Hemorrhagic Shock



Review of Fundamentals

A. ABC’s

1. A = airway

2. B = Breathing

3. C = Circulation

4. Address these ABC’s and reassess them.

B. DEF

1. D = Disability

a. Glasgow coma scale (3-15)

1. get 3 points just for being there

2. at score of 8 intubate

b. Pupillary response – look for a blown pupil

c. Cranial nerve response

d. Gag reflex – if no gag reflex present, consider intubating.

e. Focal motor or sensory deficit – Glasgow coma scale does not assess this

2. E = Exposure

a. Patient must be undresses!

b. It is very easy to miss penetrating injuries if the patient is clothed.

3. F = Fingers and tubes – endotracheal tube, orogastric tube, nasogastric tube, IV’s, Foley catheters placement, and rectal exam.

C. Amplified History – problems-focused and hig yeild

1. Allergies, side effects, toxicities – Eg: Did they fall into pesticide?

2. Medications

a. Drugs patients are taking may affect how they present to you. Crack – tachycardic

b. Patient has a history of hypertension and unsable angina, may be on a (-blocker. May never become tachycardic.

3. Past history.

4. Last meal and drink

5. Immediate events

6. Family and friends

7. Immunizations

8. EMT’s historians, old chart, person who dropped them off

9. Doctors

Hemorrhagic Shock

|Class |Total Blood Volume |Vital Signs |Treatment |Comments |

|I |Up to 15 % |Normal – No change |Oral Fluids |VS changes result of pain, intoxications, or|

| |(750cc of blood loss in 70 kg) | |(Vomiting NO PO fluids) |patient’s own meds |

|II |15 –30% |Tachycardia |Oral (PO) fluids or |Assume fluid in chest – blood |

| |(750-1500cc of blood loss) |Narrow pulse pressure |IV fluids |Chest tube |

| | | |Chest X-ray CXR – assessment of fluid in | |

| | | |chest | |

|III |30 – 40% |Tachycardia |Replace with IV fluids at a rate of 3:1- 3|Increase in Dead space ventilation |

| |(1500 – 2000cc blood loss) |Hypotension |parts IV for every 1 part blood loss |(Transfusion-profound risk to patient, HIV, |

| | |Increased Respiratory Rate (RR) – |Consider packed RBC’s (PRBCSs |Heptitis C) (blood transfusion – |

| | |increase in dead space | |immunosuppressed) |

| | |Decreased urinary output | | |

|IV |40% |Tachycardia |Replace with IV, PRBCs and “O” negative |Room temp. normal saline – hypothermic very |

| |2000cc blood loss |Hypotensive |blood |quickly |

| | |Inreased RR |(IV fluid of choice + warmed normal |Ringers – cause RBCs to explode |

| | |Organ Hypoperfusion – decresed urine |saline) |“O” blood (universal donor) |

| | |output (< 50 years old normal kidney– | | |

| | |1cc/kg/hr) | | |

The order of fluid resuscitation in patients with continuous blood loss:

1. Warmed normal saline – 2L bolus in an adult

2. “O” negative blood

3. Type specific blood

4. Complete type and cross match blood

Neurological Injuries

|Injury |Classic Patient |Presentation |Diagnostic Test |

|Epidural Hematomas |Young and active (“Bubba” syndrome) |Lucid intervals |CT scan |

|Subdural Hematomas |Older patients |Slow progressive deterioration |CT scan |

|Cerebral contusions/Clossed Head Injury (a.k.a. |Infant or Elderly |Retinal hemorrhages |CT scan |

|diffuse axonal injuries) |“Shaken Baby Syndrome” | | |

|Skull Fractures |Younger patient (“Bubba” syndrome) |LOC may or may not be present |CT scan & X-ray |

|Cord Injuries |Predominantly younger patients |Neurological deficits |X-ray & CT scan |

Bubba Syndrome: Males between the ages 17 and 25 who have the misconception that they are invincible are more likely to be involved in collisions, falls and altercations.

Thoracic Trauma

|Pathology |Trauma |Presentation |Diagnostic Test |

|Diaphragmatic Hernia |Blunt or penetrating abdominal trauma |Diminished breath sounds, possible bowel sounds |Chest X-ray |

|Tension Pneumothorax |Penetrating chest trauma or mechanical ventilation|Hemodynamic instability |Chest X-ray |

|Hemothorax |Penetrating chest trauma |Diminished breathsounds, dullness to percusssion, |Chest X-ray |

| | |and hemodynamic instability | |

|Cardiac Tamponade |Penetrating chest trauma |Hemodynamic instability |Chest X-ray & ECHO cardiogram |

|Pneumothorax |Penetrating chest trauma |Diminished breath sounds |Chest X-ray (Insp. & Expiratory) |

|Pulmonary Contusions |Associated with rib fracture |Progressive hypoxemia |Chest X-ray – hazy white |

Blunt Abdominal Trauma

|Type |Commonality |Diagnostic Test |Mechanism of Injury |

|Splenic Injury |Most common (40-55%) |Kerr’s sign = left shoulder pain | |

| | |Stable – CT scan, Diagnostic peritoneal lavage |MVC, Falls & Altercations |

| | |(DPL) | |

| | |Unstable - OR | |

|Liver Injury |2nd most common (35-45%) |Stable –CT, Ultra sound, and DPL | |

| | |Unstable - OR |MVC, Falls & Altercations |

|Kidney |3rd most common |Gross Hematuria – CT abdomen | |

| | |Microscopic hematuria – no further testing unless |MVC & Falls |

| | |hypotensive | |

Reference:

1. Advanced Trauma Life Support, (1997).

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