Hemorraghic ShockSara Parker MD

VCU Trauma ConferenceSTICU FellowJuly 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 Ib) Class IIc) Class IIId) Class V

Classification of Shock

Class 1 Class 2 Class 3 Class 4

Blood loss <750 750-1500 1500-2000 >2000

HR <100 100-120 120-140 >140

SBP Normal Normal Decreased

Decreased

Pulse Pressure

Normal Decreased

Decreased Decreased

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) Hemorrhagic shockb) Neurogenic shockc) Septic shockd) Anaphylatic shock

Types of ShockCauses Pathophysiology Signs/symptoms

Hypovolemic Dehydration, Hemorrhage,

Burn

Decreased preload, CO and

increased SVRintravascular

volume loss

Increased HR, dec pulses, dry skin, delayed cap refill, dec

UOP

Distributive AnaphylacticNeurologic

Septic

Decreased Afterload

Low BP, resp distress.

Cardiogenic Decreased CO, variable SVR

Normal to inc HR, dec pulses,

delayed cap refil, JVD

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 Plasmad) 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 beta-adrenergic activity; produces systemic arterial vasoconstriction.

What is the urine output goal for resuscitation for adults?

a) 0.2 mg/kg/hrb) 0.4 mg/kg/hrc) 0.5 mg/kg/hrd) 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.