Critical Concepts - Surgery Shock Critical Concepts - Surgery

SHOCK “Rude unhinging of the machinery of life” -Gross “A momentary pause in the act of death” -Dr. Cowley

SHOCK Inadequate delivery of oxygen and nutrients necessary for normal tissue and cellular function.

Types of Shock Hypovolemic Cardiogenic Neurogenic (distributive) Septic (distributive) Obstructive

Types of Shock CVP CO SVR other Hypovolemic Cold and clammy Cardiogenic Neurogenic Warm and rosy Septic Obstructive Clinical exam

Types of Shock Hypovolemic Cardiogenic Neurogenic (distributive) Septic (distributive) Obstructive

How to Resuscitate ABC’s Choice of line? What to use? Rate of administration? How much? When to stop?

ABCDE’s Airway Breathing Circulation Disability Exposure Tension ptx? Tamponade? Disability Neurogenic shock? Exposure Signs of hemorrhage/trauma?

Intravenous Access

Intravenous Access Hagen-Poiseuile Law

Which fluid? Crystalloid Colloid Lactated ringers Normal Saline Synthetic Albumin Blood plasma

Rate?

How much? Class Blood Loss (ml) (%) HR BP UOP Mental Status I <750 <15% <100 NL >30 II 750-1500 15-30% >100 20-30 anxious III 1500-2000 30-40% >120 5-15 confused IV >2000 >40% >140 None lethargic

How much? Bolus Blood Massive Transfusion 1 liter 1:1 >10 PRBCs in 24 hrs

When to stop? Vital signs UOP Base deficit Lactate

HEMOSTASIS METHODS

Objectives Review general concepts about achieving hemostasis in a bleeding subject Discuss non-surgical compression and tourniquet methods Discuss surgical methods using sutures, ligatures, and other devices Understand the application and use of pelvic binders for pelvic fractures

GENERAL CONCEPTS Direct control Avoid collateral damage Be as specific (pinpoint) as possible Avoid collateral damage Injury to tissue around point of control Distal ischemia Temporary versus permanent

Types of Control Non-Surgical Surgical Compression Tourniquets Pro-coagulant products Surgical Ligation Suturing/Stapling Cautery

Non-Surgical Control- Compression Applying direct pressure to the source o bleeding Usually the best first step Usually done wrong

Keys to Success 1- Pinpoint Source of Bleeding a- Use minimal surface area - Concentrate pressure to exact source of bleeding b- Use minimal gauze -Gauze is for ABSORPTION - Fold minimal amount of gauze into minimal size of square

Keys to Success 2- Apply consistent pressure A- Get into a comfortable position B- Apply bandage/device whenever possible Pressure Dressing

Non-Surgical Control- Tourniquet Circumferential compression cutting of blood flow to distal limb/appendage Generally frowned upon Only when direct pressure cannot be applied due to the nature of the injury Amputations Near-amputations a

Keys to Success Complete cessation of arterial blood flow Non-elastic bandage Tight enough to cause pain Dress the open wound

Surgical Hemostasis Bleeding Skin/Tissue Edges Severed vessel a Suture Staple Dressing/Adhesive Severed vessel Ligation Clip a

Bleeding Skin/Tissue Edges Wash out wound whenever possible Suture Simple interrupted Simple running Locking running Horizontal mattress Staple Faster but less available Dressing/Adhesive Only if able to temporarily staunch the blood low