Samuel D. Gross

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Samuel D. Gross System of Surgery 5th edition,
1872 volume 1 page 429 Chapter XII
Effects of Injuries upon the Nervous System
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Shock is a depression of the vital powers,
induced suddenly by external injury.
There is a type of shock which has been, not
inaptly, called insidious, as the symptoms are
generally of a masked character, and are,
therefore, well calculated to deceive both the
patient and the practitioner.. One would hardly
suppose, at first sight, that there was anything
serious the matter the countenance appears
well, the breathing is good, the pulse is but
little affected, except that it is too soft and
frequent, and And the mind, calm, and collected,
possess its wonted vigor, the patient asking and
answering questions very much as in health. But
a more carful examination soon serves to show
that deep mischief is lurking in the system
that the machinery of life has been rudely
unhinged, and that the whole system is shocked.
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• Wound Shock
• Traumatic Shock
• Hemorrhagic Shock
• Hypovolemic shock
• Neurogenic Shock
• Cardiogenic shock
• Septic Shock
• Anaphylactic Shock
• Burn Shock

Inadequate Perfusion
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• History
• Categories
• Clinical aspects
• Identification
• Resuscitation
• Emerging areas
• Massive Transfusion Protocols
• Factor VIIa
• Blood substitutes

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• 1731 LeDran HF Observations de Chirurgie
• 1895 Warren JC Surgical Pathology and
  Therapeutics
• 1901 Lansteiner K ABO blood groups
• 1930 Blalock A Distribution of Blood in Shock.
  Arch Surg 2026
• 1937 Fantus B Blood Bank, JAMA ,July 10
• 1964 Shires GT Fluid Therapy in Hemorrhagic
  Shock Arch Surg 88688
• 1990s Microcirculatory Injury Inflammation
• 2007 Damage control Resuscitation

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• Henry- Francois Le Dran
• First use of the term
• Shock

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• the nature of shock...A cold, clammy sweat
  exudes from pores of the skin, which has an
  appearance of profound anaemia. The lips are
  bloodless and the fingers and nails are blue. The
  pulse is almost imperceptible a weak,
  thread-like stream may, however, be detected in
  the radial artery.

Warren JC Surgical Pathology and Therapeutics
1895, pg 279
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• Karl Landsteiner
• Identified ABO blood groups

The Nobel Prize in Physiology or Medicine 1930
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1930 Blalock A Distribution of Blood in Shock.
Arch Surg 2026

• These observations suggest that hemorrhage,
  histamine and brain trauma produce a fairly
  uniform diminution in the volume of the
  circulating blood in all parts of the body

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• Bernard Fantus
• Blood Bank

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Charlie Baxter 1929-2004
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Casualties in Korea vs Vietnam Wounded/ki
lled 31 61 Ratio Renal
Failure 1200 11867
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Microvascular Endothelium 400 7000 m2 Active
participation in Leukocyte adhesion and
activation Platelet adherence Coagulation Comp
liment activation
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Shock

• Inadequate Tissue Perfusion
• Categories
• Hemorrhagic
• Cardiogenic
• Intrinsic
• Extrinsic
• Neurogenic
• Septic

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Etiology of Shock

• Hemorrhagic
• Most common
• Clinical clues
• HP
• Selecteddiagnostic tests

• Non-hemorrhagic
• Tension pneumothorax
• Cardiogenic
• Neurogenic
• Septic

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Hemorrhagic Shock

• Loss of circulating blood volume
• Normal blood volume
• Adult 7 of ideal weight
• Child 9 of ideal weight

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Sources of Hemorrhage External Internal Th
orax Abdomen Pelvis/fractures
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Early Identification of Shock/Hypoperfusion Tachy
cardia Tachypnea Anxiety Confusion Prostration
Pallor Cyanosis Oliguria Vasoconstriction
Hypotension
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Assessment and Management

• Airway and Breathing
• Oxygenate and ventilate
• PaO2 gt80 mm Hg (10.6 kPa)
• Circulation
• Assess
• Control
• Treat

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Assessment and Management

• Recognize shock
• Stop the bleeding!
• Replenish intravascular volume
• Restore organ perfusion

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BP lt 90HR gt120Obvious major blood loss
Control External bleeding CXR Fast (or
DPL) Pelvis X-ray
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Locate the Bleeding?

• Physical examination
• Diagnostic adjuncts to primary survey
• Chest x-ray
• DPL / Ultrasound
• AP pelvis x-ray

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CXR can help identify
Tension pneumothorax
Massive hemothorax

• Flail chest

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Focused Abdominal Sonogram for Trauma
F.A.S.T.

• Four standard views
• pericardial area
• right upper quadrant
• left upper quadrants
• Pelvis.

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Focused Abdominal Sonogram for Trauma (FAST)
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Open Book Pelvis
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Pelvic Binder for Open Book Pelvic Fracture
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Pelvic fracture and Considerations for
Angioembolization
                                 
Schematic representation of pelvic arterial
network. 1 Ilio-lumbar artery, 2 gluteal
artery, 3 internal pudendal artery
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Hare Traction Splint
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• Stop the bleeding!
• Direct pressure
• Operation
• Reduce pelvic volume
• Splint fractures

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Restore perfusion

• 2 large-caliber, peripheral IVs
• Central access
• Femoral
• Jugular
• Subclavian
• Intraosseous
• Saphenous cut down
• Obtain blood for crossmatch

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Restore perfusion

• Warmed crystalloid solution
• 31
• Rapid fluid bolus
• Adult 2 liters, Ringers lactate
• Child 20 mL/kg Ringers lactate
• Monitor response to initial therapy

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Volume Replacement

• Warmed fluids
• Crossmatched, PRBCs
• Type-specific
• Type O, Rh-negative
• Coagulopathy

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Therapeutic Decisions

• Patient response determines subsequent therapy
• Recognize need to resuscitate in operating room

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Response EvaluationUrinary Output

• Adequate Volume Replacement

Adult Child Infant 50 ml / hr 1 ml / kg / hr 2
ml / kg / hr
Inadequate output suggests inadequate
resuscitation
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Re - Evaluation

• Identify Improved Organ Perfusion
• CNS Improved LOC
• Renal ? Urinary output
• Skin Warm, capillary refill
• Respirations Improved rate and depth
• Vital signs Return to normal

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Base Deficit in Shock
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Relationship of Base Deficit and Mortality
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Pitfalls

• Equating BP withcardiac output
• Extremes of age
• Hypothermia

• Athletes
• Pregnancy
• Medications
• Pacemaker

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Avoiding Complications

• Continued hemorrhage
• Fluid overload
• Invasive monitoring (ICU)
• CVP
• Pulmonary artery catheter
• Other problems

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Summary

• Restore organ perfusion
• Early recognition of the shock state
• Oxygenate and ventilate
• Stop the bleeding
• Restore volume
• Continuous monitoring of response
• Anticipate pitfalls

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Emerging areas

• Damage control resuscitation
• rFVIIa (Novoseven)
• Blood replacements

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Trends in Shock Resuscitation from Military
Practice
World war II Korean War- resuscitation with
Blood and Plasma Vietnam war Blood Plasma
Crystalloid Civilian practice Crystalloid
PRBCs Components 2001-2008 Iraq
Afghanistan Wars increased early use of blood
components
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Fresh Frozen Plasma Should be Given Earlier to
PatientsRequiring Massive TransfusionErnest A.
Gonzalez, MD, Frederick A. Moore, MD, John B.
Holcomb, MD, Charles C. Miller, PhD, Rosemary A.
Kozar, MD, PhD, S. Rob Todd, MD, Christine S.
Cocanour, MD, Bjorn C. Balldin, MD, and Bruce A.
McKinley, PhD J Trauma 200762112-119
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J Trauma. 200762307-310 In combat casualties
requiring major resuscitation 10 - 40 units of
blood products, we have found as little as 5-8
liters of crystalloid are utilized during the
first 24 hours representing a decrease of
50.......the lack of intraoperative
coagulopathic bleeding has been remarkable.
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The combination of high plasma and high platelet
to RBC ratios were associated with increased
6-hour, 24-hour, and 30-day survival (P lt 0.05)
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The Ratio of Blood Products Transfused Affects
Mortality in Patients Receiving Massive
Transfusions at a Combat Support Hospital . J
Trauma 200763 805-813
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Predefined Massive Transfusion Protocols are
associated with a Reduction in Organ Failure and
Postinjury Complications J Trauma 20096641-49
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Identifying patients who will require Massive
Transfusion BP lt 90 mm Hg pH lt
7.10 BD gt 6.0 meq/L ISS gt 25
Temp lt 34 C INR gt 2.0
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UTMB - Massive Transfusion Protocol
PRBC FFP Platelets Cryoprecipitate 6 units 6
units 6 units ---- 6 units 6 units ---- 20
units rVIIa Novoseven (40 micrograms/kg) 6
units 6 units 6 units ---- 6 units 6
units ---- 10 units

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The generation or exposure of TF at the wound
site, and its interaction with factor VII, is the
PRIMARY physiologic event in initiating clotting.
The components of the intrinsic pathway (ie,
factors VIII, IX, XI) are responsible for
AMPLIFICATION of this process only after a small
initial amount of thrombin has been generated
through the extrinsic pathway.
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Mode of Action                                  
                                        
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J Trauma 2007621095-1101
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J Trauma 2007621095-1101
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Recombinant Factor VIIa (Novoseven)
1.35/microgram 15 micrograms/kg x 70
1,417 30 micrograms/kg x 70 2,835 90
micrograms/kg x 70 8,505 270 micrograms/kg x
70 25,515
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Perfluorocarbons (PFCs) are synthetic liquids
that dissolve large volumes of oxygen, and also
have the capacity to transport carbon dioxide.
These chemical liquids were first made famous in
the 1960s when scientists, led by Professor
Leland Clark at the University of Alabama showed
that a mouse could survive for up to 10 minutes
when totally sub-merged in PFC liquid.
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completed
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Human polymerized hemoglobin for the Treatment of
Hemorrhagic Shock when Blood is Unavailable The
USA Multicenter Trial Moore et al, Journal of the
American College of Surgeons 20092081-13 Pol
yheme (n355) Control (n365) p Deaths 48
(13.5) 36 (9.9)
0.13 Blunt 18.1 10
0.041 Myocardial Infarction 3.2 0.8
0.025
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Shock

InadequateTissuePerfusion
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?

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End Points for Resuscitation

• Oxygen delivery
• Lactate level
• Correction of serum level lt2 mmol/L
• Base deficit
• Gastric intramucosal pH

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• Computer Modeling
• Closed Loop Resuscitation

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Keys to Successful Treatment

• Early control of hemorrhage
• Euvolemia
• Continuous reevaluation

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• Immediate versus delayed fluid resuscitation for
  hypotensive patients with penetrating torso
  injuries

Immediate versus delayed fluid resuscitation for
hypotensive patients with penetrating torso
injuries
NEJM 1994 3311101-1105,Bickell WH, Wall JHJ,
et al.
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• A multicenter, randomized, controlled clinical
  trial of transfusion requirements in critical care

NEJM 1999 340409-417,Hebert PC, Wells G, et al.
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Lactated Ringers Solution

• A good commercially available fluid for
  replacement of extracellular fluid loss

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Transfusion

• Traditional gt100g/L
• Anesthesia gt60g/L
• NIH concensus gt70g/L
• Prospective 70-90 100-120

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End Points of Resuscitation
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Categories

• Hemorrhagic
• Cardiogenic
• Neurogenic
• Septic

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Cardiogenic Shock

• Differential Diagnosis
• Patient history
• Mechanism of injury
• Physical findings ? CVP with profound shock

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Neurogenic Shock

• Differential Diagnosis
• Isolated head injuries Do Not cause shock
• Loss of sympathetic tone
• Complicating factors
• Treat hypovolemia first

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Septic Shock

• Differential Diagnosis
• Contaminated, penetrating abdominal injury (late)
• Hypovolemia Classical shock picture
• Beware Tachycardia, warm, BP near normal, wide
  pulse pressure

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Cardiovascular Support

• Monitor with pulmonary artery catheter to follow
  PCWP, oxygen delivery and oxygen consumption
• Optimize not maximize
• Volume is the principle means to support CO may
  aggravate other organ dysfunction
• pulmonary gas exchange
• cerebral edema
• fluid replacement best monitored by response to
  therapy not an arbitrary value for urine output
  or PCWP

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Cellular/Metabolic Response

• Perfusion Restored
• Cycle broken
• Survival

Perfusion NOT Restored Low flow state Organ
failure Death
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Resuscitation

• Crystalloid vs Colloid vs Hypertonic Saline

Enough with the recounts!
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4000-7000
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R. M. Winslow Vox Sanquis 200691102-110
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1901 - Karl Landsteiner an Austrian
physician, documented t he first three human
Blood groups (based on substances present on the
red Blood cells), A, B and O. (1930 Nobel Prize
for Medicine) 1926 - The British Red Cross
instituted the first human Blood transfusion
service in the world. 1932 - The first
functioning Blood distribution facility was
established in Leningrad. 1937 - Bernard
Fantus, Cook County Hospital in Chicago, first
hospital Blood bank in the United States, Fantus
originated the term 'Blood Bank.'. 1939 and
1940 - The Rh (Rhesus) Blood group system was
discovered by Karl Landsteiner, Alex Wiener,
Philip Levine and R. E. Stetson
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R. M. Winslow Vox Sanquis 200691102-110
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2009 UpToDate

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