera
  • This response preserves central organs
  • Heart brain at the expense of peripheral organs

Fluid Compartment Shifts
  • After a combat casualty sustains a major
    hemorrhage, restoration of the intravascular
    fluid compartment may require many hours as
    interstitial fluid (extra-vascular) is drawn into
    the intravascular compartment

Extra-vascular Fluid Loss
  • Combat casualties presenting for care several
    hours after being injured may suffer from
  • Hemorrhage-induced intravascular volume depletion
  • Preexisting depletion of the extra-cellular fluid
    compartment that is caused by concomitant
    dehydration, secondary to environmental or
    nutritional factors

Extra-vascular Fluid Loss Cont.
  • Because crystalloids (Normal Saline (NS)
    /Lactated Ringers (LR)) are distributed through
    the body water, a 1950's dog study showed 3-4
    ml/1 ml blood loss is required to replace
    intravascular volume
  • Recommendations for replacing the third-space
    fluid sequestration is four, six, and eight
    ml/kg/hr for minimal, moderate, and severe trauma
    (respectively) in addition to estimated hourly
    maintenance fluids

Oxygen Transport
  • Hemorrhage interferes with normal tissue
    oxygenation by two mechanisms
  • 1.) The anemic (Inadequate oxygen carrying
  • 2.) The hemorrhagic (Inadequate tissue perfusion)
  • In the setting of severe hemorrhage, however,
    reduced hemoglobin content is rarely the cause of
    tissue hypoxia
  • A 20-year-old healthy soldier can lose 40-50 of
    his blood volume and hemodynamically compensate
    with cardiac output and vasoconstriction to
    maintain adequate tissue perfusion

Oxygen Transport
  • This example demonstrates blood replacement is
    frequently unnecessary and volume restoration is
    the key
  • If the circulating plasma volume is maintained
    then the metabolic consequences of severe
    hemorrhage can be minimized

  • Bld Loss Blood Vol. Heart
    Blood Pulse Resp Urine Mental
  • Hemorrhage (L.) Lost () Rate Pressure Pressu
    re Rate ml./hr. Status
  • Class I lt1 lt15 lt100 Normal Normal or
    14-20 gt30 Slight Increased Anxiety
  • Class II 0.75-1.5 15-30 gt100 Normal Decreased
    20-30 20-30 Mild
  • Anxiety
  • Class III 1.5-2.0 30-40 gt120 Decreased Decrease
    d 30-40 lt15 Anxious
  • Class IV gt2.0 gt40 gt140 Decreased Decreased
    Rapid Neg Confused
  • Shallow Lethargic 
  • (Committee on Trauma, American College of
    Surgeons. Advanced Trauma Life Support for
    Physicians Chicago, Ill. American College of
    Surgeons 1989 72. ) 

  • Class I (lt15) Suspected blood loss in absence of
    tachycardia or hypotension
  • Resuscitate with clear fluids (crystalloids (NS /
  •  Class II (15-30) Tachycardia without
  • Transfuse with crystalloid or colloid, transfuse
    early with continual bleeding
  •  Class III (30-40) or Class lV (gt40)
    Hypotension and tachycardia require immediate
    blood volume replacement with crystalloid,
    colloids, and or packed red blood cells

Venous Access
  • Optimal sited for venous cannulation
  • Severe hemorrhagic shock may require surgical
  • Central venous access
  • Penetrating abdominal injuries may involve the
    inferior venacava

Intravenous Fluid-Delivery System
  • Large-caliber, high-efficiency, blood-warming
    units are essential for large-vol. resuscitation
  • Level-I (one) can deliver warm fluids at a rate
    of 500 ml/min with an 18 g IV 1000 ml/min with a
    14 g IV
  • There is an in-line air vent to prevent an air
    embolus when fluid bag is pressurized

Resuscitation Fluid Selection
  • Best initial therapy for mild to moderate
    hemorrhage 10-30
  • Blood products administered to keep pace with
    blood loss and keep hemoglobin gt 7 gm/dl
  • Fresh whole blood or Packed Red Blood Cells

Crystalloid Solutions
  • 0.9 Normal Saline (NS) or Lactated Ringers (LR)
  • Glucose containing fluids
  • Dextrose

Colloid Solutions (Dextran, Hespan, Albumin)
  • Rapidly replenishes intravascular compartment
    with smaller fluid volume than crystalloids
  • Gives more prolonged expansion of the plasma
    volume and less peripheral edema
  • Has Disadvantages

Supplemental Therapeutic Measures
  • Control of bleeding and rapid infusion of
    crystalloids and blood are essential in combat
    casualty treatment of shock
  • Other Treatments

Patient Position
  • Trendelenberg's position
  • Raised legs may increase blood return to heart
    without increasing intracranial pressure

Pneumatic Antishock Garment
  • A compression device first known as the Military
    Anti-Shock Trousers (MAST) introduced by the U.S.
    Army during the Vietnam War

Pneumatic Antishock Garment
  • Studies have demonstrated significantly reduced
    survival in patients treaded with MAST garments
    for chest hemorrhage not compressed by the
  • MAST garments in combat may be useful in
    stabilizing fractures of pelvis and long bones of
    the legs

Supplemental Oxygen
  • Beneficial in multiple or massive injury
  • Flail chest, fat embolus and other injuries
    associated with impaired oxygenation
  • Expectations of tissue oxygenation in the
    presence of hypovolemic shock is unrealistic
  • Hemoglobin oxygenation in young combat casualties
    is already maximally saturated from
    hyperventilation from the injury

  • Transiently supporting blood pressure with
    vasoconstrictors until volume replacement or
    control of bleeding is possible
  • Intense vasoconstriction is typical hemostatic
    response to hemorrhagic shock and may be
    primarily responsible for adverse consequences of
    hypovolemia (acidosis and tissue hypoxia) 

Hyperthermia and Dehydration
  • Physical exertion and inadequate supplies on the
    battlefield combine to develop heat injury and
  • Coincidental trauma and hemorrhage
  • Rapid replacement of intravascular and
    intracellular fluids

  • Problem afflicting trauma victims
  • Decreases renal blood flow 75
  • Temperatures lt30 Degrees C
  • Restoration of fluid deficits
  • Re-warming the patient frequently develops
    metabolic acidosis
  • Fluid resuscitation maintenance will correct
    acidotic state
  • Treat acidosis with sodium bicarbonate

Hemorrhagic Shock and Head Injury
  • Hypovolemia and head injury is ominous
  • Increased intracranial pressure and hypotension,
    secondary to hypovolemia, further decreases
    cerebral perfusion pressure and potentiates
    cerebral ischemic injury
  • When colloid solutions have been advocated, the
    blood-brain barrier may have been damaged
    contributing to worsening edema with fluid

James Malson CPT