Early Recognition of Shock, Early intervention
and Treatment of shock
Dr Hardawani Mohd Hussain
Emergency Physician
Hospital Sultanah Bahiyah
Definition of Shock:
Shock is a clinical syndrome which
occurs when there is an abnormality
of the circulatory system that results
in inadequate organ perfusion
and tissue oxygenation.
Imbalance between
O2 demand and O2 supply
Tissue hypoperfussion
Anaerobic metabolism
Lactic acid accumulation
Metabolic acidosis
Coagulopathy, high CO2
Types of shock
1. Hypovolaemic
2. Cardiogenic
3. Obstructive
4. Distributive – septic,
anaphylactic,neurogenic
*HAEMORRHAGE IS THE MOST COMMON
CAUSE OF SHOCK IN THE INJURED PATIENT*
 Shock
in a trauma patients classified as;
-1-hemorrhagic
-1. Hypovolaemic
-2-non hemorrhagic
2. Cardiogenic
-cardiogenic shock
-tension pneumothorax3. Obstructive
-neurogenic shock
4. Distributive – septic,
anaphylactic,neurogenic
-septic shock
 Pump
– failure
 Volume – not enough
 Vessel - failure
Type
Pathophysiology
Treatment
Hypovolemic
Volume depletion
Volume
replacement
Cardiogenic
Pump failure
- Electrical
problem
(arrythmias)
- Structure (LVF)
Anti Arrythmia
Defibrillation
Inotropic
Distributive
Vessel –
generalised
vasodilatation
Fluid
Inotropes
Obstructive
Vessel – obstructed
- Pulmonary
embolism
- Tension
pneumothorax
- Cardiac tamponade
Release obstruction
Determine whether patient really in
shok or not?
- tachyrcardic, tachypneic, pale, altered
sensorium, hypotension and others.
 Determine the cause of shock
- hypovolemic, cardiogenic, distributive
or obstructive.
 Know the pathogenesis of shock
- pump, volume or vessel.
 Treat accordingly
- fluid, inotropes, release obstruction
(chest tube, pericardiocentesis)

MTLS
HYPOVOLAEMIC SHOCK
• Most common cause of shock in the trauma
patient
• Haemorrhage is defined as an acute loss of
circulating blood volume
• Normal blood volume in adult : 7% of body weight
• Normal blood volume in paed.: 80mls/kg
Note:
Tachycardia is
the first sign
of shock
INITIAL PATIENT ASSESSMENT
1. Recognition of shock
- tachycardia is the first sign
of shock
2. Assessment of blood loss
- anatomical
- physiological
Recognition of shock
 Any injured patient who is cool & has
tachycardia is considered to be in shock until
proven otherwise
 Infant
> 160/min
 Preschool-age child
> 140/min
 School to puberty
>120/min
 Adult
>100/min
Mini MTLS 2014
MTLS
ESTIMATED BLOOD LOSS CAUSED
BY FRACTURES
Pelvis
2.0 - 4.0 L (40 - 80% TBW)
Femur
1.0 - 2.5 L (20 - 50% TBW)
Tibia
0.5 - 1.5 L (10 - 30% TBW)
Humerus
0.5 - 1.5 L (10 - 30% TBW)
For an open fracture the loss is two or three
times greater
Life Threatening Injuries
 multiple
trauma
 severe crush injury
 severe vascular injury
 amputation
 Pelvic injury
Limb Threatening Injuries
 vascular
injury
 compartment syndrome
 compound fracture
 major joint dislocation
 nerve injury
MANAGEMENT OF
HAEMORRHAGIC SHOCK
A. Physical Examination
ABCDE
B. Vascular Access
C. Initial Fluid Therapy
D. Evaluation and Monitoring
E. Definitive treatment
A. PHYSICAL EXAMINATION
1. Airway
- establish a patent airway
- administer oxygen
- maintain SpO2 >95%
2. Breathing
- ensure adequate ventilation
- consider tension pneumothorax
3. Circulation
- control obvious haemorrhage by direct
pressure over bleeding site
- obtain adequate intravenous access
- assess tissue perfusion
4. Disability
- neurologic examination
5. Exposure
B. VASCULAR ACCESS
• 2 large bore IV cannula 16 - 14 G
- forearm or antecubital veins
- central venous line using a short
cannula
- cutdown at the saphenous or arm
veins
• In paediatrics, intraosseous needle access
in failure to get a peripheral line
C. INITIAL FLUID THERAPY
• Initial fluid bolus
- paediatric - 20ml/kg
- adults - 1 - 2 L balanced salt solution
• Crystalloid
- Ringer’s lactate (Hartmann’s solution)
- Normal Saline (0.9% saline)
- replace 3 ml of crystalloid for 1 ml
of blood lost
The patient’s response to initial fluid
resuscitation is the key to determing
subsequent therapy.
There are three possible patterns of response
to the initial fluid bolus:
• rapid response,
• transient response, and
• minimal or no response.
Rapid Response
These patients respond rapidly and favorably
to the initial fluid bolus with hemodynamic
normalization
•remain stable when IV fluids are decreased to
maintenance
•Usually these patients have lost less than 20%
of their blood volume
•don’t need addition fluid boluses or blood
transfusion
However, it is still critical to ensure that
surgical consultation be obtained immediately
as emergency surgery may become suddenly
necessary.
Transient Responders
These patients respond to the initial fluid bolus
with improvement in their vital signs and
improvement in perfusion
• But when the bolus infusion is slowed to
maintenance their vitals and perfusion
deteriorate
•These patients either have continuing blood
loss or they need more fluid and/or blood
•Usually these patients have lost 20% to 40% of
their blood volume
They need blood and blood products and they
need immediate surgical or angiographic control
of internal hemorrage.
Minimal or No Response
These patients have minimal or no response to
fluid bolus and blood administration
• They
need
immediate
surgical
or
angiographic control of internal or they will
die
•In patients with minimal or no response to
fluid bolus, it is important to consider other
causes of failure to respond to fluids and
blood (namely pump failure caused by cardiac
contusion, cardiac tamponade, and tension
pneumothorax) but they are uncommon
•By far the most common cause of minimal or
no response to fluids and blood is
exasanguinating hemorrhage.
D. EVALUATION AND MONITORING
1. General
- return of normal PR, BP, pulse pressure
- improvement in central nervous system
status
- improvement in skin circulation
2. Urinary output
• The renal response to restoration of
perfusion is sensitive i.e. it can
reflect organ perfusion
• adult
: 50ml/hr
• paediatric
: 1ml/kg/hr
3. Central Venous Pressure
- reflects the intravascular volume
4. Acid - base balance
- metabolic acidosis is due to prolonged
shock and inadequate resuscitation
- persistent acidosis should be treated
with increased fluid and not IV NaHCO3
E. DEFINITIVE TREATMENT
Fluid resuscitation does not replace early
definitive intervention and surgery to control the
haemorrhage.
Definitive care should be instituted within
the “GOLDEN HOUR”.
THANK YOU