Shock Hemorrhage

and IV Fluid Resuscitation

dr. Yunus, Sp.BS

 Shock

Definition: Inadequate tissue Perfusion and

Oxygenation

Effect: Cellular injury, Organ failure, Death

Causes: hemorrhagic and non-hemorrhagic

Types of Shock

?
 Types of Shock
S Septic & Spinal

H Hypovolemic & Hemorrhagic

O Obstructive

C Cardiogenic

K Anaphylactic
 Hemorrhage & Trauma
Normal blood volume
Adults: 7% of ideal weight
70 kg man had blood volume of 5 liters
Child: 9% of ideal weight

Hemorrhage
Loss of circulating blood volume
How much volume loss to cause shock?
Classes of hemorrhage I-IV
 Hemorrhagic Shock: The Classes

Class I Class II Class III Class IV

EBL EBL EBL EBL

<750cc 750cc 1500cc 1.5L 2L >2L

<15% of TBV 15 30% of TBV 30 40% of TBV >40% of TBV

S&S S&S S&S

S&S
HR: increased
HR: increased HR: increased
BP: decreased
None/minimal Pulse Pressure: decreased BP: decreased (<60)
MS: agitated
BP: no change MS: decreased
Urine Output: decreased

Tx Tx Tx Tx

1. Crystalloid (1 2L) 1. Crystalloid (2L)

Crystalloids Crystalloids 2. Transfusion (1 2units) 2. Transfusion (2 4 units)
3. Identify source of Bleed(*5) 3. Identify source of Bleed(*5)
4. Operating Room
 Two Goals in the management of
any Shock

GOAL #1 GOAL #2

ID and Tx the cause Support the patient

 Two Goals in the management of
Hemorrhagic Shock
1 - ID and Tx the cause 2 - Support the patient

Locate the source of Establish IV access

bleeding

Control it Fluid Resuscitation

 Goal #1
Identification and Treatment of the cause

A-Locate the source of bleeding

B-Control it
 Algorithm to Identify the Bleeding Source
in a Hypotensive Trauma Patient

5 Possible locations
for significant bleeding

1 2 3 4 5

Chest cavity Abdominal Cavity Pelvis/Retroperitoneum External Bleeding Long Bones

Clue: Clue: Clue: Clue:

Clue:
-Abdominal/Pelvic trauma Blood on Floor 1) Deformed extremity
-Chest trauma - Abdominal trauma
-Flank ecchymosis Check head/scalp 2) Crush injury
- Diminished breath sounds - Distended abdomen
-Unstable pelvis Check extremity 3) Mangled extremity
- Desaturation, O2 requirement
-Hematuria

Place chest tube Chest Extremity EBL

DPL (+) First do DPL Pelvic Scalp
On affected side X-Ray Bleed Femur Fx 750cc1L
FAST -Gross blood (supra umbilical) X-Ray bleed
(+) Ptx-Htx Tib Fx 500-750cc
Free fluid r/o intrabdominal (+) Fx
- >105 RBCs
bleed
Chest tube Whip-stitch Pressure Consult Ortho
1L of Blood DPL (+) DPL (-)
with
and
nylon suture
Elevation Immobilization and
minimal manipulation
1) Wrap sheet around pelvis Bleeding not of injured extremity
OR Thoracotomy 2) Pelvic angiography controlled using splint (3Ps)
OR Exploratory laparotomy

(+) Blush/Extravasation Tourniquet proximal

to injury Be alert for
compartment
- set > systolic BP
syndrome
Angioembolization
 Algorithm to Identify the Bleeding Source
in a Hypotensive Trauma Patient

5 Possible locations
for significant bleeding

1 2 3 4 5

External Bleeding
Chest cavity Abdominal Cavity Pelvis/Retroperitoneum Long Bones
floor
 Algorithm to Identify the Bleeding Source
in a Hypotensive Trauma Patient

5 Possible locations
for significant bleeding

1 2 3 4 5

External Bleeding
Chest cavity Abdominal Cavity Pelvis/Retroperitoneum Long Bones
floor

Clue: Clue: Clue: Clue:

Clue:
-Abdominal/Pelvic trauma Blood on Floor 1) Deformed extremity
-Chest trauma - Abdominal trauma
-Flank ecchymosis Check head/scalp 2) Crush injury
- Diminished breath sounds - Distended abdomen
-Unstable pelvis Check extremity 3) Mangled extremity
- Desaturation, O2 requirement
-Hematuria

Place chest tube Chest Extremity EBL

First do DPL Pelvic Scalp
On affected side X-Ray DPL (+) Bleed Femur Fx 750cc1L
FAST (supra umbilical) X-Ray bleed
(+) Ptx-Htx -Gross blood Tib Fx 500-750cc
Free fluid r/o intrabdominal (+) Fx
bleed
Chest tube Whip-stitch Pressure Consult Ortho
1L of Blood DPL (+) DPL (-)
with
and
nylon suture
Elevation Immobilization and
minimal manipulation
1) Wrap sheet around pelvis Bleeding not of injured extremity
OR Thoracotomy 2) Pelvic angiography controlled using splint (3Ps)
OR Exploratory laparotomy

(+) Blush/Extravasation Tourniquet proximal

to injury Be alert for
compartment
- set > systolic BP
syndrome
Angioembolization
 Goal #2

Support the patient

A-Establish IV access

B-Fluid Resuscitation
Establish IV access before it is too late
 A - Establish good IV access

Must insure good vascular access:

2 large caliber: 14-16-gauge IV
-Rate of flow is proportional

Central Access: Central line or Cordis

-Cannot obtain peripheral access
- Severe hypovolemia, extremity injury
-Massive bleeding
(*Unless pelvic or abdominal vascular injury suspected!)
 B - Fluid Resuscitation

Initial fluid bolus

1-2 liters in adults
20mL/kg in children

Type of fluid for resuscitation

-Isotonic electrolyte solution
Lactated ringers vs. normal saline
 Electrolyte composition of crystalloid solutions

pH Na Cl Lactate Ca K Osm
Fluid (mEq/L) (mEq/L) (mEq/l) (mEq/L) (mEq/L) (mOsm/L)

LR 6.7 130 109 28 3 4 279

NS 6.0 154 154 0 0 0 308

LR, lactated Ringers solution; NS, normal saline solution

 Assess patients response to fluid
resuscitation

Clinical parameters:
MS: return of
CVS: HR, MAP
Urinary output
 Assess patients response to fluid
resuscitation
Three possible responses:

1. Responders
Bleeding has stopped

2. Transient responders
Something is still slowly bleeding!

3. Non responders:
Ongoing significant bleeding!
Immediate need for intervention!
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