1. Hemorraghic Shock Sara Parker MD VCU Trauma Conference STICU Fellow
July 8, 2015

2. Learning objectives 1) Review the classes of shock
2) Review treatment options
3) Review endpoints of resuscitation

3. SL
26 yo female who presents from OSH as transfer with multiple GSW to chest, abdomen and extremities.
At OSH, had L chest tube placed and was given 2u RBC and 1L crystalloid.

4. Vital signs per EMS HR 120 BP 98/53 RR 30 O2. Sats 99%
SBP as low as 80s

5. What next?
ABCD
Airway
Breathing
Circulation
Disability

6. Repeat Vitals
HR 145
BP 86/53
RR 45
Sats 95%

7. What next?
Diagnose hemorrhagic shock
Treat the cause

8. Shock
Inadequate oxygen delivery unable to meet the demands of the tissue leading to global tissue hypoxia and metabolic acidosis

9. With what class of hemorrhaghic shock do you have low blood pressure?
a) Class I
b) Class II
c) Class III
d) Class V

10. Classification of Shock
Blood loss
<750
>2000 HR
<100
>140
SBP
Normal
Decreased
Pulse Pressure
Classification of Shock

11. Fluid responsiveness
Infusion of 500cc IVF—improvement of HR, BP and UOP
Caveats: Athletes, pregnancy, extremes of age and medication use

12. What type of shock is likely to be hypotensive and bradycardic?
a) Hemorrhagic shock
b) Neurogenic shock
c) Septic shock
d) Anaphylatic shock

13. Types of Shock Causes Pathophysiology Signs/symptoms Hypovolemic
Dehydration, Hemorrhage, Burn
Decreased preload, CO and increased SVRintravascular volume loss
Increased HR, dec pulses, dry skin, delayed cap refill, dec UOP
Distributive
Anaphylactic
Neurologic
Septic
Decreased Afterload
Low BP, resp distress.
Cardiogenic
Decreased CO, variable SVR
Normal to inc HR, dec pulses, delayed cap refil, JVD

14. Diagnosis Hgb 12.5, platelets 350, coags pending
Pulses are weak, skin clammy, patient can’t remember where she is
Clinical diagnosis--early recognition is KEY

15. Treatment of Shock Control of bleeding crystalloid blood products
1 Hypotensive volume resuscitation
crystalloid
blood products
Goal SBP <100 or MAP >50
Control of bleeding

17. Hypotensive resuscitation
Titration of initial fluid therapy to a lower than normal SBP during active hemorrhage did not affect mortality. --Dutton.
Hypotensive resuscitation results in a significant reduction in blood product transfusions and overall IV fluid administration. Specifically, resuscitating patients with the intent of maintaining a target minimum MAP of 50 mm Hg, rather than 65 mm Hg, significantly decreases postoperative coagulopathy and lowers the risk of early postoperative death and coagulopathy. --Morrison

18. What is the 4th step of the massive transfusion protocol at VCU?
a) set up platelets and cyro, release 4 RBC and 4 plasma
b) setup 4 RBC and 2 Plasma, release 4 RBC and 2 plasma
c) keep ahead 4 RBC and 4 Plasma
d) release 4 RBC and 4 plasma

19. Massive Transfusion Protocol
Step 1: Set up 4 RBC, 2 Plasma. Keep Ahead 4 RBC and 4 plasma. Release 4 RBC and 2 plasma
Step 2: Release 4 RBC and 4 plasma
Step 3: Setup platelets and cyro. Release 4 RBC, 4 plasma, Platelets and cyro.
Step 4: Release 4 RBC and 4 plasma.
Step 5: Release 4 RBC and 4 plasma.
Step 6: Setup platelets and cyro. Release 4 RBC, 4 plasma, platelet, cyro.
Step 7: Release 4 RBC and 4 plasma.
Step 8: Release 4 RBC and 4 plasma.
Step 9: Setup platelet and cyro. Release 4 RBC, 4 plasma, platelets, cyro.

20. Massive transfusion
Patients who will require a massive transfusion will have improved outcomes the earlier that this is identified and the earlier that damage control hematology is instituted. Current evidence does not describe the best ratio but the preponderance of the data suggests it should be greater than 2: 3 plasma-to-packed red blood cells. --Nunez et al.
Trauma patients who arrived to the hospital with an elevated INR had a greater risk of death than those with a lower INR. However, as the ratio of FFP:PRBC transfused increased, mortality decreased similarly between the INR quartiles. --Brown L and Trauma Outcomes Group

21. Ionotropes Norepinephrine—preferred for shock/sepsis
Stimulates beta1-adrenergic receptors and alpha-adrenergic receptors causing increased contractility and heart rate as well as vasoconstriction
Vasopressin—refractory shock
Increases systemic vascular resistance and mean arterial blood pressure and decreases heart rate and cardiac output
Phenylephrine—alpha receptor only, peripheral use
Potent, direct-acting alpha-adrenergic agonist with virtually no beta- adrenergic activity; produces systemic arterial vasoconstriction.

22. What is the urine output goal for resuscitation for adults?
a) 0.2 mg/kg/hr
b) 0.4 mg/kg/hr
c) 0.5 mg/kg/hr
d) 1.0 mg/kg/hr

23. End Points of Resuscitation
Skin perfusion
Urinary output
Lactate

24. Bilbiography
ATLS Student Manual. Chicago: American College of Surgeons, 2012.
Brown L et al with the Trauma Outcomes Group. A High FFP:PRBC Transfusion Ratio Decreases Mortality in All Massively Transfused Trauma Patients Regardless of Admission INR. J Trauma 2011: 71(2 O 3) S
Cotton BA et al. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma 2009: 66: 41-9.
Dutton, et al. Hypotensive resusciation during active hemorrhage: impact on in-hospital mortality. J Trauma :
Marino, Paul. The ICU Book, 4th ed. Philadelphia: Wolters Kluwer, 2014.
Morrison C Anne et al. Hypotensive Resuscitation Strategy Reduces Transfusion Requirements and Severe Postoperative Coagulopathy in Trauma Patients With Hemorrhagic Shock: Preliminary Results of a Randomized Controlled Trial. J Trauma - Injury, Infection and Critical Care :3:
Nunez TC. Transfusion therapy in massive hemorrhage. Current Opinion in Critical Care : 15 (6)