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ShockCritical Concepts - Surgery
SHOCK
“Rude unhinging of the machinery of life”
-Gross
“A momentary pause in the act of death”
-Dr. Cowley
SHOCK
Inadequate delivery of oxygen and nutrients necessary for normal tissue and cellular
function.
Types of Shock
Hypovolemic
Cardiogenic
Neurogenic (distributive)
Septic (distributive)
Obstructive
Types of Shock
CVP CO SVR other
Hypovolemic Cold and clammy
Cardiogenic
Neurogenic Warm and rosy
Septic
Obstructive Clinical exam
Types of Shock
Hypovolemic
Cardiogenic
Neurogenic (distributive)
Septic (distributive)
Obstructive
How to Resuscitate
ABC’sChoice of line?What to use?Rate of administration?How much?When to stop?
ABCDE’s
AirwayBreathing
Tension ptx?Circulation
Tamponade?Disability
Neurogenic shock?Exposure
Signs of hemorrhage/trauma?
Intravenous Access
Intravenous Access
Hagen-Poiseuile Law
Which fluid?
CrystalloidLactated ringersNormal Saline
ColloidSyntheticAlbuminBlood plasma
Rate?
How much?
Class Blood Loss(ml)
Blood Loss(%)
HR BP UOP Mental Status
I <750 <15% <100 NL >30 NL
II 750-1500
15-30% >100 20-30 anxious
III 1500-2000
30-40% >120 5-15 confused
IV >2000 >40% >140 None lethargic
How much?
Bolus1 liter
Blood1:1
Massive Transfusion>10 PRBCs in 24 hrs
When to stop?
Vital signsUOPBase deficitLactate
HEMOSTASIS METHODS
Objectives
Review general concepts about achieving hemostasis in a bleeding subject
Discuss non-surgical compression and tourniquet methods
Discuss surgical methods using sutures, ligatures, and other devices
Understand the application and use of pelvic binders for pelvic fractures
GENERAL CONCEPTS
Direct controlBe as specific (pinpoint) as possible
Avoid collateral damageInjury to tissue around point of controlDistal ischemia
Temporary versus permanent
Types of Control
Non-SurgicalCompressionTourniquetsPro-coagulant products
SurgicalLigationSuturing/StaplingCautery
Non-Surgical Control- Compression
Applying direct pressure to the source o bleeding
Usually the best first step
Usually done wrong
Keys to Success
1- Pinpoint Source of Bleeding
a- Use minimal surface area
- Concentrate pressure to exact source of bleeding
b- Use minimal gauze
-Gauze is for ABSORPTION
- Fold minimal amount of gauze into minimal size of square
Keys to Success
2- Apply consistent pressure
A- Get into a comfortable position
B- Apply bandage/device whenever possible
Pressure Dressing
Non-Surgical Control- Tourniquet
Circumferential compression cutting of blood flow to distal limb/appendage
Generally frowned uponOnly when direct pressure cannot be
applied due to the nature of the injuryAmputationsNear-amputations
a
Keys to Success
Complete cessation of arterial blood flowNon-elastic bandageTight enough to cause pain
Dress the open wound
Surgical Hemostasis
Bleeding Skin/Tissue EdgesSutureStapleDressing/Adhesive
Severed vesselSutureLigationClip
a
Bleeding Skin/Tissue Edges
Wash out wound whenever possible Suture
Simple interruptedSimple runningLocking runningHorizontal mattress
StapleFaster but less available
Dressing/AdhesiveOnly if able to temporarily staunch the blood low