1. Shock and Trauma Resuscitation Bonjo Batoon, CRNA, MS R Adams Cowley Shock Trauma Center Baltimore, MD

2. The Problem of Trauma 50% die before they reach a hospital Head injury major cause of death in the field/hospital Uncontrolled hemorrhage or MOF-related shock is the cause of death in about 40% of deaths 20% of hemorrhagic deaths potentially preventable 17% of military casualties from failed hemorrhage are potentially preventable Dubick MA, et al. US Army Institute of Surgical Research, 2006; report # A508184

3. Shock by definition A failure of adequate oxygen delivery or utilization at the cellular level, perpetuated by cellular and humoral responses Prolonged shock results in a cumulative “oxygen debt”, severe metabolic derangement, and disruption of end- organ integrity and homeostasis

4. Shock by definition A state of inadequate tissue perfusion A cellular and end-organ disorder Not a disorder of the macro-circulation Decreased BP does not equal shock

5. Oxygen Debt

6. Types of shock Hemorrhagic- Most common Non-hemorrhagic Cardiogenic Neurogenic Septic Tension pneumothorax Poisoning

7. Signs & Symptom of Shock Tachycardia Tachypnea Decreased capillary refill Hypotension Narrow pulse pressure Altered mental status Cyanosis, pallor, diaphoresis Hypothermia Decreased urine output Absent pulse oximetry signal* +FAST/CT*

8. Classification of Shock

9. Lethal Triad Hypothermia Acidosis Coagulopathy

10. More than the Lethal Trial Hess JR, Brohi K, Dutton RP; et al. The coagulopathy of trauma: a review of mechanisms, J Trauma 2008 654 748-754.

11. Resuscitation Goals Early recognition of the shock state Oxygenate and ventilate Restore organ perfusion Restore homeostasis / repay “oxygen debt” Stop the bleeding- Surgeon’s job Treat coagulopathy Restore the circulating volume Continuous monitoring of the response

12. Components to Resuscitation Airway Breathing Circulation Exposure

13. Airway DL Video laryngoscopy AFOI RSI vs MRSI Cricoid pressure C-spine issues Surgical cricothyrotomy when all else fails

14. Breathing Secure airway most important Adequately oxygenate Monitor CO2 Consider lower Vt in hypotensive pts

15. Circulation Adequate IV access Peripheral 16G or greater Know flow rates for each cathether Preferably central access IJ vs SC vs femoral Cordis vs double lumen catheters vs triple lumen

16. Exposure 34° C was the critical point at which enzyme activity slowed significantly, and at which significant alteration in platelet activity was seen. Fibrinolysis was not significantly affected at any of the measured temperatures Watts, Dorraine Day, et al. "Hypothermic coagulopathy in trauma: effect of varying levels of hypothermia on enzyme speed, platelet function, and fibrinolytic activity." The Journal of Trauma and Acute Care Surgery 44.5 (1998): 846-854. Keeping pt warm Warm blood products Bair hugger type devices Warm operating room

17. Monitoring Basic Advanced A line CVP? PPV- FloTrac TEE Labs- CBC, coags, lytes, ABGs POC Hemoque- Hgb iStat- lytes/gases ROTEM- coagulation

18. Clotting Dynamics

19. Components to Resuscitation Crystalloids Colloids Blood products

20. Crystalloids LR NS Plasmalyte Crystalloids are not and should not be the mainstay of trauma resuscitation!!

21. Prehospital fluids

22. Prehospital Fluids

23. Colloids Starches Coagulopathy Hespan max dose 20ml/kg Albumin Allergic rxs

24. Blood Products RBCs FFP Plts Cryoprecipitate Other hemostatic agents fVIIa, PCCs, fibrinogen concentrate

25. Resuscitation Strategies Ratio based resuscitation RBC;FFP; RBC:FFP:PLTs Laboratory based resuscitation Lab delays Lost samples Point of Care Coagulation concentrates ROTEM

26. Component Therapy Dutton, R. P. (2012), Resuscitative strategies to maintain homeostasis during damage control surgery. Br J Surg, 99: 21–28. doi: 10.1002/bjs.7731

27. Damage Control Anesthesia Dutton, RP. Damage Control Anesthesia. Trauma Care. 2005;15:197-201.

31. Thank you!!