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Shock 848th Forward Surgical Team

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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

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Title: Shock 848th Forward Surgical Team


1
Shock 848th Forward Surgical Team
2
Introduction
  • 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
  •  

3
Physiological Consequences of Hemorrhage
  • Adverse effects of hemorrhage on young, healthy
    soldiers are directly related to two primary
    factors
  • 1.)     Decreased intravascular volume
  • 2.)     Inadequate oxygen-carrying
    capacity

4
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
    system
  • 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

5
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

6
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

7
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

8
Oxygen Transport
  • Hemorrhage interferes with normal tissue
    oxygenation by two mechanisms
  • 1.) The anemic (Inadequate oxygen carrying
    capacity)
  • 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

9
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

10
Hypovolemia
  • 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
    Confused
  • 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. ) 

11
Hypovolemia
  • Class I (lt15) Suspected blood loss in absence of
    tachycardia or hypotension
  • Resuscitate with clear fluids (crystalloids (NS /
    LR)
  •  Class II (15-30) Tachycardia without
    hypotension
  • 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

12
Venous Access
  • Optimal sited for venous cannulation
  • Severe hemorrhagic shock may require surgical
    cut-down
  • Central venous access
  • Penetrating abdominal injuries may involve the
    inferior venacava

13
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

14
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
    (PRBC)

15
Crystalloid Solutions
  • 0.9 Normal Saline (NS) or Lactated Ringers (LR)
  • Glucose containing fluids
  • Dextrose

16
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

17
Supplemental Therapeutic Measures
  • Control of bleeding and rapid infusion of
    crystalloids and blood are essential in combat
    casualty treatment of shock
  • Other Treatments

18
Patient Position
  • Trendelenberg's position
  • Raised legs may increase blood return to heart
    without increasing intracranial pressure

19
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

20
Pneumatic Antishock Garment
  • Studies have demonstrated significantly reduced
    survival in patients treaded with MAST garments
    for chest hemorrhage not compressed by the
    trousers
  • MAST garments in combat may be useful in
    stabilizing fractures of pelvis and long bones of
    the legs

21
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

22
Vasopressors
  • 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) 

23
Hyperthermia and Dehydration
  • Physical exertion and inadequate supplies on the
    battlefield combine to develop heat injury and
    dehydration
  • Coincidental trauma and hemorrhage
  • Rapid replacement of intravascular and
    intracellular fluids

24
Hypothermia
  • 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

25
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
    resuscitation

26
Questions
James Malson CPT
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