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AIP: Trauma > Hypotensive shock > Flashcards

Hypotensive shock Flashcards

1
Q

What is the definition of shock?

A

inadequate tissue perfusion and oxygenation

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2
Q

What are the 4 key types of shock in the trauma patient?

A
  1. Hypovolaemic
  2. Cardiogenic
  3. Obstructive
  4. Neurogenic
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3
Q

What is hypovolaemic shock?

A

loss of circulating volume e.g. haemorrhage or burns

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4
Q

What is cardiogenic shock?

A

faliure of the pump mechanism e.g. cardiac contusion

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5
Q

What is obstructive shock?

A

cardiac output is compromised by external compressive forces e.g. tension pneumothorax or cardiac tamponade

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6
Q

What is neurogenic shock?

A

vasodilatation from loss of sympathetic outflow e.g. spinal injury

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7
Q

What is the definition of haemorrhage?

A

acute loss of circulating blood volume

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8
Q

What is the most common cause of shock in the trauma patient?

A

haemorrhage

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9
Q

What are 5 examples of potential sources of haemorrhage?

A
  1. External bleeding
  2. Chest
  3. Abdomen and retroperitoneum
  4. Pelvis
  5. Femurs
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10
Q

What are 7 clinical features of shock due to haemorrhage?

A
  1. Tachypnoea
  2. Tachycardia (bradycardia is a late terminal sign)
  3. Hypotension (systolic BP < 90mmHg)
  4. Pallor and cold peripheries
  5. Reduced conscious level
  6. Reduced urinary output
  7. ABG metabolic acidosis
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11
Q

What pattern might an ABG show in shock due to haemorrhage?

A

metabolic acidosis

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12
Q

What is the blood volume in a healthy adult?

A

7% of ideal body weight i.e. 70kg patient has circulating blood volume of approimately 5L

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13
Q

How can hypovolaemic shock be graded?

A

Grades I-IV based on volume of blood loss

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14
Q

What is the volume of blood loss is seen in each grade of hypovolaemic shock?

A

I: up to 750ml, <15%

II: 750-1500ml, 15-30%

III: 1500-200ml, 30-40%

IV: >2000ml, >40%

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15
Q

What clinical features may be seen in Grade I blood loss?

A

tachypnoea, may have mild tachycardia

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16
Q

What are 3 clinical features of grade II blood loss?

A
  1. tachycardia >100
  2. narrowed pulse pressure
  3. pallor
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17
Q

What are 2 clinical features of grade III blood loss?

A
  1. hypotension
  2. reduced GCS, confused or anxious
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18
Q

What are 3 clinical features of grade IV blood loss?

A
  1. may become bradycardic
  2. marked hypotension
  3. becoming unconscious
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19
Q

What are 7 situations when there may be an underestimation of blood loss in haemorrhage?

A
  1. elderly
  2. medications e.g. beta blockers
  3. pacemarkers
  4. hypothermia
  5. children
  6. pregnancy
  7. athletes
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20
Q

Why might there be an underestimation of blood loss in the elderly?

A

less able to compensate for acute hypovolaemia as their sympathetic drive is reduced

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21
Q

Why might there be an underestimation of blood loss in people taking beta blockers?

A

beta blockers will prevent a tachycardia in response to blood loss

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22
Q

Why might there be an underestimation of blood loss in the patients with pacemakers?

A

pulse will not be altered by blood loss i.e. won’t see tachycardia

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23
Q

Why might there be an underestimation of blood loss in hypothermia?

A

respiratory rate, pulse and blood pressure will be low regardless of blood loss

24
Q

Why might there be an underestimation of blood loss in children?

A

they will compensate well initially then deteriorate catastrophically

25
Q

Why might there be an underestimation of blood loss in pregnancy?

A

blood volume increases by up to 50% of normal so may only display minimal signs fo shock with severe blood loss

26
Q

Why might there be an underestimation of blood loss in athletes?

A

physiological responses to training means a larger blood volume and lower resting heart rate. therefore even with pulse of 90 may be significant tachycardia in these patients

27
Q

What type of manoeuvre is it very important to avoid in patients with hypovolaemia due to haemorrhage?

A

log roll - if non-compressible haemorrhage, movements can cause dislodgement of formed clots and allow further ongoing haemorrhage

28
Q

What should be used to transfer patients with hypovolaemia due to haemorrhage?

A

scoop stretcher or PAT slide to transfer patient off spinal board or trolley - NOT log roll

29
Q

How can the back be examined in patients with hypovolaemia due to haemorrhage?

A

running gloved hands down back to check for haemorrhage, or 10-15 degree mini log roll to examine first one half of back then other

30
Q

What are 6 aspects of the management of hypovolaemia due to haemorrhage?

A
  1. Haemorrhage control
  2. Fluid resuscitation
  3. Massive transfusion
  4. Damage control surgery
  5. Prevention of hypothermia
  6. Monitor response
31
Q

How can the majority of external bleeding be controlled?

A

direct pressure and elevation

32
Q

On the rare occasion that direct pressure and elevation does not help to stop external bleeding, what is the next step?

A

commercial tourniquet may be necessary to control limb haemorrhage

33
Q

What are the ways to manage internal bleeding in each of the following structures:

  1. chest
  2. abdomen
  3. pelvis
  4. femurs?
A
  1. Chest = theatre
  2. Abdomen = theatre
  3. Pelvis = external splintage ± theatre or embolisation
  4. external splintage ± theatre
34
Q

Which fluids should be used for initial fluid resuscitation in hypotensive shock?

A

warmed crystalloid

35
Q

What blood test should be performed immediately in hypotensive shock?

A

blood should be taken for cross match as soon as possible, also phone blood bank to let them know if sample is urgent

36
Q

What should be done for patients who are non-responders i.e. show no haemodynamic improvement wiht initial fluid administration?

A

receive urgent surgical input and O-negative blood

37
Q

What is the management of transient responders to initial fluids?

A

should receive urgent surgical inpt and group-specific or O-negative blood

38
Q

What is meant by a transient responder?

A

patients who, after receiving initial fluid resuscitation with crystalloid, have improved vital signs but subsequently deteriorate due to ongoing haemorrhage

39
Q

What is meant by rapid responders?

A

patients whose vital signs stabilise permanently after fluids

40
Q

What is the management of rapid responders to initial fluid resuscitation?

A

normally require only crystalloid and can wait for fully cross-matched blood if required

41
Q

What are 2 reasons why large volumes of fluid given to patients with ongoing non-compressible haemorrhage are thought to cause poor outcomes?

A
  1. Raising blood pressure may dislodge clots resulting in further haemorrhage
  2. Fluids dilute clotting factors and the oxygen carrying capacity of the blood
42
Q

What is the aim determining the volume of fluids given to resuscitate patients with hypovolaemic shock?

A

administer sufficient fluids to maintain perfusion fo the vital organs until the patient gets to theatre

43
Q

What is the typical aim for initial fluid resuscitation in hypovolaemic shock?

A

boluses of 250ml to maintain a systolic blood pressure of 80-90 mmHg, a radial pulse or a verbal response

44
Q

What is the exception to the rule of patients requiring fluid resuscitation to achieve systolic blood pressure of 80-90?

A

patients with evidence of head injury who require higher BP to maintain cerebral perfusion pressure: target BP is 100 mmHg

45
Q

What are 4 options for vascular access in hypovolaemic patients?

A
  1. peripheral venous cannulation
  2. intra-osseous access
  3. central venous cannulation e.g. femoral, internal jugular, subclavian
  4. venous cut down e.g. saphenous
46
Q

What is the definition of ‘massive transfusion’?

A

replacement of the patient’s total blood volume in <24h or acute administration of >50% estimated blood volume per hour

47
Q

What are 5 complications of massive blood transfusion?

A
  1. Hypothermia
  2. Dilutional thrombocytopenia
  3. Depletion of clotting factors
  4. Oxygen affinity changes
  5. Hypocalcaemia
48
Q

What are 4 blood tests that should be used within the hour of administering massive transfusion if the patient is still under your care?

A
  1. INR
  2. APTT
  3. Platelets
  4. Fibrinogen
49
Q

Who should you seek advice from when administering a massive tranfusion and regarding what?

A

from haematology: regarding administration of platelets, fresh frozen plasma, or cryoprecipitate

50
Q

What is the triad that often causes death in multiple injured trauma patients?

A
  • coagulopathy
  • hypothermia
  • acidosis

→acidosis

51
Q

What should damage control surgery involve for multiple injured trauma patients?

A

to control haemorrhage, prevent contamination and protect against further injury

e.g. packing abdominal cavity to stop bleeding, use of shunts, only temporarily closing the abdomen or leaving it open

52
Q

What happens following damage control surgery for trauma patients?

A

patient transferred to critical care unit for aggressive correction of coagulopathy and rewarming, before a definitive surgical procedure at a later date (usually 24-48h)

53
Q

Why is it so important to prevent hypothermia in patients with hypovolaemia?

A

it can worsen acidosis and coagulopathy

54
Q

What method of temperature monitoring should be considered?

A

oesophageal temperature probe

55
Q

What can cause temperature measurements to be omitted in a trauma patient?

A

if patient immobilised in head blocks for suspected cervical spine injury

56
Q

What are 3 ways to help warm a patient with hypovolaemic shock?

A
  1. Keep patient warm externally with blankets and a Bair hugger
  2. Fluids should be kept in warming cupboard in resuscitation room prior to administration
  3. Use of a warming system around the giving set is another option but will slow rate of administration
57
Q

What are 5 things that should be measured ot monitor response to fluid resuscitation in hypovolaemic shock?

A
  1. Respiratory rate, O2 sats
  2. ECG for pulse, BP
  3. Catheterise for hourly urine output
  4. GCS
  5. ABG for acidosis, lactate or Hb

AIP: Trauma (20 decks)

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