Hemorrhage and shocks

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Information about Hemorrhage and shocks

Published on October 18, 2008

Author: aSGuest1248

Source: authorstream.com

Hemorrhage & Shock : Hemorrhage & Shock Review of Hemorrhage : Review of Hemorrhage Location Anatomical Type & Timing Coagulation Fibrinolysis Assessment Management Review of Hemorrhage : Review of Hemorrhage Location External Internal Traumatic Non-Traumatic Examples? Review of Hemorrhage : Review of Hemorrhage Anatomical Type Arterial Venous Capillary Timing Acute Chronic Severity of Hemorrhage : Severity of Hemorrhage Comparison of Adult vs Child Hematocrit : Hematocrit % of RBC in blood (hematocrit) Normal: 37% - 47% (Female) 40% - 54% (Male) Thrombocytes : Thrombocytes Platelets Form platelet plugs contact collagen & adhere to injured surface activate platelets aggregate to form platelet plug Coagulation : Coagulation Formation of blood clots Prothrombin activator Prothrombin  Thrombin Fibrinogen  Fibrin entrap platelets, blood cells & plasma Clot retraction Fibrinolysis : Fibrinolysis Breaking up the clot tissue plasminogen activator (tPA) plasminogen  plasmin Assessing Hemorrhage : Assessing Hemorrhage Clues Bright red blood from wound, mouth, rectum or other orifice Hematemesis Coffee ground appearance of vomitus Hematochezia Melena Orthostatic hypotension Dizziness or syncope on sitting or standing Signs and symptoms of hypovolemic shock Management of Hemorrhage : Management of Hemorrhage Airway and Ventilatory Support Circulatory Support From nose or ears after head trauma = loose drsg Control bleeding direct pressure, elevation, pressure points tourniquet packing of large wounds splinting PASG transport to appropriate facility Shock : Shock “A rude unhinging of the machinery of life” “A brief pause in the act of dying” Shock : Shock Inadequate peripheral perfusion leading to failure of tissue oxygenation  may lead to anaerobic metabolism Shock : Shock Homeostasis cellular state of balance perfusion of cells with oxygen is one of its cornerstones Shock : Shock Adequate Cellular Oxygenation Red Cell Oxygenation Red Cell Delivery To Tissues Fick Principle Fick Principle : Fick Principle Air’s gotta go in and out. Blood’s gotta go round and round. Any variation of the above is not a good thing! Shock : Shock Red Cell Oxygenation Oxygen delivery to alveoli Adequate FiO2 Patent airways Adequate ventilation Shock : Shock Red Cell Oxygenation Oxygen exchange with blood Adequate oxygen diffusion into blood Adequate RBC flow past alveoli Adequate RBC mass/Hgb levels Adequate RBC capacity to bind O2 pH Temperature Shock : Shock Red Cell Delivery To Tissues Adequate perfusion Blood volume Cardiac output Heart rate Stroke volume (pre-load, contractility, after-load) Conductance Arterial resistance Venous capacitance Shock : Shock Red Cell Delivery To Tissues Adequate RBC mass Adequate Hgb levels Adequate RBC capacity to unbind O2 pH Temperature Distance between capillaries and cells Shock : Shock Inadequate oxygenation or perfusion causes: Inadequate cellular oxygenation Shift from aerobic to anaerobic metabolism AEROBIC METABOLISM : AEROBIC METABOLISM Glycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid Oxidative phosphorylation: Each pyruvic acid is converted into 34 ATP ANAEROBIC METABOLISM : ANAEROBIC METABOLISM Glycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid Anaerobic Metabolism : Anaerobic Metabolism Occurs without oxygen oxydative phosphorylation can’t occur without oxygen glycolysis can occur without oxygen cellular death leads to tissue and organ death can occur even after return of perfusion  organ or organism death Slide 25: Ultimate Effects of Anaerobic Metabolism Maintaining perfusion requires: : Maintaining perfusion requires: Volume Pump Vessels Failure of one or more of these causes shock Shock : Shock Hypovolemic Shock = Low Volume Trauma Non-traumatic blood loss Vaginal GI GU Burns Diarrhea Vomiting Diuresis Sweating Third space losses Pancreatitis Peritonitis Bowel obstruction Shock : Shock Cardiogenic Shock = Pump Failure Acute M I CHF Bradyarrhythmias Tachyarrhythmias Mechanical obstruction (“distributive shock”) Cardiac tamponade Tension pneumothorax Pulmonary embolism Shock : Shock Vasogenic Shock = Low Resistance Spinal cord trauma neurogenic shock Depressant drug toxicity Simple fainting Shock : Shock Mixed Shock Septic Shock Overwhelming infection Inflammatory response occurs Blood vessels Dilate (loss of resistance) Leak (loss of volume) Shock : Shock Mixed Shock Septic Shock Fever Increased O2 demand Increased anaerobic metabolism Bacterial toxins Impaired tissue metabolism Shock : Shock Mixed Shock Anaphylactic Shock Severe allergic reaction Histamine is released Blood vessels Dilate (loss of resistance) Leak (loss of volume) Shock : Shock Mixed Shock Anaphylactic Shock Histamine release Extravascular smooth muscle spasm Laryngospasm Bronchospasm Shock : Shock Progressive syndrome Three phases Compensated Decompensated Irreversible Shock : Shock Signs and symptoms due to: Hypoperfusion Compensatory responses Compensated Shock : Compensated Shock Baroreceptors detect fall in BP Usually 60-80 mm Hg (adult) Sympathetic nervous system activates What are the primary SNS Neurotransmitters & their effects? Compensated Shock : Compensated Shock Cardiac effects Increased force of contractions Increased rate Increased cardiac output Compensated Shock : Compensated Shock Peripheral effects Arteriolar constriction Pre-/post-capillary sphincter contraction Increased peripheral resistance Shunting of blood to core organs Compensated Shock : Compensated Shock Decreased renal blood flow Renin released from kidney arteriole Renin & Angiotensinogen combine Converts to Angiotensin I Angiotensin I converts to Angiotensin II Peripheral vasoconstriction Increased aldosterone release (adrenal cortex) promotes reabsorption of sodium & water Compensated Shock : Compensated Shock Decreased blood flow to hypothalamus Release of antidiuretic hormone (ADH or Arginine Vasopressin) from posterior pituitary Retention of salt, water Peripheral vasoconstriction Compensated Shock : Compensated Shock Insulin  secretion caused by epinephrine contributes to hyperglycemia Glucagon  release caused by epinephrine promotes liver glycogenolysis & gluconeogenesis ACTH stimulates adrenal cortex release of cortisol  glucose production Compensated Shock : Compensated Shock Peripheral capillaries contain minimal blood Stagnation Aerobic metabolism changes to anaerobic Extracellular potassium shifts begin Compensated Shock : Compensated Shock Presentation Restlessness, anxiety Earliest sign of shock Tachycardia ?Bradycardia in cardiogenic, neurogenic Compensated Shock : Compensated Shock Presentation Normal BP, narrow pulse pressure Falling BP = late sign of shock Mild orthostatic hypotension (15 to 25 mm Hg) “Possible” delay in capillary refill Compensated Shock : Compensated Shock Presentation Pale, cool skin Cardiogenic Hypovolemic Flushed skin Anaphylactic Septic Neurogenic Compensated Shock : Compensated Shock Presentation Slight tachypnea Respiratory compensation for metabolic acidosis Compensated Shock : Compensated Shock Presentation Nausea, vomiting Thirst Decreased body temperature Feels cold Weakness Slide 48: Decreased Cardiac Output Aldosterone, ADH Release Catecholamine Release Increased Blood Volume Increased PVR Increased Cardiac Output Increased Myocardial Work, O2 Demand Increased Volume Loss Myocardial Ischemia Compensated Shock Leading to Decompensation Decompensated Shock : Decompensated Shock Presentation Cardiac Effects Decreased RBC oxygenation Decreased coronary blood flow Myocardial ischemia Decreased force of contraction Decompensated Shock : Decompensated Shock Presentation Peripheral effects Relaxation of precapillary sphincters Continued contraction of postcapillary sphincters Peripheral pooling of blood Plasma leakage into interstitial spaces Decompensated Shock : Decompensated Shock Presentation Peripheral effects Continued anaerobic metabolism Continued increase in extracellular potassium Rouleaux formations of RBCs “pile up like coins” Cold, gray, “waxy” skin Decompensated Shock : Decompensated Shock Presentation Listlessness, confusion, apathy, slow speech Tachycardia; weak, thready pulse Decreased blood pressure Moderate to severe orthostatic hypotension Decreased body temperature Tachypnea Irreversible Shock : Irreversible Shock Post-capillary sphincter relaxation Loss of peripheral vascular resistance Irreversible Shock : Irreversible Shock Washout of accumulated products Hydrogen ion Potassium Rouleaux formations Carbon dioxide Rouleaux formations microembolize in lungs Systemic metabolic acidosis occurs Cardiac Output decreases further Irreversible Shock : Irreversible Shock Presentation Confusion, slurred speech, unconscious Slow, irregular, thready pulse Falling BP; diastolic goes to zero Cold, clammy, cyanotic skin Slow, shallow, irregular respirations Dilated, sluggish pupils Severely decreased body temperature Irreversible Shock : Irreversible Shock Irreversible shock leads to: Renal failure Hepatic failure Disseminated intravascular coagulation (DIC) Multiple organ systems failure Adult respiratory distress syndrome (ARDS) Death Disseminated Intravascular Coagulation (DIC) : Disseminated Intravascular Coagulation (DIC) Decreased perfusion causes tissue damage/necrosis Tissue necrosis triggers diffuse clotting Diffuse clotting consumes clotting factors Fibrinolysis begins Severe, uncontrolled systemic hemorrhage occurs Adult Respiratory Distress Syndrome (ARDS) : Adult Respiratory Distress Syndrome (ARDS) AKA: “Shock Lung”, “Da Nang Lung” Decreased perfusion damages alveolar and capillary walls Surfactant production decreases Fluid leaks into interstitial spaces and alveoli Gas exchange impaired Work of breathing increases Shock Classifications : Shock Classifications Hypovolemic Cardiogenic Vasogenic (Distributive) Neurogenic Shock Classifications : Shock Classifications Hypovolemic Causes Hemorrhage Plasma Fluid & Electrolytes Endocrine Shock Classifications : Shock Classifications Cardiogenic Causes Contractility Rate Obstructive (Preload/Afterload) Tension pneumothorax Pericardial tamponade Pulmonary embolism Severe Hypertension Shock Classifications : Shock Classifications Vasogenic (distributive) Increased venous capacitance low resistance, vasodilation anaphylaxis sepsis Shock Classifications : Shock Classifications Neurogenic (spinal shock) loss of spinal cord function below site of injury loss of sympathetic tone cutaneous vasodilation relative bradycardia Key Issues In Shock : Key Issues In Shock Tissue ischemic sensitivity Heart, brain, lung: 4 to 6 minutes GI tract, liver, kidney: 45 to 60 minutes Muscle, skin: 2 to 3 hours Resuscitate Critical Tissues First! Key Issues In Shock : Key Issues In Shock Recognize & Treat during compensatory phase Best indicator of resuscitation effectiveness = Level of Consciousness Restlessness, anxiety, combativeness = Earliest signs of shock Key Issues In Shock : Key Issues In Shock Falling BP = LATE sign of shock BP is NOT same thing as perfusion Pallor, tachycardia, slow capillary refill = Shock, until proven otherwise Key Issues In Shock : Key Issues In Shock Isolated head trauma does NOT cause shock (“possible” in peds) General Shock Management : General Shock Management Airway Open, Clear, Maintained Consider Intubation General Shock Management : General Shock Management High concentration oxygen Oxygen = Most Important Drug in Shock Assist ventilation as needed When in Doubt, Ventilate BVM Decompress Tension Pneumothorax General Shock Management : General Shock Management Establish venous access Replace fluid Give drugs, as appropriate Don’t delay definitive therapy Maintain body temperature Cover patient with blanket if needed Avoid cold IV fluids General Shock Management : General Shock Management Monitor Mental Status Pulse Respirations Blood Pressure ECG Hypovolemic Shock : Hypovolemic Shock Control severe external bleeding Elevate lower extremities Avoid Trendelenburg Pneumatic anti-shock garment Hypovolemic Shock : Hypovolemic Shock Two large bore IV lines Infuse Lactated Ringer’s solution Titrate BP to 90-100 mm Hg Hypovolemic Shock : Hypovolemic Shock Do NOT delay transport Start IVs enroute to hospital Where does stabilization of critical trauma occur? Cardiogenic Shock : Cardiogenic Shock Supine, or head and shoulders slightly elevated Do NOT elevate lower extremities Cardiogenic Shock : Cardiogenic Shock Keep open line, micro-drip set Fluid challenge based on cardiovascular mechanism and history Titrate to BP ~ 90 mm Hg Cardiogenic Shock : Cardiogenic Shock Treat the underlying cause if possible Treat rate, then rhythm, then BP Correct bradycardia or tachycardia Correct irregular rhythms Treat BP Cardiac contractility Dobutamine, Dopamine Peripheral resistance Dopamine, Norepinephrine Cardiogenic Shock : Cardiogenic Shock Obstructive Shock Treat the underlying cause Tension Pneumothorax Pericardial Tamponade Isotonic fluids titrated to BP w/o pulmonary edema Control airway Intubation Shock Management : Shock Management Avoid vasopressors until hypovolemia ruled out, or corrected Shock Management : Shock Management Squeezing partially empty tank can cause ischemia, necrosis of kidney and bowel Vasogenic Shock : Vasogenic Shock Consider need to assist ventilations Patient supine; lower extremities elevated Avoid Trendelenburg Vasogenic Shock : Vasogenic Shock Infuse isotonic crystalloid “Top off tank” Consider PASG Consider possible hypovolemia Consider vasopressors Vasogenic Shock : Vasogenic Shock Maintain body temperature Hypothermia may occur Vasogenic Shock : Vasogenic Shock Anaphylaxis Suppress inflammatory response Antihistamines Corticosteroids Oppose histamine response Epinephrine bronchospasm & vasodilation Replace intravascular fluid Isotonic fluid titrated to BP ~ 90 mm Pneumatic AntiShock Garment (PASG) : Pneumatic AntiShock Garment (PASG) Function Primary effect is increased PVR Hemorrhage control through Direct pressure Fracture stabilization Increased intra-abdominal pressure Little effect from autotransfusion Pneumatic AntiShock Garment : Pneumatic AntiShock Garment Indications Multiple lower extremity fractures Pelvic fractures Abdominal injuries Abdominal aortic aneurysm Refractory decompensated shock Pneumatic Antishock Garment : Pneumatic Antishock Garment Contraindications Absolute Pulmonary edema Pneumatic Antishock Garment : Pneumatic Antishock Garment Contraindications Relative Closed head injury Thoracic hemorrhage Impaled object (abdomen, chest?) Pregnancy (abdominal section) Evisceration Ruptured diaphragm Cardiogenic shock Shock in Children : Shock in Children Small blood volume Increased hypovolemia risk Very efficient compensatory mechanisms Failure may cause “sudden” shock Pallor, altered LOC, cool skin = shock UPO Shock in Children : Shock in Children Avoid massive fluid infusion Use 20 cc/kg boluses High surface to volume ratio Increased hypothermia risk Shock in the Elderly : Shock in the Elderly Poor cardiovascular condition Rapid decompensation Sepsis more likely Hypoperfusion can cause: CVA AMI Seizures Bowel Infarctions Renal failure Shock in the Elderly : Shock in the Elderly Assessment more difficult Peripheral vascular disease Weak pulses Altered sensorium Hypertension masking hypoperfusion Beta-blockers masking hypoperfusion Fluid infusion may produce volume overload/CHF Shock in OB Patients : Shock in OB Patients Pulse increases 10 to 15 bpm BP lower than in non-pregnant patient Blood volume increased by 45% Slower onset of shock signs/ symptoms Fluid resuscitation requires greater volume Shock in OB Patients : Shock in OB Patients Oxygen requirement increased 10 to 20% Pregnant uterus may compress vena cava, decreasing venous return to heart Place women in late-term pregnancy on left-side Fetus can be in trouble even though mother looks well-perfused Transport Considerations : Transport Considerations Indications for Rapid Transport Indications for Trauma Center Transport Considerations for Air Medical Transport

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