TRAUMATIC SHOCK

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TRAUMATIC SHOCK

• Do Ngoc Son MD., PhD. Emergency DepartmentBach
  Mai Hospital, Hanoi

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Objectives

• Definition of traumatic shock
• Recognition of shock stages and severity
• Management of shock according to stages and
  severity

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DEFINITION AND PATHOPHISIOLOGY OF SHOCK
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DEFINITION OF SHOCK

• Inadequate organ perfusion and tissue
  oxygenation.
• Circulatory system failed to meet the metabolic
  demand of the body

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HUMAN CIRCULATORY SYSTEM
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ARTERIAL BLOOD PRESSURE
Cardiac contractility
Afterload
Heart rate
Systemic vascular resistance
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BOOD PRESSURE REGULATION(ROLE OF NEURO-ENDOCRINE
SYSTEM)

• Pressure receptors located at the aortic arch and
  carotids
• Sympathoadrenal axis ? regulate the release of
  catecholamine
• Renin-angiotensin-aldosteron system ? blood
  vessel tone and urine secretion

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VOLUME STATUS
BLOOD VOLUME
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PHYSIOLOGICAL RESPONSES DURING SHOCK

• In normal condition, the body can compensate for
  the reduction of tissue perfusion
• When the compensated capabilities are overloaded
  ? SHOCK ? irreversible shock if undetected and
  untreated

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PHYSIOLOGICAL RESPONSES DURING SHOCK

• Systemic vascular constriction
• Increased blood flow primarily to important
  organs (brain, heart)
• Increased cardiac output
• Increased respiratory rate and tidal volume
• Decreased urine output
• Decreased gastroenterological activity

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COMPENSATED SHOCK

• Defense mechanism try to maintain the blood
  perfusion to main organs by
• Constrict the pre-capillary sphincter, blood
  bypasses capillary through shunt
• Increased heart rate and cardiac muscle
  contractility
• Increased respiratory activity, bronchial dilation

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COMPENSATED SHOCK

• Progresses until causes of shock are treated or
  continues to next stage
• Difficult to diagnose due to obscure symptoms
• Tachycardia
• Signs of reduced skin perfusion
• Altered mental status
• Some medication (B- blockers) could undermine the
  symptoms by preventing the tachycardia.

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UNCOMPENSATED SHOCK

• Physiological responses
• Pre-capillary sphincter opens
• Hypotension
• Reduced cardiac output
• Blood accumulate in capillary bed
• Aggregation of the erythrocytes

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UNCOMPENSATED SHOCK

• Easier to diagnose than compensated shock
• Longer capillary refill time
• Marked increased heart rate
• Increased and thready pulses
• Agitated, disorientated and confused
• Hypotension

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IRIVERSIBLE SHOCK

• Failed compensated mechanism
• Sometimes difficult to distinguish
• Resuscitatable but high mortality (ARDS, ARF,
  hepatic failure, sepsis)
• Prolonged organ ischemia, cellular death, MODS
  brain, lung, heart and kidney
• Coagulation disorders (DIC)

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CELULAR O2 DIFFICENCY
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INITIAL ASSESSMENT AND MANGAGEMENT OF SHOCK

• Initial clinical manifestation may be poor
• Identification of the causes is not so as
  important as prompt treatment for shock
• Aim of treatment is recover the circulatory
  volume and shock management
• It is important to exam shock patient regularly
  to assess their response

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ETIOLOGIES

• Blood lost
• Trauma
• Fracture of long bone or opened fracture
• Plasma lost due to burn

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ETIOLOGIES

• Fluid lost to third compartment
• Causes
• Peritonitis
• Burn

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INTERNAL HEMORRHAGE

• Hematemesis, black or bloody stools
• Hemoptysis
• Pleural effusion of blood (Hemothorax)
• Peritoneal effusion of blood (Hemoperitoneum)

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STAGES OF HEMORRHAGIC SHOCK
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STAGES OF HEMORRHAGIC SHOCK

• Stage 1 blood lost lt 15 total blood volume
• Stage 2 15-30 total blood volume
• Stage 3 30-40 total blood volume
• Stage 4 gt 40 total blood volume

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STAGES OF HEMORRHAGIC SHOCK
Blood lost (ml) blood volume Clinical signs SBP DBP Resp Rate Heart Rate Urine volume (ml) Treatment
1 lt750 0-15 Slightly anxious Normal Normal 14-20 lt100 gt30 Crystalloid solution
2 750-1500 15-30 Mildly anxious Normal ? 20-30 gt100 20-30 Crystalloid solution or blood products
3 1500-2000 30-40 Anxious, confused ? ? 30-40 gt120 5-15 Colloid and blood
4 gt2000 gt40 Confused Lethargic ? ? ? ? gt40 gt140 None Colloid and surgery
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STAGE 1

• Blood lost lt 750 mL
• Total blood volume () 0-15
• Central nervous manifestation slightly anxious
• Systolic BP normal
• Diastolic BP normal
• Respiratory rate 14 - 20 BPM
• Pulse lt 100
• Urine output gt 30 ml/h
• Treatment Crystalloid infusion (ratio 3/1)

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STAGE 2

• Blood lost 750 1500 mL
• Total blood volume ( ) 15 30
• Central nervous manifestation mild anxious
• Systolic BP normal
• Diastolic BP increased
• Respiratory rate 20 - 30 BPM
• Pulse gt 100
• Urine output 20 - 30 ml/h
• Treatment Crystalloid or blood transfusion

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STAGE 3

• Blood lost 1500 - 2000 mL
• Total blood volume () 30 40
• Central nervous manifestation Anxious and
  confused
• Systolic BP decreased
• Diastolic BP decreased
• Respiratory rate 30 40 BPM
• Pulse gt 120
• Urine output 5 - 15 ml/h
• Treatment Crystalloid or blood transfusion

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STAGE 4

• Blood lost gt 2000 mL
• Total blood volume () gt 40
• Central nervous manifestation Confused Lethargic
• Systolic BP decreased
• Diastolic BP decreased
• Respiratory rate gt 40 BPM
• Pulse gt 140
• Urine output Negligible
• Treatment colloid, blood and surgery

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PITFALLS

• Not all traumatic shock patients go through all 4
  stages
• In healthy young adults, the heart rate may be
  normal even patients are on stage 2 or 3

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DIAGNOSIS
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SEQUENCES OF EXAMINATION

• Order of ABC
• A Airway
• B Breathing
• O2 supply
• Assisted ventilation

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SEQUENCES OF EXAMINATION

• Order of ABC
• C Circulation
• Hemostasis by local bandage
• Blood volume replacement by fluid infusion
• Identification of obstructive shock
• - Tension pneumothorax prompt thoracocentesis
• - Cardiac tamponade prompt Pericardiocentesis

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Symptoms and diagnosis

• Hemorrhagic shock
• Manifestations
• Obvious blood lost Hematemesis, black or bloody
  stools.
• Tachycardia, hypotension, low CVP.
• Thirsty, dizziness, vertigo, agitation, LOC.
• Pale, cold, sweating, cyanosis.

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Symptoms and diagnosis

• Hemorrhagic shock
•  Respiratory disorders tachypnea, cyanosis
• Oliguria, anuria
• Monitor, assessment of the severity of blood
  lost
• Orthostatic hypotension BP ? gt 20 mmHg, pulse ?gt
  20 BPM 10-20 blood lost
• Supine hypotension gt20 blood lost

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Symptoms and diagnosis

• Non-hemorrhagic shock (Hypovolemia)
• Causes dehydration or electrolyte disturbance
• Manifestation mainly symptoms of dehydration and
  electrolyte disturbance
• ECF dehydration
• ICF dehydration
• Others oliguria, cold

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Consequences of shock

• Consequences of shock
• Kidney acute renal failure
• Lungs ARDS
• Heart hypoxic heart failure, metabolic acidosis,
  cardiac muscle stress
• GE gastric ulcers or bleeding
• Liver failure
• Pancreas edema, necrosis
• Endocrinological glands pituitary gland is most
  vulnerable in bleeding ? necrosis (Sheehan
  syndrome)

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MANAGEMENT
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Emergency treatment

• Emergency treatment
• Position head down, open the airway
• Breathing O2 4-8 LPM. Ambu bag or endotracheal
  intubation for ARF
• Monitoring for heart rate, blood pressure, SpO2,
  EKG
• Basic labs CBC, hematocrit, platelets, blood
  group, fibrinogen, prothrombin.

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Emergency treatment

• Large venous access
• 500-1000ml Ringer lactate (NaCl 0.9)/15-20 min.
  Continue infusion until BP increase and heart
  rate slow down ? ? infusion rate
• Fluid infusion helps to replace the blood lost
  until blood arrival

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Emergency treatment

• Large venous access
• Blood transfusion should be started after 3
  liters of fluid infusion
• If blood is not available, fluid infusion should
  be continued
• It should be remembered that fluid is not able to
  carry O2

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Emergency treatment

• Blood transfusion for hemorrhagic shock
• Packed red blood cells targeted Ht 25 - 30
• Fresh plasma or packed platelet if platelet
  lt50.000/mm3 or Prothrombin lt 50
• Many trauma centers now resuscitate patients with
  a 111 strategy. For every unit of red blood
  cells, a unit of platelets and a unit of fresh
  plasma is given
• 1 unit blood cell 1 unit plasma 1 unit
  platelets
• Consider auto transfusion

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Emergency treatment

• Urinary catheter placement
• If fluid infusion and blood transfusion is
  adequate, CVP gt7 but still hypotension
• Dopamine 5- 20 ?g/kg/min
• If failed add Dobutamine
• If failed add Norepinephrine

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Emergency treatment

• Ventilatory support if respiratory failure is
  detected
• Identify and treat the causes
• Trauma ? operate

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FLUID MANAGEMENT

• Large venous accessgt 18 F if possible
• 2 lines in case of stage 3-4 of shock
• Vasopressors are not indicated if circulatory
  volume is not adequate

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FLUID MANAGEMENT

• Start with large bore venous access
• Can use compressor bag
• Ringers lactate is common
• - Choose NS 0.9 if suspected hyperkalemia
• - NS 0.9 can be used for the line of blood
  transfusion.

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POSITION OF INFUSION

• Upper extremity peripheral vein preferred
• ? precaution in case of upper extremity
  fracture
• Central veins sub-clavian and internal jugular
  vein best choice even at stage 4
• ? risk of pneumothorax (chest X ray is needed
  after procedure)

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POSITION OF INFUSION

• Femoral vein easy and safe
• Precaution in case of abdominal trauma due to
  coincidental hemoperitoneum
• Intraosseous infusion easiest especially in
  children may also use in adult
• Peritoneal infusion

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CENTRAL VENOUS PRESSURE

• CVP assesses the preload of right ventricle
• CVP Catheters are not necessity in most trauma
  patients
• CVP is more useful in trauma patients who have
• Predisposed heart failure
• Intra ventricle pacemaker
• Neurogenic shock
• Myocardial contusion
• Suspected tamponade

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CVP IN TRAUMATIC PATIENTS

• Low CVP (lt 6 mmHg) ? hypovolemia
• - continue infusion or blood transfusion
• High CVP (gt 15 mmHg)
• Cardiac overload (over blood transfusion)
• Right heart failure (AMI)
• Cardiac tamponade
• Lung disease
• Tension pneumothorax
• Dislocation of catheter
• Hypocalcemia

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CVP IN TRAUMATIC PATIENTS
Initial CVP Change in CVP Causes Solution
Low No Consistent with blood loss Increase infusion rate
Low Increase Good resuscitation Slow down infusion rate
Low or moderate Decrease Continued blood loss Continue rapid infusion
High No overload or predisposed condition Slow down infusion rate
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CONTROVERSAL ISSUES

• Fluid type?
• When?
• Rate?
• Targets of hemorrhagic shock?
• Opened of blunt trauma?

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FLUID TYPE?
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COLLOIDS

• Albumin, hydroxyethylstarch, pentastarch,
  gelatin, dextran
• Advantages smaller volume, more intravascular
  volume, stronger fluid shift from extravascular
  to intravascular spaces
• Disadvantages expensive, allergic reaction and
  coagulation disorders

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COLLOIDS

• Cochrane. BMJ 1998 317235-40.
• Objectives effect of albumin on mortality rate
• Study multiple analysis of 30 trials (total
  number of patients 1419)
• Conclusion albumin increased mortality rate in
  trauma patients

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COLLOIDS

• Cochrane 2003.
• Objectives compare the effectiveness between
  crystalloid and colloids
• Study albumin (18 trials) HES (7 trials)
  Gelatin (4 trials) Dextran (8 trials)
• Conclusion no difference in mortality on trauma,
  burn and surgery patients

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HYPERTONIC SALINE

• Advantages less volume, longer intravascular
  half life, stronger water shift
• Disadvantages hypernatremia, hyperosmolarity,
  convulsion, coagulation disorders
• Fluid types
• Hypertonic salt (7.5 NaCl) /- 6 dextran
• Bolus 250 cc ( 4ml/kg) in 5-10 min

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HYPERTONIC SALINE

• Cochrane 2003
• Objectives evaluate the effect of hypertonic
  salt on mortality rate
• Study 25 trials
• Conclusion tendency of reduced mortality rate on
  hypertonic salt group
• ROC Trial
• Very large USA multicenter trial
• No benefit of hypertonic saline (and perhaps harm)

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CONTROLLED INFUSION

• Also called permissive hypotension
• Increase of BP before successful hemostasis may
  be harmful
• Reasons
• Increased hydrostatic pressure
• Dislodge the clot
• Dilute the coagulation factors

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CONTROLLED INFUSION

• Excess and early infusion in blunt trauma
  increased the mortality
• Controlled infusion seem to be better (targeted
  systolic BP 70 90)
• Delayed infusion (until successful hemostasis)
  may be better
• More research required on blunt trauma

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OTHER MANAGEMENT

• Blood transfusion
• Blood group O (-) immediately available
• Type and screen (if needed within lt 15min)
• Type and complete cross-matched 45-60 min
• Emergency thoracostomy, Pericardiocentesis,
  aortic cross-clamping
• Auto transfusion blood from chest tubes

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INDICATION FOR EMERGENCY BLOOD TRANSFUSION GROUP
O (-)

• No blood pressure on arrival
• Many patients need transfusion at the same time
• Blood group is not available

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TRANSFUSION THE TYPE AND SCREEN COMPLETE
CROSS-MATCHED

• Type and screen blood (5-10 minutes delay from
  blood bank)
• ? emergency transfusion but can wait gt 10
  minutes but less than 1 hour
• Complete cross matched (45-60 minutes delay)
• ? stable patient who can wait 45-60 minutes

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NON-HEMORRAGIC SHOCK

• Hypovolemic shock (non-hemorrhage)
• vomiting, diarrhea, water lost to third
  compartment
• treated by Ringers lactate or normal saline
• no need hemostasis
• Anaphylactic shock
• allergic reaction to anaphylactic agents
• treated by epinephrine, anti-histamine and
  fluid infusion

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NON-HEMORRAGIC SHOCK

• Septic shock
• May be late complication of trauma
• Patient may have fever or hypothermia
• Treated by fluid transfusion and isotopes
• Identify and treat the causes of infection
  plays important role in trauma patients (initiate
  antibiotics and abscess drainage)

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NON-HEMORRAGIC SHOCK

• Obstructive shock main symptom is cervical vein
  enlargement
• Tension pneumothorax
• - Emergency decompression
• Acute cardiac tamponade
• - Fluid infusion
• - Pericardiocentesis
• Pulmonary embolism
• - Need definitive diagnosis
• - Fibrinolysis or surgery

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NON-HEMORRAGIC SHOCK

• Cardiac shock pumping dysfunction
• Acute myocardial infarction
• Myocardial contusion
• - very rare even among blunt chest trauma
• Treated by inotropes
• - Dopamine
• - Dobutamine

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NON-HEMORRAGIC SHOCK

• Neurologic shock spinal cord injury
• Due to peripheral blood vessel dilation
• Usually coincide with relative bradycardia
• Treated by fluid infusion and then inotropes
• Spinal cord shock
• paralysis and lost of reflexes
• Can be totally recovered (within 24 hours)

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HEMOSTASIS TECHNIQUES

• Direct pressure on the bleeding site
• Temporary tourniquets

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MONITORING

• Mental status
• Heart rate, blood pressure, respiratory rate
• Urine output (target gt 30 cc/h)
• Capillary refill time
• CVP
• Laboratory (less important)

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LABORATORY

• Hematocrit
• may be normal at the beginning even though
  patients are in severe blood lost
• lower at the beginning indicating that patients
  are in very severe blood lost
• BUN
• may be elevated if there is reduced blood
  volume to the kidney (functional renal
  insufficiency) or GI bleeding
• Slightly elevated in children who are dehydrated

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LABORATORY

• Blood sugar may be elevated due to stress
• WBC less value for diagnosis
• Elevates following stress
• Hypocalcaemia if transfused blood containing
  citrate, treatment is not necessary
• Hypokalemia temporary shift of potassium into
  cells from stress. Patients do not need
  potassium replacement.

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CAUSES OF COAGULATORY DISORDERS

• Hypothermia (temperature lt 35.5oC)
• most common reason
• warm patient as quick as possible
• Massive blood transfusion
• lost of coagulation factors and platelet
• transfuse 1 unit of frozen fresh plasma and 1
  unit of packed platelet for every 6-8 units of
  packed RBC
• (note many trauma centers now using a 111
  ratio of prbcplasmaplatelets)

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CAUSES OF COAGULATORY DISORDERS

• Infection
• Coagulopathy or predisposed hepatic failure
• Adverse effects of medications or toxins

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IRRIVERSIBLE SHOCK

• Invisible dehydration
• Ventilatory problem
• Gastric distension
• Cardiac tamponade
• AMI
• Acute adrenal insufficiency
• Neurologic shock
• Hypothermia
• Medication or toxins

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HYPOTHERMIA IN TRAUMA

• Trauma patients at risk for hypothermia due to a
  variety of causes
• Hypothermia results in increased blood loss
  (clotting disorders), increased risk of infection
  and increased cardiac dysfuntion/events
• Prevent Hypothermia
• Warm all fluids being given to the severely
  injured trauma patients
• Keep warm blankets on patient once unclothed
• Frequently check patients temperature

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BLOOD LOST IN BONE FRACTURE
Position of fracture Amount of blood lost (mL)
Tibia (closed) 500-1000
Femur (closed) 500-2500
Femur (opened) 1000-gt2500
Arm (closed) 500-750
Vertebral column (closed) 500-1500
Pelvic (closed) 1000-gt3000
Pelvic (opened) gt2500
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THANK YOU FOR YOUR ATTENTION