Bonjo Batoon, CRNA, MS
R Adams Cowley
Shock Trauma Center
Baltimore, MD

The Problem of Trauma
• 50% die before they reach a hospital
• Head injury major cause of death in the field/hospital
• Uncontrolled hemorrhage or MOF-related shock is the cause of death in about 40% of deaths
• 20% of hemorrhagic deaths potentially preventable
• 17% of military casualties from failed hemorrhage are potentially preventable
Dubick MA, et al. US Army Institute of Surgical Research, 2006; report # A508184

Shock by definition
• A failure of adequate oxygen delivery or utilization at the cellular level, perpetuated by cellular and humoral responses
• Prolonged shock results in a cumulative “oxygen debt”, severe metabolic derangement, and disruption of endorgan integrity and homeostasis

Shock by definition
• A state of inadequate tissue perfusion
• A cellular and end-organ disorder
• Not a disorder of the macro-circulation
• Decreased BP does not equal shock

Oxygen Debt

Types of shock
• Hemorrhagic- Most common
• Non-hemorrhagic
• Cardiogenic
• Neurogenic
• Septic
• Tension pneumothorax
• Poisoning

Signs & Symptom of Shock
• Tachycardia
• Tachypnea
• Decreased capillary refill
• Hypotension
• Narrow pulse pressure
• Altered mental status
• Cyanosis, pallor, diaphoresis
• Hypothermia
• Decreased urine output
• Absent pulse oximetry signal*
• +FAST/CT*

Classification of Shock

Lethal Triad
Coagulopathy
Acidosis
Hypothermia

More than the Lethal Trial
Hess JR, Brohi K, Dutton RP; et al. The coagulopathy of trauma: a review of mechanisms, J
Trauma 2008 654 748-754.

Resuscitation Goals
• Early recognition of the shock state
• Oxygenate and ventilate
• Restore organ perfusion
• Restore homeostasis / repay “oxygen debt”
• Stop the bleedingSurgeon’s job
• Treat coagulopathy
• Restore the circulating volume
• Continuous monitoring of the response

Components to Resuscitation
• Airway
• Breathing
• Circulation
• Exposure

Airway
• DL
• Video laryngoscopy
• AFOI
• RSI vs MRSI
• Cricoid pressure
• C-spine issues
• Surgical cricothyrotomy when all else fails

Breathing
• Secure airway most important
• Adequately oxygenate
• Monitor CO2
• Consider lower Vt in hypotensive pts

Circulation
• Adequate IV access
• Peripheral
• 16G or greater
• Know flow rates for each cathether
• Preferably central access
• IJ vs SC vs femoral
• Cordis vs double lumen catheters vs triple lumen

Exposure
• 34 ° C was the critical point at which enzyme activity slowed significantly, and at which significant alteration in platelet activity was seen. Fibrinolysis was not significantly affected at any of the measured temperatures
• Watts, Dorraine Day, et al. "Hypothermic coagulopathy in trauma: effect of varying levels of hypothermia on enzyme speed, platelet function, and fibrinolytic activity." The Journal of Trauma and
Acute Care Surgery 44.5 (1998): 846-854.
• Keeping pt warm
• Warm blood products
• Bair hugger type devices
• Warm operating room

• Basic
• Advanced
• A line
• CVP?
• PPV- FloTrac
• TEE
Monitoring
• Labs- CBC, coags, lytes,
ABGs
• POC
• Hemoque- Hgb
• iStat- lytes/gases
• ROTEM- coagulation

Clotting Dynamics

Components to Resuscitation
• Crystalloids
• Colloids
• Blood products

Crystalloids
• LR
• NS
• Plasmalyte
• Crystalloids are not and should not be the mainstay of trauma resuscitation!!

Prehospital fluids

Prehospital Fluids

Colloids
• Starches
• Coagulopathy
• Hespan max dose 20ml/kg
• Albumin
• Allergic rxs

Blood Products
• RBCs
• FFP
• Plts
• Cryoprecipitate
• Other hemostatic agents
• fVIIa, PCCs, fibrinogen concentrate

Resuscitation Strategies
• Ratio based resuscitation
• RBC;FFP; RBC:FFP:PLTs
• Laboratory based resuscitation
• Lab delays
• Lost samples
• Point of Care
• Coagulation concentrates
• ROTEM

Component Therapy
Dutton, R. P. (2012), Resuscitative strategies to maintain homeostasis during damage control surgery. Br J Surg, 99: 21–28. doi: 10.1002/bjs.7731

Damage Control
Anesthesia
Dutton, RP. Damage Control Anesthesia. Trauma Care.
2005;15:197-201.

Thank you!!