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- 1. HEMORRHAGE DR RAJESH SISODIYA KMC MANIPAL
- 2. Introduction Hemorrhagic shock is the most common cause of death among combat casualties
- 3. TYPES PRIMARY: at time of surgery REACTIONARY: with 24 hrs due to slipping of ligature, dislodgement of a clot or cessation of reflex vasospasm SECONDARY: after 7 to 14 days due to infection, sloughing of a part of wall of an artery as a result of pressure of drainage tube, fragment of a bone, ligature in infected area or cancer.
- 4. Blood loss estimation Clenched fist is roughly equal to 500ml. Moderate swelling in closed fracture of tibia equals 500- 1500 ml and in fracture shaft of femur equals 500 2000 ml. Swab weighing :1gm =1ml is added to the volume of blood collected in suction bottles.
- 5. pulse appearance of tachycardia indicates a loss of 1530% of circulating blood volume Approximate SBP on basis of pulse Radial- 90mm Hg Brachial 80 mm Hg Femoral 70 mm Hg Carotid 60 mmHg
- 6. Hypovolemia Bld Loss Blood Vol. Heart Blood Pulse Resp Urine Mental Hemorrhage (L.) Lost (%) Rate Pressure Pressure Rate ml./hr. Status Class I <1 <15% <100 Normal Normal or 14-20 >=30 Slight Increased Anxiety Class II 0.75-1.5 15%-30% >100 Normal Decreased 20-30 20-30 Mild Anxiety Class III 1.5-2.0 30%-40% >120 Decreased Decreased 30-40 <15 Anxious Confused Class IV >2.0 >=40% >=140 Decreased Decreased Rapid Neg Confused Shallow Lethargic (Committee on Trauma, American College of Surgeons. Advanced Trauma Life Support for Physicians Chicago, Ill.: American College of Surgeons)
- 7. Blood pressure the length of the bladder of the cuff should be at least 80% of the circumference of the upper arm, and the width at least 40% of the circumference of the upper arm in order for the measurement to be accurate. listening for sounds generated from the artery (Korotkoff sounds) as the cuff deflates can be very inaccurate, especially during hypotension. On the other hand, automated blood pressure cuffs are not consistently accurate when systolic blood pressures are below 110 mmHg
- 8. Arterial line the transducer must be zeroed at the level of the right atrium or else reading will be erroneous: falsely elevated if the transducer is too low, falsely depressed if the transducer is too high. Catheter whip is due to movement of the catheter within the lumen of the vessel. This usually occurs when the catheter is placed in a relatively large vessel, such as the femoral artery, and can cause the measurements of systolic pressure to vary by approximately 20 mmHg.
- 9. Central venous pressure transducer must be placed at the zero reference point, known as the phlebostatic axis, for central venous pressures to be accurate. This phlebostatic axis is the artificial point on the thorax where the fourth intercostal space meets the midaxillary line, and corresponds to the position of the right and left atria in the supine position. normal CVP is quoted as between 48 mmHg
- 10. Pulmonary artery catheter the pulmonary capillary wedge pressure approximates the left atrial pressure (except in cases of pulmonary hypertension) which will equal left-ventricular end diastolic pressure in patients with competent mitral valves.
- 11. Serum lactate elevated blood lactate is a reliable marker of hypoperfusion. Furthermore, failure to clear the lactate level to normal levels with 24 h was associated with a mortality of > 75%.
- 12. Physiological Consequences of Hemorrhage Adverse effects of hemorrhage on young, healthy are directly related to two primary factors 1.) Decreased intravascular volume 2.) Inadequate oxygen-carrying capacity
- 13. Cardiovascular Response The immediate response to the fall in venous return to the heart, and decrease in pressure to the aortic arch and carotid baro-receptors is a diffuse activation of the sympathetic nervous system Release of catecholamines from adrenal medulla Increase in heart rate and contractility Increase in systematic vascular resistance due to vasoconstriction of skeletal muscles and viscera This response preserves central organs Heart & brain at the expense of peripheral organs
- 14. Fluid Compartment Shifts After a casualty sustains a major hemorrhage, restoration of the intravascular fluid compartment may require many hours as interstitial fluid (extra-vascular) is drawn into the intravascular compartment
- 15. Extra-vascular Fluid Loss casualties presenting for care several hours after being injured may suffer from: Hemorrhage-induced intravascular volume depletion Preexisting depletion of the extra-cellular fluid compartment that is caused by concomitant dehydration, secondary to environmental or nutritional factors
- 16. Extra-vascular Fluid Loss Cont. Because crystalloids (Normal Saline (NS) /Lactated Ringers (LR)) are distributed through the body water, a study showed 3-4 ml/1 ml blood loss is required to replace intravascular volume Recommendations for replacing the third-space fluid sequestration is four, six, and eight ml/kg/hr for minimal, moderate, and severe trauma (respectively) in addition to estimated hourly maintenance fluids
- 17. Oxygen Transport Hemorrhage interferes with normal tissue oxygenation by two mechanisms 1.) The anemic (Inadequate oxygen carrying capacity) 2.) The hemorrhagic (Inadequate tissue perfusion) In the setting of severe hemorrhage, however, reduced hemoglobin content is rarely the cause of tissue hypoxia A 20-year-old healthy soldier can lose 40-50% of his blood volume and hemodynamically compensate with cardiac output and vasoconstriction to maintain adequate tissue perfusion
- 18. Oxygen Transport This example demonstrates blood replacement is frequently unnecessary and volume restoration is the key If the circulating plasma volume is maintained then the metabolic consequences of severe hemorrhage can be minimized
- 19. Hypovolemia Class I (<15%) Suspected blood loss in absence of tachycardia or hypotension Resuscitate with clear fluids (crystalloids (NS / LR) Class II (15%-30%) Tachycardia without hypotension Transfuse with crystalloid or colloid, transfuse early with continual bleeding Class III (30%-40%) or Class lV (>=40%) Hypotension and tachycardia require immediate blood volume replacement with crystalloid, colloids, and or packed red blood cells
- 20. Investigations routine trauma panel (type and cross-match, complete blood count, blood chemistries, coagulation studies, lactate level, and arterial blood gas analysis) should be sent to the laboratory.
- 21. four life-threatening injuries that must be identified are (a) massive hemothorax, (b) cardiac tamponade, (c) massive hemoperitoneum, and (d) mechanically unstable pelvic fractures. Three critical tools used to differentiate these in the multisystem trauma patient are chest radiograph, pelvis radiograph, and focused abdominal sonography for trauma (FAST)
- 22. any episode of hypotension (defined as a SBP <90 mmHg) is assumed to be caused by hemorrhage until proven otherwise. Blood pressure and pulse should be measured manually at least every 5 minutes in patients with significant blood loss until normal vital sign values are restored. Two broad categories of shock causing persistent hypotension are hemorrhagic and cardiogenic. An evaluation of the CVP will usually distinguish between these two categories. A patient with flat neck veins and a CVP of <5 cm H2O is hypovolemic and is likely to have ongoing hemorrhage. A patient with distended neck veins or a CVP of >15 cm H2O
- 23. IV access with two peripheral catheters, 16-gauge or larger in adults. Blood should be drawn simultaneously and sent for measurement of hematocrit level, as well as for typing and cross- matching for possible blood transfusion. According to Poiseuille's law, the flow of liquid through a tube is proportional to the diameter and inversely proportional to the length; therefore, venous lines for volume resuscitation should be short with a large diameter
- 24. Resuscitation Fluid resuscitation begins with a 2 L (adult) or 20 mL/kg (child) IV bolus of isotonic crystalloid, typically Ringer's lactate. For persistent hypotension, this is repeated once in an adult and twice in a child before red blood cells (RBCs) are administered. Patients who have a good response to fluid infusion (i.e., normalization of vital signs, clearing of the sensorium) and evidence of good peripheral perfusion (warm fingers and toes with normal capillary refill) are presumed to have adequate overall perfusion. Urine output is a quantitative, reliable indicator of organ perfusion. Adequate urine output is 0.5 mL/kg per hour in an adult
- 25. PRBC transfusion should occur once the patient's hemoglobin level is <7 g/dL, in the acute phase of resuscitation the endpoint is 10 g/dL. Fresh-frozen plasma is transfused to keep the patient's International Normalized Ratio (INR) less than 1.5 and partial thromboplastin time (PTT) <45 seconds. Primary hemostasis relies on platelet adherence and aggregation to injured endothelium, and a platelet count of 50,000/L is considered adequate if platelet function is normal. With massive transfusion, however, platelet dysfunction is common, and therefore a target of 100,000/L is advocated. If fibrinogen levels drop below 100 mg/dL, cryoprecipitate should be administered.
- 26. Colloid Solutions (Dextran, Hespan, & Albumin) Rapidly replenishes intravascular compartment with smaller fluid volume than crystalloids Gives more prolonged expansion of the plasma volume and less peripheral edema Has Disadvantages
- 27. DAMAGE CONTROL SURGERY Goal of DCS is to control surgical bleeding and limit GI spillage. The operative techniques used are temporary measures, with definitive repair of injuries delayed until the patient is physiologically replete.
- 28. Hypothermia from evaporative and conductive heat loss and diminished heat production occurs despite the use of warming blankets and blood warmers. The metabolic acidosis of shock is exacerbated by aortic clamping, administration of vasopressors, massive transfusions, and impaired myocardial performance. Coagulopathy is caused by dilution, hypothermia, and acidosis. Once the cycle starts, each component magnifies the others, which leads to a downward spiral and ultimately a fatal arrhythmia. The purpose of DCS is to limit operative time so that the patient can be returned to the SICU for physiologic restoration and the cycle thus broken.
- 30. Indications to limit the initial operation and institute DCS techniques include temperature <35属C (95属F), arterial pH <7.2, base deficit <15 mmol/L (or <6 mmol/L in patients over 55 years of age), and INR or PTT >50% of normal. The decision to abbreviate a trauma laparotomy is made intraoperatively as laboratory values become available
- 31. Supplemental Therapeutic Measures Control of bleeding and rapid infusion of crystalloids and blood are essential in combat casualty treatment of shock Other Treatments
- 32. Patient Position Trendelenberg's position Raised legs may increase blood return to heart without increasing intracranial pressure
- 33. Pneumatic Antishock Garment A compression device first known as the Military Anti-Shock Trousers (MAST) introduced by the U.S. Army during the Vietnam War
- 34. Supplemental Oxygen Beneficial in multiple or massive injury Flail chest, fat embolus and other injuries associated with impaired oxygenation
- 35. Vasopressors Transiently supporting blood pressure with vasoconstrictors until volume replacement or control of bleeding is possible Intense vasoconstriction is typical hemostatic response to hemorrhagic shock and may be primarily responsible for adverse consequences of hypovolemia (acidosis and tissue hypoxia)
- 36. Hyperthermia and Dehydration Physical exertion and inadequate supplies on the battlefield combine to develop heat injury and dehydration Coincidental trauma and hemorrhage Rapid replacement of intravascular and intracellular fluids
- 37. Hypothermia Temperatures <30 Degrees C Decreases renal blood flow 75% Restoration of fluid deficits Re-warming the patient frequently develops metabolic acidosis Fluid resuscitation & maintenance will correct acidotic state Treat acidosis with sodium bicarbonate
- 38. Hemorrhagic Shock and Head Injury Hypovolemia and head injury is ominous Increased intracranial pressure and hypotension, secondary to hypovolemia, further decreases cerebral perfusion pressure and potentiates cerebral ischemic injury When colloid solutions have been advocated, the blood-brain barrier may have been damaged contributing to worsening edema with fluid resuscitation