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• krongdai_at_hotmail.com

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12 Essensial needs of the injured patient ATLS -
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• Pneumothorax ??? Hemothorax ??????????????????????
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• ??????????????????? airway
• obstruction
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• diffusion ?

• Airway
• Breathing

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12 Essensial needs of the injured patient ATLS -
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• ?????????????????? shock ??????

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• cardiac output ?
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• perfusion ?

• Circulation

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• Tachycardia
• Skin pallor
• Hypotension
• Confusion
• Tachypnea
• General weakness
• Thirst
• Reduce urine output

• Catecholamine release
• Vasoconstriction
• Hypovolemia
• Cerebral hypoxia
• Hypopxia
• Hypoxia
• Hypovolemia
• Reduced perfusion

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Hemorrhage

• The most common cause of shock in
  trauma patient
• An acute loss of circulating blood loss
• Normal Adult Bl.volume is 7 BW
• Normal Child Bl.volume is 80-90 ml/kg

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Shock

• An abnormality of the circulatory system
• Inadequate tissue perfusion and
  oxygenation

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Class I Hemorrhage

• 15 blood volume loss
• Minimal tachycardia
• No measurement changes
• Do not required replacement
• Restore blood volume within 24 hr

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Class II Hemorrhage

• 15-30 blood volume loss
• Present clinical symptoms
• Pertinent clinical findings

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Class III Hemorrhage

• 30-40 blood volume loss
• Present classic signs of inadequate perfusion
• Require transfusion
• Emergency operation

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Class IV Hemorrhage

• gt 40 blood volume loss
• Immediately life-threatened
• Require rapid transfusion
• Require immediate surgical intervention

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Pathophysiology

• Depletion of ECF volume
• Increased Sympathetic nervous system
• Compensatory mechanism

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Decrease blood pressure
Arterial baroreceptors
Cardiovascular center
Increased sympathetic output
Reduced parasympathetic output
Increased venous wall tension (tone)
Heart
Arteriolar vasconstriction
Increased peripheral rsistance
Increased heart rate
Increased stroke volume
Increased venous return
Increased blood pressure
Increased cardiac output
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Assessment

• Neurogenic
• cardiovascular
• respiratory
• integumentary

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Physical examination

• Airway Breathing
• Circulation hemorrhage control
• Disability Neurologic examination
• Exposure Complete examination

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Organs effect from shock

• Brain
• Heart
• Lungs
• Kidneys
• Liver

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Resuscitation

• A Airway
• B Breathing
• C Circulation

• Oxygenation ventilation
• Shock management
• Management of life-threatened problems

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Compensatory mechanisms in shock

• Sympathetic activation
• Activation of the renin-angiotensin-aldosterone
  mechanism
• Antidiuretic hormone

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Reduce blood pressure
RAS
Angiotensin II
Vasoconstriction
Aldosterone
Sodium retention
Increased blood pressure
Water retention
Renal Compensation mechanisms in Shock
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Regulator fluid balance

• Thirst
• Na
• Protien, Albumin
• ADH, Aldosterone, Renin
• Lymphatics
• Skin, Lung, Kidneys

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• Improve oxygenation
• Control hemorrhage
• Replacement of lost volume
• Monitor 1, 2, 3
• Support myocardial contractility
• Relief of pain

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Replacement of blood loss
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Estimated fluid blood loss based on patients
initial presentation
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IV cannulation

• 2 short, large bore IV cannulate
• Blood samples CBC, Elyte, Blood gas,
  cross match
• IV access / cut down / intraosseous

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Vascular access line

• Insertion of 2 large-caliber
• Use fluid warmers rapid infusion pumps in
  massive hemorrhage

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Types of fluids

• Crystalloids
• Colloids
• Blood and blood components

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choice of IV fluid

• Fast efficient restoration of IV volume
• Colloids IV volume expansion
• Crystalloid no risk of anaphylaxis

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Rate

• Severe loss, BP drop,
• Urine lt0.5 ml/kg
• crystalloid 10-20 ml/kg in 30 min
• colloid 5-10 ml/kg in 30
  min

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Initial fluid therapy

• Insertion of 2 large-caliber
• Use fluid warmers rapid infusion pumps in
  massive hemorrhage

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Fluid Challenge test

• CVP
• lt 8 cm H2O
• 8-14 cm H2O
• gt 14 cm H2O

• Fluid
• 200 ml. In 10 min
• 100 ml. In 10 min
• 50 ml. In 10 min

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Expected Outcome good perfusion

• SBP gt 90 mm.Hg
• core temp. gt 36.0 c
• urine output 0.5-1cc / kg / hr
• hemodynamic stability

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