1. Critical Concepts - Surgery
Shock
Critical Concepts - Surgery

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

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

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

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

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

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

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

9. Intravenous Access

10. Intravenous Access
Hagen-Poiseuile Law

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

12. Rate?

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

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

15. When to stop?
Vital signs
UOP
Base deficit
Lactate

16. HEMOSTASIS METHODS

17. 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

18. 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

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

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

21. 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

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

23. 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

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

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

26. 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