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Conflict And Catastrophe Medicine > Shock And Haemorrhage Control > Flashcards

Shock And Haemorrhage Control Flashcards

1
Q

Learning Objectives

A
  • Define shock
  • Identify clinical shock syndromes
  • Compressible vs non compressible bleeding
  • Relate casualty symptoms to underlying condition
  • Discuss management principles
  • Demonstrate shock management skills
  • Sidenote: Steve said you likely won’t be asked to go into too much detail in the actual exam
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2
Q

What is shock?

A

The body’s reaction to inadequate tissue perfusion and oxygenation

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3
Q

List the different types of shock

A
  • Hypovolaemic
  • Cardiogenic
  • Neurogenic
  • Anaphylactic
  • Septic
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4
Q

Describe the early pathology of shock

A
  • Decreased venous return
  • Reduction in cardiac output
  • Hypotension
  • Hypoperfusion, if uncorrected………
  • Leading to Tissue hypoxia
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5
Q

What are the corrective mechanisms for shock?

A
  • Fluid moves from tissues into blood vessels
  • Increase in heart rate: Tachycardia - sympathetic response
  • Vasoconstriction: Cold & pale - sympathetic response
  • Reduced urinary output
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6
Q

Describe the late pathology of shock

A
  • Anaerobic metabolism
  • Production of lactic acid
  • Metabolic acidosis
  • Cellular oedema
  • Tissue oedema
  • Loss of organ function
  • Cell death
  • Leads to death
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7
Q

Describe Hypovolaemic shock

A
  • lMost common cause of shock in war
  • Due to FLUID LOSS: (haemorrhage / burns etc)
  • Most amenable to prompt management
  • Must be recognised early
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8
Q

Where is this blood from Hypovolaemic shock found?

A
  • “Blood on the floor and 4 more”
  • Chest
  • Abdomen
  • Pelvis & retroperitoneum
  • Thighs - long bones
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9
Q

Where is this blood from Hypovolaemic shock found?

A
  • “Blood on the floor and 4 more”
  • Chest
  • Abdomen
  • Pelvis & retroperitoneum
  • Thighs - long bones
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10
Q

What occurs as a result of the loss of circulating volume?

A
  • Injury tissue -> Blood loss -> Oedema
  • Not just blood loss
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11
Q

List the classifications of the circulating blood volume loss

A
  • Class I: 0-15% - 750ml
  • Class II: 15-30% - 750-1500ml
  • Class III: 30-40% - 1500-2000ml
  • Class IV: > 40% - 2000ml
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12
Q

How do you assess blood loss?

A
  • Closed tibial fracture
  • Wound size of adult hand
  • Clot size of adult fist
  • Coverage of 2m square on non porous surface
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13
Q

Give examples of assessing blood loss

A
  • Closed femur fracture: 1.5 litres
  • Fractured pelvis: 3 litres
  • Hemithorax: 2 litres
  • Fractured rib: 150 ml
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14
Q

Describe Class 1 Shock

A
  • Heart rate: <100
  • Systolic BP: Normal
  • Pulse pressure: Normal
  • Cap refill: Normal
  • Resp. Rate: 14-20
  • Urine output: >30
  • Cerebral function: Normal /sl
  • Mood: Anxious
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15
Q

Describe Class 2 Shock

A
  • Heart rate: >100
  • Systolic BP: Normal
  • Pulse pressure: Narrowed
  • Cap refill: Prolonged
  • Resp. Rate: 20-30
  • Urine output: 20-30
  • Cerebral function:
  • Mood: Anxious/Frightened/hostile
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16
Q

Describe Class 3 Shock

A
  • Heart rate: 120 - 140
  • Systolic BP: Decreased
  • Pulse pressure: Narrowed
  • Cap refill: Prolonged
  • Resp. Rate: >30
  • Urine output: 5-20
  • Cerebral function:
  • Mood: Anxious/Confused
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17
Q

Describe Class 4 shock

A
  • Heart rate: >140
  • Systolic BP: Very low
  • Pulse pressure: Very narrow / abnormal
  • Cap refill: Very long
  • Resp. Rate: >35
  • Urine output: negligible
  • Cerebral function:
  • Mood: Confused/unresponsive
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18
Q

What are some concerns about Hypovolaemic shock

A
  • Beware of:
  • The very old: Poorly tolerated
  • The very young: Well compensated before signs start to appear
  • The very fit: Well compensated before signs start to appear
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19
Q

What examinations can be performed to find out the types of shocks

A
  • Primary survey: Identifies presence of bleeding + or - site
  • Secondary survey: Identifies site of bleeding
  • If the site is non compressible: You identify presence of bleeding, Surgeons identify what is bleeding
20
Q

List the immediate assessments after shock

A
  • Mental state - AVPU
  • Respiratory rate
  • Colour (pale & cyanosed) & temperature
  • Capillary refill
  • Pulse - rate & volume
  • Blood pressure.
21
Q

Give a quick guide to Blood Pressure

A
  • BP 90 = Palpable radial pulse
  • BP 80 = Palpable femoral pulse
  • BP 70 = Palpable carotid pulse
22
Q

What is the assessment and management of shock?

A
  • Classical signs obvious: But are late in onset & equate to 1500ml or more blood loss
  • Early signs are: Vasoconstriction (cold), Tachycardia, Narrow pulse pressure
  • Assume shock if cold and has rapid pulse: ‘Rapid’ in a fit soldier may be < 100
23
Q

What Resuscitation techniques can be used for shock?

A
  • ABCD
  • Establish, maintain, secure, protect airway
  • Oxygen if available
  • Ensure adequate ventilation
  • Now assess and treat circulation: Stop the bleeding, Establish iv access, Restore lost volume
24
Q

What are the management principles?

A
  • Save life
  • Prevent deterioration
  • Promote recovery
25
Q

Describe the “Stopping the bleeding” aspect of resuscitation for compressible haemorrhage

A
  • Stop Bleeding
  • Compressible haemorrhage: Limb fracture! External wounds, Pelvic fracture (to a degree)
  • Management: Direct pressure, Indirect pressure, Correct use of tourniquet, Splintage
26
Q

Describe the “Stopping the bleeding” aspect of resuscitation for non compressible haemorrhage

A
  • Stop Bleeding
  • Non compressible haemorrhage: Chest, Abdomen, Pelvis, Retroperitoneum
  • Management: Urgent surgery
27
Q

How is vascular access carried out

A
  • Percutaneous access upper limbs
  • Intravenous cutdown: Medial malleolus - long saphenous vein, Antecubital fossa
  • Femoral vein cannulation: Seldinger technique
28
Q

What can be used as a replacement of lost volumes?

A
  • Crystalloids: All roles
  • Colloids: All roles
  • Blood: Roles 2 & 3
  • But to do no harm: make sure it’s warm
29
Q

Give some features of crystalloids as a use of replacement

A
  • Immediate replacement of lost volume
  • 3:1 rule
  • Short duration
  • Safe
  • Initial challenge of two litres & reassess
  • Challenge in a child - 20 ml/kg body weight
  • Challenge may be repeated
30
Q

Give some features of colloids as a use of replacement

A
  • Immediate replacement of lost volume
  • 1:1 rule
  • Long duration
  • Safe
  • Initial challenge of one litre & reassess
  • 10 ml/kg body weight in a child
  • Forms a jelly when cold
31
Q

List the principles of management (PART 1)

A
  • Early recognition
  • Early restoration of tissue perfusion:
  • Stop the bleeding
  • Compressible haemorrhage - YOU
  • Non compressible haemorrhage - SURGEON
  • Then Restore volume
  • Resuscitation end point - systolic BP 90, Dilemma! - Closed HI, ideal systolic BP 120+
32
Q

List the principles of management (Part 2)

A
  • IV fluid resuscitation protocol
  • With non compressible haemorrhage
  • “Better a live casualty who has stopped bleeding & stabilised with a low BP without iv fluids, than one given iv fluids causing a transient rise in BP with re-bleeding that consumes what clotting factors remain. He then bleeds to death!
  • A live clot or a dead bleeder? - You can’t stop the re-bleed
    only a surgeon can!
33
Q

What is the IV fluid resuscitation protocol

A
  • If bleeding is non compressible and surgery not readily available, a low BP is better than no BP!
  • If the radial pulse is present, curtail the fluid challenge or, don’t challenge at all
  • But…monitor!…monitor!…monitor!
34
Q

Provide the IV Fluid Resuscitation Protocol for Compressible + non compressible patients under shocked/unshocked conditions

A
  • Compressible: Not shocked - no fluids
  • Compressible: Shocked - IV fluids
  • Non compressible: Urgent evacuation feasible - no fluids
  • Non compressible: Urgent evacuation not feasible - IV fluids
  • Apply common sense to these rules!
35
Q

State the management of shock for compressible patients

A

Compressible -> Control -> IV -> Reassess -> Stabilise or Improves -> IV fluids to maintain radial pulse -> Surgery

36
Q

State the management of shock for non compressible patients

A
  • Non compressible -> Control -> IV -> Reassess-> Fails to improve or deteriorates -> Recognise the need for surgery
  • Either (2 pathways from here) ->
  • Immediate evacuation -> IV en-route if possible -> Surgery
  • Delayed evacuation -> IV fluids to maintain radial pulse -> Surgery
37
Q

List some supportive measures that can take place

A
  • Treat hypothermia: Clotting mechanism is temperature sensitive
  • Analgesia: Pain = agitation - worsens shock
  • Fracture immobilisation: Controls blood loss & pain
  • Tubes in orifice: Gastric dilatation
38
Q

How can we monitor these patients?

A
  • lPulse oximetry
  • ABGs
  • ECG & non-invasive monitoring
  • End tidal CO2 (intubated casualties)
  • Urinary output
39
Q

List the management problems that can occur

A
  • Continuing haemorrhage: From where
  • Fluid overload: Pulmonary oedema, NB, beware blast lung
  • Acid/base imbalance: Occurs but should be furthest form your mind in the early stages of management
40
Q

List the other types of shock

A
  • Cardiogenic
  • Anaphylactic
  • Neurogenic
  • Septic
41
Q

Briefly describe the causes of cardiogenic shock

A
  • Cardiac tamponade
  • Myocardial contusion
  • Myocardial infarction
  • Tension pneumothorax
  • Pulmonary embolism
  • Air embolism
42
Q

Briefly describe the causes of anaphylactic shock

A
  • Medications
  • Allergens: Bronchospasm, Urticaria, Peripheral vasodilation
43
Q

Briefly describe the causes and signs of neurogenic shock

A
  • Causes: Brain stem injury, Cervical or high thoracic spine injury
  • Signs: Hypotension & bradycardia, warm periphery, Rule out mixed aetiology before atropine
44
Q

Briefly describe the causes and signs of septic shock

A
  • Causes: Delayed evacuation! Penetrating abdominal injuries, vasodilation due to endotoxaemia
  • Signs: Bounding pulse (Wide pulse pressure), Rule out mixed aetiology
45
Q

Summary

A
  • Hypovolaemic until proven otherwise
  • High index of suspicion: Early signs subtle, especially young / fit
  • Control of haemorrhage
  • Compressible & non-compressible: Recognise the need for surgery early
  • Sense of urgency is paramount

Conflict And Catastrophe Medicine (29 decks)

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