Transcript Resuscitation from hemorrhagic shock

Injury is the leading cause of death between the ages of
1 and 45 years and the third leading cause of death
overall.
3th leading cause of death and disability in all age groups
Mortality increased by 2020 in low and middle income
countries
Decreased mortality in trauma center
• Anesthesiologists are involved:
beginning with airway and resuscitation management in the
emergency department (ED) and proceeding through the
operating room (OR) to the intensive care unit (lCU).
• Critical care and pain management specialists see trauma
patients as a large fraction of their practice.
in European practice anesthesiologist working in the
prehospital environment, as an ED director, or as leader of
a hospital's trauma team.
• The presence of an experienced anesthesiologist
and the immediate availability of an open OR are
both core resource standards for accreditation of a
"level 1" trauma center.
***Anesthesia for trauma patient is different
from routine OR practice:
• Most urgent cases occur during off-hours
• Small hospital-military and humanitarian
practice,auster condition (Resources avibility)
• limitation in Patient information
• Full stomach-intoxicate-cervical spine instability
• Multiple positioning-multiple procedure-need to
consider priorities in management
• Occult injuries such as tension Pneumothorax can be
manifested at unexpected times
• Multiple injury
• The advanced trauma life support (ATLS) course of the American
College of Surgeons is the most popular training program for
trauma physicians
ATLS:
Based on primary survey that means:
• simultaneous diagnostic and therapeutic activities intended to
identify and treat life and limb-threatening injuries, beginning with
the most immediate.
• This focus on urgent problems is first captured by the " Golden
hour“ catch phrase and is one of the most important lessons of
ATLS.
• ATLS begins with the ABCDE :
• airway, breathing, circulation, disability, and
exposure and secondary survey.
• adequate open airway and acceptable respiratory
mechanics is of primary Importance because hypoxia
is the most immediate threat to life.
• Trauma patients are at risk for airway obstruction
and inadequate respiration for the reasons listed
later.
• cause of obstructed airway or inadequate ventilation in trauma
patients:
Airway Obstruction:
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Direct injury to the face, mandible, or neck
Hemorrhage in the nasophrynx, sinuses, mouth, or upper airway
Diminished consciousness secondary to traumatic brain injury, intoxication, or
analgesic medications
Aspiration of gastric contents or a foreign body (e.g., dentures)
Misapplication of oral airway or endotracheal tube (esophageal intubation)
Inadequate Ventilation
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Diminished respiratory drive secondary to traumatic brain injury, shock, intoxication,
hypothermia, or over sedation
Direct injury to the trachea or bronchi
Pneumothorax or hemothorax
Chest wall injury
Aspiration
Pulmonary contusion
Cervical spine injury
Bronchospasm secondary to smoke or toxic gas inhalation
• Endotracheal intubation must be immediately
confirmed by :
• capnometry for patients who have vital signs; esophageal
intubation or endotracheal tube dislodgement is common
• Patients in cardiac arrest may have very low end-tidal CO2
values;
• direct laryngoscopy should be performed if there is any
question about the location of the endotracheal tube.
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• continue
• If establishment of a secure airway and adequate
ventilation require a surgical procedure such as a
tracheostomy, tube thoracostomy, or open thoracotomy,
this procedure must be precede.
• Subsequent surgery to convert a cricothyroidotomy to a
tracheostomy or close an emergency thoracotomy may then
follow in the OR on an urgent basis.
Hemorrhage is the next most pressing concern because ongoing
loss of blood will be fatal in minutes to hours.
Shock is presumed to be a consequence of hemorrhage until
proved otherwise.
• Assessment of the circulation consists of:
• an early phase, during active hemorrhage
• late phase, which begins when hemostasis is achieved and
continues until normal physiology is restored.
• In the early phase, diagnostic efforts will focus on the
five sites of bleeding detailed
• they are the only areas in which Exanguinating
hemorrhage can occur.
• Neurologic examination:
• measurement of the Glasco Coma Scale (GCS) score; examination
of the pupils for size, reactivity, and symmetry
• determination of preserved sensation and motor function in each
of the extremities.
• In few patients who require operative evacuation of an
epidural or subdural hematoma, the timeliness of diagnosis
and treatment has a strong influence on outcome.
• patients with unstable spinal canal injuries and incomplete
neurologic deficits may benefit from early operative
intervention.
• The final step in the primary survey is
complete exposure of the patient and a
head-to-toe search for visible injuries or
deformity-soft tissue bruising, and any
breaks in the skins.
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secondary survey:
history and physical examination
diagnostic studies
subspecialty consultation
treatment plans established
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Indications for urgent or emergency surgery:
pulseless extremity,
compartment syndrome
near amputation
massively fractured extremity
must go to the operative room as soon as possible.
Infection:
• sepsis is a leading cause of complications and death in trauma patien:
open injuries should be thoroughly debrided-and closed if
appropriate-at the earliest opportunity.
• Other indication for urgent surgery:
• perforation of the bowel
• open fracture
• extensive soft tissue wounds
• The frequency of infectious increases in linear fashion with time
**the anesthesiologist must balance the need for early surgery
against the need for diagnostic studies and adequate
preoperative resuscitation.
Surgical priorities:(fig72-2)
 1:Airway management
• 2:Control of exanguinating hemorrhage
(Laparaotmy-thoracotomy-pelvic external fixation-neck exploration)
 3:Intracranial mass excision
 4:Treatment limb or eyesight - High risk sepsis
Control of ongoing hemorrhage-Early patient mobilization- spinal fixationClosed long bone fixation
Better cosmetic outcome-Facial fracture repair-Soft tissue closure
Emergency air way management:
• Adequate oxygenation and ventilation
• Protection from aspiration
• ASA algorithm for management of difficult air
way is useful starting point for the trauma
anesthesiologist whether in the ED or OR.
• (figure72-4)
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Indication of endotracheal intubation:
• Cardiac or respiratory arrest
• Respiratory insufficiency
• Airway protection
• The need for deep sedation or analgesia, general anesthesia
• Transient hyperventilation of patients with space occupying
intracranial lesions and evidence of increased intracranial
pressure (ICP)·
• Delivery of %100 FIO2 patients with carbon monoxide
poisoning ·
• Facilitation of the diagnostic workup in uncooperative or
intoxicated patients.
Approach to Endotracheal Intubation:
• the anesthesiologist should insist on the same monitoring
standards for airway management in the ED as in the OR, including
an electrocardiogram, blood pressure (BP), oximetry, and
capnometry
• Appropriate equipment:
oxygen source,
bag-valve-mask ventilating system,
mechanical ventilator,
suction, selection of laryngoscope blades,
endotracheal tubes,
devices for managing difficult intubations
• Neuromuscular usage???
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Although concern may exist that the use of
neuromuscular blocking drugs and potent induction
anesthetics outside the OR will be associated with a
higher complication rate, the opposite is in fact more
likely correct.
• Attempts to secure the airway in an awake or lightly
sedated patient increase the risk of airway trauma
,pain, aspiration, hypertension, laryngospasm, and
combative behavior.
Prophylaxis against aspiration of gastric content
• A trauma patient is always considered to have a full
stomach
• ingestion of food or liquids
• swallowed blood from oral or nasal injuries
• delayed gastric emptying
• administration of liquid contrast medium
• If time and patient cooperation allow, it is reasonable
to administer non particulate antacids for patient
before induction and intubation.
• Cricoid pressure-the Sellick maneuver-should applied
continuously
• Sellick maneuver consists of elevating the patient's chin (without
displacing the cervical spine) and then pushing the Cricoid
cartilage posteriorly to close the esophagus.
• A bimanual technique was later described by Crowley and
Gieseckel. in which the left hand is placed under the patient's
neck to stabilize it. The cricoid is stabilized between the thumb
and third finger while the index finger pushes down.
• Sellick's original paper described ventilation during Cricoid
pressure in patients with full stomachs.
• because preoxygenation may be difficult in a trauma patient as a
result of facial trauma, decreased respiratory effort, or agitation,
desaturation will occur rapidly.
Protection of the Cervical Spine
• Standard practice dictates that all blunt trauma, should
be assumed to have an unstable cervical spine until this
condition is ruled out.
• laryngoscopy causes cervical motion, with the
potential to exacerbate spinal cord injury
• continue
• The presence of an "uncleared" cervical spine mandates the use
of in-line manual stabilization (not traction) throughout any
intubation attempt
• Emergency awake fiberoptic intubation
• Indirect larengoscope
Personel:
• Three providers are required to ventilate the patient,
hold Cricoid pressure, and provide in-line cervical
stabilization; a fourth provider to administer anesthetic
medications
• Additional assistance may be required to restrain a
patient who is combative as a result of intoxication or
TBl.
• The immediate presence of a surgeon or other physician
Who can perform a cricothyroidotomy is desirable.
• Urgent tube thoracostomy may prove necessary in
some trauma patients to treat the tension Pneumothorax
that develops with the onset of positive pressure
ventilation
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Anesthetic for induction of anesthesia:
• in hemorrhagic shock may potentiate
profound hypotension and
even cardiac arrest as a result of inhibition of circulating catecholamines.
• propofol and thiopental both drugs are vasodilators and
both have a negative inotropic effect
• Effects of anesthetics on brain Increased
• Etomidate more cardiovascular stability than other
intravenous hypnotic
• Ketamine :
causes a release of catecholamines, primarily by direct action
on the CNS
it is also a direct myocardial depressant.
• continue:
• In normal patients, the effect of catecholamine release masks the
cardiac depression and results in hyper tension and tachycardia.
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In hemodynamically stressed patients , cardiac depression may be
unmasked and lead to cardiovascular collapse.
• Hypovolemic patients will become hypotensive with the
administration of any the induction anesthetic :
• Sever hypotension:
• healthy young patients can lose up to 40% of their blood volume
before experiencing a decrease in arterial BP, which can lead to
potentially catastrophic circulatory collapse with anesthetic
induction, regardless of the agent chosen.
• The dose of anesthetic must be decreased in the face of
hemorrhage in patient with life threatening
hypovolemia.
Neuromuscular blocking drugs:
• succinylcholine has fastest onset time and short of
action
• make it popular for rapid-sequence induction
• “In can not ventilate can not intubated patient”
• The anesthesiologist should not rely on return of
spontaneous breathing
• Suuccinylcoline ………
• Serum potassium increases of 0.5 to 1.0 mEq/L but in
certain patients potassium may increase by more than 5
mEq/L.
• The hyperkalemic response is typically seen in burn
victims, patients with muscle pathology caused by direct
trauma, denervation (as with SCI), or immobilization
• Hyperkalemia is not seen in the first 24 hours after these
injuries
• should be used cautiously in patient with ocular trauma
and increase ICP
• Rocuronium (09-1.2 mg/kg) and vecuronium (0.1 to 0.2 mg/kg).
(sugamadex)
• large doses can be used to achieve rapid (1 to 2 minutes) systemic
relaxation.
• Awareness &Recall:
• Subsequent patient recall of intubation and emergency procedures
is highly variable and affected by the presence of coexisting TBI,
intoxication, and the depth of hemorrhagic shock
• Decreased cerebral perfusion appears to inhibit memory
formation but cannot be reliably associated with any particular BP
or chemical marker.
• Administration of 0.2 mg of **scopolamine (a tertiary ammonium
vagolytic) has been advocated to inhibit memory formation in the
absence of anesthetic drugs in this situation,
• Small doses of **midazolam will reduce the incidence of patient
awareness, but can also contribute to hypotension.
• Specific situation:
• There will always be specific situations where maintaining
spontaneous ventilation during intubation is the preferred and
indeed the safest manner in which to proceed.
• If patients are able to maintain their airway temporarily but have
clear indications for an artificial airway (penetrating trauma to the
trachea), slow induction with ketamine or inhaled sevoflurane
through Cricoid pressure will enable placement of an endotracheal
tube without compromising patient safety.
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Fiberoptic intubation can also be performed under such
circumstances
Adjuncts to endotracheal intubation:
• Equipment to facilitate difficult intubation should be readily available
wherever emergency airway management is performed
• The gum elastic bougie, or intubating stylet
• The stylet is placed through the vocal cords under the guidance of
direct laryngoscopy, with the endotracheal tube then advanced over
it into the trachea.
• esophageal combitube :(Kendall Sheridan Catheter)
• Because placement of the Combitube has been
associated with esophageal injury, its use should be
reserved for emergency situations
The laryngeal mask airway (LMA):
LMA placement is possible in most patients who cannot be
intubated and will permit adequate oxygenation and
ventilation
The LMA is an appropriate rescue device for difficult air way
situation in trauma, provide that there is no major anatomic
injury or hemorrhage in the mouth and larynx.
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• Trans tracheal jet ventilation:
• through a Percutaneous catheter attached to a high-pressure
fresh gas source
• After initial successful placement the catheter may kink or pull out
of the trachea with motion of the patient's head or neck.
• Tension Pneumothorax ,this condition should be suspected
whenever a patient deteriorates suddenly after jet ventilation
• reserved for only the most urgent situations and should be closely
followed by open cricothyroidotomy
Oral versus nasal intubation:
oral intubation is preferred over nasal intubation in the emergency
setting because of the risk of direct brain trauma from nasal
instrumentation in a patient with a basal skull or cribriform plate
fracture
nasal intubation poses a:
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risk of sinusitis in a patient who will be mechanically ventilated
for more than 24 hours;
• use of a smaller-diameter tube will also increase the difficulty of
subsequent airway suctioning and fiberoptic bronchoscopy.
Facial and pharyngeal trauma:
Serious skeletal derangements may be masked by apparently
minor soft tissue damage
Failure to identify an injury to the face or neck can lead to acute
airway obstruction secondary swelling and hematoma.
Laryngeal edema is also a risk patients who have suffered chemical
or thermal injury the pharyngeal mucosa.
indications for early intubation:
Intra oral hemorrhage
pharyngeal erythema
change in voice
Continue:
• both maxillary and mandibular fractures will make mask
ventilation more difficult, whereas mandibular fractures will
make intubation easier
• Palpation of facial bones before manipulation of the airway help
to diagnosis
• Patients with jaw and zygomatic arch injuries often have
trismus.
• trismus will resolve with the administration of neuromuscular
blocking agents
• Bilateral mandibular fractures and pharyngeal hemorrhage may
lead to upper airway obstruction, particularly in a supine patient
• A patient arriving at the ED in the sitting or prone position
because of airway compromise is best left in that position until the
moment of anesthetic induction and intubation.
Resuscitation from hemorrhagic shock:
• refers to the restoration of normal physiology
after injury specifically to the restoration of:
• normal circulating blood volume
• normal vascular tone
• normal tissue perfusion.
• Pathophysiology of hemorrhagic shock:
• Decreased BP leads to vasoconstriction and catecholamine
release.
• Pain, hemorrhage, and cortical perception of traumatic injuries
lead to the release of a number of hormones, including
• renin-angiotensin
• vasopressin
• anti diuretic hormone
• growth hormone
• glucagon
• Cortisol
• epinephrine, and norepinephrine
continue
• Individual ischemic cells respond to hemorrhage by taking up
interstitial fluid
further depleting intravascular
fluid.
• Cellular edema may choke off adjacent capillaries and result
in a "no-reflow" phenomenon that prevents the reversal
ischemia in the presence of adequate macro perfusion.
• Ischemic cells produce lactate and free radicals, which
accumulate in the circulation if perfusion is diminished.
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• These compounds cause direct damage to the cell, as well as form
the bulk of the toxic load that will be washed back to the central
circulation when flow is reestablished.
• The ischemic cell will also produce and release a variety of
inflammatory factors
• prostacyclin
• thromboxane
• prostaglandins
• leukotrienes, endothelin,
• complement
• interleukins
• tumor necrosisfactor
• and others
• This why a patient may die of multiple organ
failure after traumatic hemorrhage, even
when bleeding has been controlled and the
patient resuscitated to normal vital signs and
perfusion.
• The CNS is the prime trigger of the neuroendocrine response to
shock, which maintains perfusion to the heart, kidney, and brain at
the expense of other tissues.
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Regional glucose uptake in the brain changes during shock.
• Reflex activity and cortical electrical activity are both depressed
during hypotension; these changes are reversible with mild
hypoperfusion but become permanent with prolonged
ischemia.
• Specific organ systems respond to traumatic shock in specific ways:
• The kidney and adrenal glands are prime responders to the
neuroendocrine changes associated with shock; these organs produce
renin, angiotensin, aldosterone, cortisol, erythropoietin, and
catecholamines.
• The kidney itself maintains glomerular filtration in the face of
hypotension by selective vasoconstriction and concentration of blood
flow in the medulla and deep cortical area.
• Prolonged hypotension leads to decreased cellular energy and an
inability to concentrate urine(renal cell hibrination), followed by
patchy cell death, tubular epithelial necrosis, and renal failure
• continue
• The heart is relatively preserved from ischemia during shock
because of an increase in nutrient blood flow
• cardiac dysfunction as the terminal event in the shock spiral
because of Lactate, free radicals, and other humoral factors
released by ischemic cells all act as negative inotropes and, in a
decompensated patient
• A patient with cardiac disease or cardiac trauma(fixed stroke
volume)…….
• Shock in the elderly may therefore be rapidly progressive and may not
respond predictably to fluid administration.
Continue
• Accumulation of immune complex and cellular factors in
pulmonary capillaries leads to neutrophils and platelet
aggregation, increased capillary permeability, destruction
of lung architecture, and respiratory distress syndrome.
• This is evidence that traumatic shock is
more than just a hemodynamic disorder.
• continue
• The Gut is one of the earliest organs affected by hypoperfusion and may
be the prime trigger of MOSF.
• Intestinal cell death causes a breakdown the barrier function of the gut that
results in increased translocation of bacteria to the liver and lung, thereby
potentiate ARDS.
• The liver has a complex microcirculation and has been demonstrated to suffer
reperfusion injury during recovery from shock.
• Failure of the synthetic functions of the liver after shock are
almost always lethal
• continue
• Skeletal muscles:
tolerates ischemia better than other organs
• The large mass of skeletal muscle, though, makes it important in
the generation of lactate and free radicals from ischemic cells.
• Sustained ischemia of muscle cells leads to an increase in
intracellular sodium and free water with an aggravated
depletion of fluid in the vascular and interstitial compartments.
• Resuscitation of these patients should be considered in
two phase:
• Early, while active bleeding is still ongoing
• Late; once all hemorrhage has been controlled.
• Early resuscitation is much more complex because the risks of
aggressive volume replacement summarized in Table 63-6
including the potential for exacerbating hemorrhage and thus
prolonging the crisis, must be weighed against the risk of
ongoing hypoperfusion.
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• Early resuscitation:
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Fluid administration is the cornerstone of acute resuscitation.
Intravascular volume is lost because:
hemorrhage
uptake by ischemic cells
extravasation into the interstitial space.
• The ATLS curriculum advocates the rapid infusion of up to 2 L of
warmed isotonic crystalloid solution for any hypotensive patient,
with the goal of restoring normal BP .
Fluid administration:
• reduces oxygen delivery
• hypothermia
• coagulopathy.
Elevation of Blood pressure leads to:
• increased bleeding as a result of disruption of clots
• reversal of compensatory vasoconstriction.
• The result of aggressive fluid administration is often a transient
rise in BP, followed by increased bleeding and another episode
of hypotension, followed by the need for more volume
administration.
• This vicious cycle has been recognized since the First World War and remains
a complication of resuscitation therapy today.
Deliberate hypotensive
• Application of this technique to the initial management of
a hemorrhaging trauma victims highly controversial and
has been the focus of numerous laboratory and clinical
research efforts.
• A large body of laboratory data have shown the benefits of
limiting fluid administration to actively hemorrhaging animals
• Moderate resuscitation (to a lower than normal BP) improved
perfusion of the liver.
• Burris and coworkers found that rebleeding was correlated with
higher mean arterial pressure (MAP) and that survival was best
in groups resuscitated to a lower than normal MAP.
• A 1994consensus panel on resuscitation from hemorrhagic shock:
mammalian species are capable tolerate Sustaining MAP as low
as 40 mm Hg for periods as long as2 hours without deleterious
effects.
• this panel conclude that spontaneous hemostasis and
long-term survival were maximized by reduced
administration of resuscitation fluids during the period
of active bleeding while seeking to keep perfusion only
above the threshold for ischemia.
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in another study The authors concluded that administration of
fluids to an actively hemorrhaging patient should be titrated to
specific physiologic end points, with the anesthesiologist navigating
a course between the risk of increased hemorrhage and
hypoperfusion.
Blood loss without shock does not produce systemic
complications such as ARDS in experimental models
• The emphasis in this situation must be on rapid diagnosis and
control of ongoing hemorrhage
the anesthesiologist should attempt to:
• restore vascular volume
• provide anesthesia
in equal measure such that the patient is moved from a
vasoconstricted state to a vasodilated
• facilitating hemostasis by maintenance of a lower than normal
BP.
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Vulnerable Patient Populations
• Clinical trials of deliberate hypotensive resuscitation have restricted this
teqnique:
• ischemic coronary disease
• elderly patients (reduced physiologic reserve)
• Those with injuries to the brain or spinal cord
• Clinical care of these patients is focused on avoidance of ischemic
stress and rapid correction of hypovolemia
Resuscitation Fluids:
• isotonic Crystalloids (normal saline, lactated Ringer's solution Plasma-Lyte ) are
the initial resuscitative fluids administered, to any trauma patient.
• Advantages:
• Inexpensive
• readily available
• non allergenic
• noninfectious,
• efficacious in restoring total-body fluid.
• mix well with most infused medications,
• rapidly warmed to body temperature.
Disadvantages:
• lack of oxygen-carrying capacity,
• their lack of coagulation capability,
• and their limited intravascular half-life.
• immunosuppressant and triggers of cellular apoptosis(is the process of
programmed cell death that may occur in multicellular organisms)
• apoptosis is an important element of reperfusion injury
• In a rat model of controlled hemorrhage, animals receiving
LR solution showed an immediate increase in apoptosis
in the liver and small intestine after resuscitation
with LR.
Neither whole blood nor hypertonic saline
increased the amount of apoptosis.
• Hypertonic saline solutions, with or without the addition of
polymerized dextran have been extensively studied in
resuscitation from hemorrhagic shock.
• HS will draw fluid into the vascular space from the interstitium,
HS a popular choice for fluid resuscitation
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Multiple studies of otherwise lethal hemorrhage in animals
have demonstrated improved survival after resuscitation with
HSD versus either normal saline solution or the components of
HSD alone.
• Studies of the efficacy of HSD in trauma patients have been
inconclusive
• the most obvious benefit has been in a subset of poly
traumatized patients with both hemorrhage and TBI, where
improved neurologic status was demonstrated in patients who
received HSD as a resuscitation fluid
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HS is commonly used as an osmotic agent in the management
of TBI with increased ICP.
• Colloids:
hetastarch solutions and albumin, have long been advocated for
rapid plasma volume expansion.
colloids are readily available
easily stored and administered
relatively inexpensive.
As with the hypertonic solutions, colloids will increase
intravascular volume by drawing free water back into the
vascular space.
Continuous :
When intravenous access is limited, colloidal resuscitation will
restore intravascular volume more rapidly than crystalloid
infusion will and at a lower volume of administered fluid.
Because colloids do not specifically transport oxygen or facilitate
clotting, their dilutional effect on blood will be similar to that of
crystalloids.
recent Studies have demonstrated no great benefit of colloids over
crystalloids in a variety of resuscitation models.
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Continuous
• Recognition of dilutional effects of fluid administration and
continued improvement in the safety of donated blood have led to
• increased use of blood products in the management of early
hemorrhagic shock .
• The risk of systemic ischemia is decreased by the maintenance of
an adequate hematocrit, and the potential for dilutional
coagulopathy can be avoided with the early administration of
plasma.
• 141 patients received massive blood transfusions (20 U or more of
packed red blood cells (PRBC) during preoperative and
intraoperative resuscitation
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• Eleven variables were significantly different: aortic clamping for
control of BP, use of inotropic drugs, time with systolic BP less
than 90 mm Hg, time in the OR, temperature lower than 34°C, urine
output, pH less than 7.0, Pao2/Flo2 ratio less than 150, Paco2
higher than 50 mm Hg, potassium greater than 6 mM/L, and
calcium less than 2 mM/L

Continuous
Of these variables, the presence of the first three in the face of
transfusion of more than 30 U of PRBCs was invariably fatal.
Total blood loss and the amount of transfused blood were less
critical than the
depth and duration of shock.
These concern to the concept of damage control surgery, which
emphasizes rapid control of active hemorrhage.
• Red blood cell:
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are the mainstay of treatment of hemorrhagic shock.
A unit of RBCs :
• will predictably restore oxygen-carrying capacity
• expand intravascular volume as well as any colloid solution will.
• cross matching is desirable when time allows
• Type O blood the "universal donor“ can be given to patients of
any blood type with little risk of a major reaction
• If O positive blood is given to Rhesus-negative woman who
survives, prophylactic administration of anti-Rh antibody is
indicated.
Continuous
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Risks of PRBC administration include
transfusion reaction
transmission of infectious agents
hypothermia.
• PRBCs are stored at 4°C and will lower the patient's
temperature rapidly if not infused through a
warming device
• FFP:
Plasma required blood typing but not crossmatched
Very busy centers are experimenting with Keeping 2-4 units as
prethawed plasma Universal donor (AB)
Plasma and PRBCs should be administered prophylactic in a 1:1
ratio to any patient with obvious massive hemorrhage, even
before confirmatory laboratory studies are available.
• Platelet:
• Platelet transfusion should be reserved for clinically
coagulopathic patients with a documented low
serum<50000
Platelets should not be administered :
• filter
• Warmer
• rapid infusion devices.
 When the patient in shock and blood loss is likely to be
substantial palates should be empirically administrated in
proportion of RBC
and plasma(1:1:1)
• Rapid transfusion of banked blood:
• caries the Risk of inducing citrate intoxication" in the recipient.
• Every component unit is packaged with one of several
anticoagulation agents (citrate being a common choice) that bind
free calcium, an essential requirement of the clothing cascade
• Consecutive administration of multiple units of banked blood
overwhelms the body's ability to mobilize free calcium and causes a
marked reduction in circulating serum calcium with a profound
negative inotropic effect on the heart.
• unrecognized hypocalcaemia is a common cause of hypotension
that persists despite an adequate volume of resuscitation.
• Ionized calcium levels should be measured at regular intervals in a
hemorrhaging patient, and calcium should be administered as
needed (in a separate intravenous line from That for transfusion
products)
• Resuscitation equipment:
• Immediate placement of at least two large bore catheter
• patient's underlying state of health and specific injury pattern
may eliminate some sites from consideration
The internal jugular approach, thought familiar to most
anesthesiologists, will require removal of the cervical collar and
manipulation of the patient's neck and is therefore not
recommended
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• Continuous:
• The femoral vein is easily and rapidly accessed and is
an appropriate choice in patients without apparent
pelvic or thigh trauma who require urgent drug or
fluid administration.
• Caution should be used in patients with penetrating
trauma to the abdomen because fluids infused
through the femoral vein may contribute to
hemorrhage from an injury to the inferior vena cava
or iliac vein; these patients should have intravenous
access placed above the diaphragm if possible.
• Continuous:
• Femoral vein catheterization carried a high risk of deep venous
thrombosis ,thereby limiting the use of this approach to the acute
setting.
• Femoral lines should be removed as soon as possible after the
patient's condition stabilizes.
• the subclavian vein is the most common site for early and ongoing
central access in trauma patients because the subclavian region is
easily visible and seldom difficulty traumatized.
• Risk of Pneumothorax
• Arterial line
• Hypothermia:
• Anesthesiologist must maintain thermal equilibrium in any
trauma patient:
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•
•
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Potentiate dilutional coagulopathy
Potentiate systemic acidosis
shivering and vasoconstriction lead to myocardial ischemia.
Increase subsequent rate of sepsis
• Because many trauma patients arrive at the ED already cold
from exposure to the elements, early active warming measures
are requited.
• Continuous
• All intravenous fluid should he prewarmed
• blankets whenever possible, and the environment
should be kept warm enough to make the patient
comfortable.
• If hypothermia has already developed, the use of
forced hot air warming is strongly indicated to
restore normothermia.
• This devices must prepare in ct scan room and
angiography room and ED
• rapid infusion devices are of great benefit in
treatment care, particularly in the presence of
hemorrhagic shock.
• Reduce acidosis
• Higher patient temperature
Disadvantages:
• over infusion of fluids
• Inappropriate blood pressure
• rebleeding
• Late resuscitation :
Late resuscitation begins once bleeding is definitively controlled :
• by surgery
• angiography
• the passage of time.
• Fluid administration is an integral, mandatory component of late
resuscitation
• The adequacy of resuscitation should not be judged by the presence of
normal vital signs but by normalization of organ and tissue perfusion
• resuscitate the patient with the appropriate fluid, in the appropriate
amount, at the appropriate time.
• The practitioner's goal at that time is to rapidly restore normal perfusion
to all organ systems while continuing to support vital functions.
• Hypoperfusion caused by hemorrhagic shock triggers a
predictable cascade of biochemical events that will cause
physiologic derangements persisting long after adequate blood
flow is restored.
• The extent of hypoperfusion and the depth and duration of
shock-is highly correlated with the development of subsequent
organ system failure
• traditional vital sign markers such as BP, heart rate, and urine
output have been shown to be insensitive to the adequacy of
resuscitation.
Occult hypoperfusion syndrome
• is common in postoperative trauma patients, particularly young ones
•
•
•
•
normal BP maintained by intense systemic vasoconstriction
intravascular volume is low
cardiac output is low
and organ system ischemia persists.
• Such patients are at high risk for MOSF if hypoperfusion is
not promptly corrected.
• Technique
•
•
•
•
•
•
•
•
•
•
Vital signs
Urine output
Systemic acid-base status
Lactate clearance
Cardiac output
Mixed venous oxygenation
Gastric tonometry
Tissue oxygenation
Stroke volume variation
Acoustic blood flow
100
shorcomings
Will not indicate occult hypoperfusion
confounded by intoxication, diuretic renal injury
Confounded by respiratory status
Requires time to obtain laboratory result
pulmonary artery catheter or use of noninvasive technology
Difficult to obtain, but a very accurate marker
Requires time to equilibrate, subject to artifact
Emerging technology, appears beneficial
Emerging technology, requires an arterial line
Investigational technology, unproven
• Invasive monitoring change to noninvasive approaches that assess
of adequate metabolism,respiration, and oxygen transport in
peripheral tissue beds.
• One minimally invasive technique is tissue oxygen monitoring (skin,
subcutaneous tissue, or skeletal muscle).
• Skeletal muscle blood flow decreases early in the course of shock
and is restored late during resuscitation, thus making the skeletal
partial pressure of oxygen a sensitive indicator of low flow.
• Early goal directed treatment of septic shock ,with an
emphasis on measurement of mixed venous oxygen
saturation ,has influenced the care of trauma patient ,and
many of ICUs are now using continiucely measured venous
oxygenation to guide resuscitation.
• Stroke volume variation
Change in arterial pressure
driven by the respiratory cycle(during positive pressure
ventilation) a reliable predictor of decrease intravascular
volume.
• Tissue hypercapnia
has been suggested as a universal indicator of critically reduced
perfusion
• measurement of *gastric mucosa Pco2 through gastric
tonometry has been used in trauma patients as an indicator of
restoration of splanchic blood flow, and **distal gut PH has
shown promise as a reliable indicator.
• the most proximal area of the gastrointestinal tract, the
***sublingual mucosa, has been shown to be a useful site for
measurement of Pco2
•
continuous
• When sublingual Pco2(PsLco2) exceeded a threshold of 70 mm Hg
(normal = 45.2 ± 0.7 mm Hg), its positive predictive value for the
circulatory shock was 100%.
• Inadequate tissue perfusion as indicated by these specific
monitoring or by the traditional systemic markers of serum
lactate, base deficit, and decreased PH, must be treatment
promptly once ongoing hemorrhaged is controlled.
• The rate at which a shock patient's lactate returns to the normal
range is strongly correlated with outcome:
• failure to reach to normal range within 24 hours of a traumatic
injury carries a greater of organ system failure and eventual death