Shock and Trauma Resuscitation 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 bleeding- Surgeon’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 Monitoring • Basic • Labs- CBC, coags, lytes, ABGs • Advanced • POC • A line • Hemoque- Hgb • CVP? • iStat- lytes/gases • PPV- FloTrac • ROTEM- coagulation • TEE 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!!