2. Objectives  To understand the structured approach to circulation problems  To recognise and manage shock

3.  Blood pressure  Heart rate  Capillary refill  Peripheral temperature  Peripheral colour  Urine output

4.  Inadequate organ perfusion and tissue oxygenation  Most often due to hypovolaemia in trauma

5.  Hypovolaemic  Cardiogenic  Neurogenic  Septic  Anaphylactic

6. Closed Femoral #1.5-2 litres Closed Tibial # 500 ml Pelvic # 3 litres Rib # (each)150 ml Haemothorax 2 litres Hand sized wound 500 ml Fist sized clot 500 ml

7.  Abdominal Cavity  Pleural Cavity  Femoral Shaft  Pelvic Fractures  Scalp (children)

8.  Compressible - usually peripheral  Non-compressible - e.g. intra-abdominal - Surgery required

9.  Altered mental state : anxiety to coma  Pulse present ? - radial systolic > 80 mmHg - femoral systolic >70 mmHg - carotid systolic > 60 mmHg  Tachycardia  Pulse pressure narrowed

10.  Skin - cold, pale, sweaty, cyanosed  Capillary refill time > 2 seconds  Blood pressure  JVP  Urine output < 0.5 ml/kg/hr  Respiratory rate

15.  Myocardial contusion  Cardiac tamponade  Tension pneumothorax  Penetrating wound of heart  Myocardial infarction

16.  A + B, oxygen (if available)  Two large bore i/v cannulae  Stop obvious bleeding  Fluid replacement  Maintain temperature  Analgesia

17.  Chest  Drain tube and re-expand lung  Emergency thoracotomy rarely  Abdomen  Laparotomy if hypotensive after fluids  Limbs  Pressure dressing  Tourniquet last resort

18.  Warm fluids if possible  Colloids or crystalloids?  Consider hypotensive resuscitation if haemostasis not secure  Consider oral resuscitation

19. 1000-2000ml 0.9% Saline or Ringer’s Reassess 1000-2000ml 0.9% Saline or Ringer’s Reassess Consider blood Consider surgery Aim for systolic BP>90 + HR <100

20. Consider blood transfusion if:  Haemodynamic instability in spite of fluids  Haemoglobin <7g/dl and patient still bleeding

21. Summary  Careful assessment  Stop the bleeding  Replace volume

22.  Sustained direct pressure with  gloved fingers  gauze sponges  packing material  combined with elevation 1/7/2013 22

23.  Patient with multiple injuries and several urgent problems  compression dressing  Absorptive sponges are applied, and secured in place with an elastic bandage  The bleeding part should be elevated  Wound care can then be deferred while the clinician attends to more pressing matters 1/7/2013 23

24.  Epinephrine  Ligation with absorbable suture  Chemical hemostasis  Tourniquets if  bleeding from an extremity wound is refractory to direct pressure, electrocauterization, or ligation  the patient presents with exsanguinating hemorrhage from the wound 1/7/2013 24