Hemorraghic Shock
Sara Parker MD
VCU Trauma Conference
STICU Fellow
July 8, 2015
Learning objectives
•
1) Review the classes of shock
•
2) Review treatment options
•
3) Review endpoints of resuscitation
SL
•
26 yo female who presents from OSH as
transfer with multiple GSW to chest, abdomen
and extremities.
•
At OSH, had L chest tube placed and was
given 2u RBC and 1L crystalloid.
Vital signs per EMS
•
HR 120
•
BP 98/53
•
RR 30
•
O2. Sats 99%
•
SBP as low as 80s
What next?
ABCD
•
Airway
•
Breathing
•
Circulation
•
Disability
Repeat Vitals
•
HR 145
•
BP 86/53
•
RR 45
•
Sats 95%
What next?
•
Diagnose hemorrhagic shock
•
Treat the cause
Shock
•
Inadequate oxygen delivery unable to meet the
demands of the tissue leading to global tissue
hypoxia and metabolic acidosis
With what class of hemorrhaghic shock
do you have low blood pressure?
a) Class I
b) Class II
c) Class III
d) Class V
Class 1
Class 2
Class 3
Class 4
Blood loss
<750
750-1500 1500-2000
>2000
HR
<100
100-120
>140
SBP
Normal
Normal
Pulse
Pressure
Normal
120-140
Decreased Decreased
Decreased Decreased Decreased
Classification of Shock
Fluid responsiveness
Infusion of 500cc IVF—improvement of HR, BP
and UOP
Caveats: Athletes, pregnancy, extremes of age
and medication use
What type of shock is likely to be hypotensive
and bradycardic?
a)
b)
c)
d)
Hemorrhagic shock
Neurogenic shock
Septic shock
Anaphylatic shock
Types of Shock
Causes
Pathophysiology
Signs/symptoms
Hypovolemic
Dehydration,
Hemorrhage,
Burn
Decreased preload, Increased HR, dec
CO and increased
pulses, dry skin,
SVRintravascular delayed cap refill,
volume loss
dec UOP
Distributive
Anaphylactic
Neurologic
Septic
Decreased Afterload
Low BP, resp
distress.
Decreased CO,
variable SVR
Normal to inc HR,
dec pulses,
delayed cap refil,
JVD
Cardiogenic
Diagnosis
•
Hgb 12.5, platelets 350, coags pending
•
Pulses are weak, skin clammy, patient can’t remember where
she is
•
Clinical diagnosis--early recognition is KEY
Treatment of Shock
1
Hypotensive volume resuscitation
•
•
crystalloid
•
blood products
•
Goal SBP <100 or MAP >50
Control of bleeding
Hypotensive resuscitation
Titration of initial fluid therapy to a lower than normal
SBP during active hemorrhage did not affect
mortality. --Dutton.
•
Hypotensive resuscitation results in a significant
reduction in blood product transfusions and overall IV
fluid administration. Specifically, resuscitating
patients with the intent of maintaining a target
minimum MAP of 50 mm Hg, rather than 65 mm Hg,
significantly decreases postoperative coagulopathy
and lowers the risk of early postoperative death and
coagulopathy. --Morrison
What is the 4th step of the massive transfusion
protocol at VCU?
a) set up platelets and cyro, release 4 RBC
and 4 plasma
b) setup 4 RBC and 2 Plasma, release 4 RBC
and 2 plasma
c) keep ahead 4 RBC and 4 Plasma
d) release 4 RBC and 4 plasma
Massive Transfusion Protocol
•
Step 1: Set up 4 RBC, 2 Plasma. Keep Ahead 4 RBC and 4 plasma. Release 4
RBC and 2 plasma
•
Step 2: Release 4 RBC and 4 plasma
•
Step 3: Setup platelets and cyro. Release 4 RBC, 4 plasma, Platelets and cyro.
•
Step 4: Release 4 RBC and 4 plasma.
•
Step 5: Release 4 RBC and 4 plasma.
•
Step 6: Setup platelets and cyro. Release 4 RBC, 4 plasma, platelet, cyro.
•
Step 7: Release 4 RBC and 4 plasma.
•
Step 8: Release 4 RBC and 4 plasma.
•
Step 9: Setup platelet and cyro. Release 4 RBC, 4 plasma, platelets, cyro.
Massive transfusion
• Patients who will require a massive transfusion will have improved
outcomes the earlier that this is identified and the earlier that damage
control hematology is instituted. Current evidence does not describe
the best ratio but the preponderance of the data suggests it should be
greater than 2: 3 plasma-to-packed red blood cells. --Nunez et al.
• Trauma patients who arrived to the hospital with an elevated INR had
a greater risk of death than those with a lower INR. However, as the
ratio of FFP:PRBC transfused increased, mortality decreased similarly
between the INR quartiles. --Brown L and Trauma Outcomes Group
Ionotropes
•
Norepinephrine—preferred for shock/sepsis
•
Stimulates beta1-adrenergic receptors and alpha-adrenergic receptors
causing increased contractility and heart rate as well as
vasoconstriction
•
Vasopressin—refractory shock
•
Increases systemic vascular resistance and mean arterial blood
pressure and decreases heart rate and cardiac output
•
Phenylephrine—alpha receptor only, peripheral use
•
Potent, direct-acting alpha-adrenergic agonist with virtually no betaadrenergic activity; produces systemic arterial vasoconstriction.
What is the urine output goal for resuscitation for
adults?
a) 0.2 mg/kg/hr
b) 0.4 mg/kg/hr
c) 0.5 mg/kg/hr
d) 1.0 mg/kg/hr
End Points of Resuscitation
•
Skin perfusion
•
Urinary output
•
Lactate
Bilbiography
•
ATLS Student Manual. Chicago: American College of Surgeons, 2012.
•
Brown L et al with the Trauma Outcomes Group. A High FFP:PRBC Transfusion Ratio
Decreases Mortality in All Massively Transfused Trauma Patients Regardless of Admission
INR. J Trauma 2011: 71(2 O 3) S358-363.
•
Cotton BA et al. Predefined massive transfusion protocols are associated with a reduction in
organ failure and postinjury complications. J Trauma 2009: 66: 41-9.
•
Dutton, et al. Hypotensive resusciation during active hemorrhage: impact on in-hospital
mortality. J Trauma 2002 52:1141-1146.
•
Marino, Paul. The ICU Book, 4th ed. Philadelphia: Wolters Kluwer, 2014.
•
Morrison C Anne et al. Hypotensive Resuscitation Strategy Reduces Transfusion
Requirements and Severe Postoperative Coagulopathy in Trauma Patients With Hemorrhagic
Shock: Preliminary Results of a Randomized Controlled Trial. J Trauma - Injury, Infection and
Critical Care 2011 70:3: 652-663.
•
Nunez TC. Transfusion therapy in massive hemorrhage. Current Opinion in Critical Care.
2009: 15 (6) 536-41.