Shock & Hemostatic Resuscitation

Transcription

1 Shock & Hemostatic Resuscitation Norman McSwain, MD FACS, NEMT-P Professor Tulane University, Surgery Clinical professor, LSU, Surgery Clinical professor, USUHS, Surgery Medical Director PreHospital Trauma Life Support Trauma Director Spirit of Charity Trauma Center

2 Physiology of Life & Death Keep I t Simple Stupid

3 Judgment based on Knowledge

4 Most important diagnostic tool

5 Car Gasoline provides fuel Moves car Lights show the road Energy Everything Heater that warms moves the or inside functions requires energy Power brakes stops movement Buildings Power steering aids in control Computers Lights Cars No energy the thing fails All body functions are energy dependent Heat muscle action brain function everything Death

6 Life What is it?

7 Life Adequate energy production to meet the needs for body functions

8 What is Shock? Inadequate energy production to meet the needs for body functions

9 Why does energy production fail? No substrate to make energy Oxygen delivery system

10 Aerobic 38 ATP Metabolism ATP = Energy 2 ATP Anaerobic Metabolism

11 Energy production Ficke Principle Prevent Anaerobic metabolism On-loading of O 2 onto RBC in lung Transportation of RBC with O 2 to tissue cells Off-loading of O 2 into tissue cells for Krebs cycle Requirement Open airway & ventilation Adequate Red Cell Mass to carry O 2 O 2

12 Triangle of Death Symptoms of Dying Acidosis Why ENERGY Not the Cause Coagulopathy Hypothermia

13 Energy Ficke Principle Oxygenation Delivery Process Energy production Krebs cycle

14 The Secret to the treatment of shock is Management of anaerobic metabolism to Restore energy production Control the source of the problem Oxygen Delivery system Aerobic metabolism

15 Circulatory (delivery) System Pump (heart) Pipes (vessels) Fluid (blood) Failure of any component will reduce effectiveness of the delivery system (flow)

16 Life Air goes in and out Blood goes round and round Cells make energy Energy = Life No energy = Death

17 Think Energy

18 Peter Pons, MD, FACEP Editor, 8 th edition November 2014

19 Principles vs Preferences Principle Standard of patient care Preferences How YOU can achieve the standard Situation of the encounter Condition of the patient Ability of provider Knowledge Skill Experience Resources available

20 Gross Early American Surgeon 1854 Shock DEATH rude unhinging of the machinery of life

21 Preservation of Life Prevention of Death

22 Energy production Ficke Principle Prevent Anaerobic metabolism On-loading of O 2 onto RBC in lung Transportation of RBC with O 2 to tissue cells Off-loading of O 2 into tissue cells for Krebs cycle

23 Energy Ficke Principle Delivery Process Fluid - Blood Pump Heart Pipes Vessels Oxygenation Energy Krebs cycle

24 On loading oxygen to RBC FiO 2 Patient airway Gas movement Transfer O2 from Alveolus to RBC

25 Breathing (Lungs) (1 of 2) When air reaches the alveoli: Oxygen crosses the alveolar capillary membrane Oxygen Enters the RBCs Attaches to hemoglobin for transport

26 On loading oxygen to RBC FiO 2 Nasal prongs Nasal Cannula 0.30 Non- rebreather mask Ventilator controlled ~ 1.0 Patient airway Open airway Oral airway ET tube Most Frequent Mistake ED & ICU

27 On loading oxygen to RBC Gas movement Ventilation Spontaneous Bag Valve mask Endotracheal tube Surgical Airway Alveolus open Atelectasis Mucus fluid

28 On loading oxygen to RBC Transfer O2 from Alveolus to RBC Wall thickness Edema RBC Oxygen hemoglobin dissociation curve

29 Oxygen hemoglobin dissociation curve

30 Energy Ficke Principle Delivery Process Fluid - Blood Pump Heart Pipes Vessels Oxygenation Off Loading

31 Fluid Blood Plasma Crystalloid

32 Benefits of blood Delivery of oxygen to tissue cells Stopping leaks in the vessels clotting factors platelets Maintain fluid in vascular system Oncotic pressure Packed RBC s supply only O 2 delivery

33 Plasma Oncotic pressure Stays in the cardiovascular system Clotting factors Carbon dioxide off loading to lung

34 Red Blood Cells PRBC Oxygen carrying capacity only Mistaken for whole blood ability

35 Crystalloid No Oxygen carrying capacity No clotting factors No oncotic pressure Remains in cardiovascular system <60 minutes Edema Michelin Man Reduces oxygen transfer Lungs Tissue cells

36 Major Components for Resuscitation Maintain aerobic metabolism

37 Trauma Maintenance of energy production Aerobic metabolism Stop the hemorrhage

38 Volume failure Reduced energy production Hemorrhage External Internal Dehydration Vomiting, diarrhea Reduced intake Increased evaporation Skin Lungs Blood Crystalloid

39 Most common mistake in shock management Confusion of the properties of crystalloid and blood

40 PreHospital Fluid Resuscitation When? What? How much?

41 Emergency Department resuscitation Crystalloid Resuscitation of 1.5 L or more Increased Mortality in Elderly and Nonelderly Trauma Patients 1.5 L crystalloid fluid Elderly Odds ratio , Nonelderly Odds ratio , ( 0.002). 3 L, crystalloid fluid Elderly Odds ratio- 8.61, (p 0.014), Nonelderly Odds Ratio 2.69, (p ). Eric J. Ley, MD, et al J trauma Feb 2011

42 PreHospital Fluid Resuscitation For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative intervention improves the outcome Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries Bickell WH, Wall MJ, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL N Engl J Med (1994 Oct 27) 331(17):1105-9

43 PreHospital Fluid Resuscitation prehospital fluid administration was associated with increased survival (hazard ratio, 0.84; 95% confidence interval, ; p = 0.03). Site differences in ISS and fluid volumes were demonstrated (p < 0.001).CONCLUSION: Prehospital IVF volumes commonly used by PRospective Observational Multicenter Massive Transfusion Study (PROMMTT) investigators do not result in increased systolic blood pressure but are associated with decreased in-hospital mortality in trauma patients compared with patients who did not receive prehospital IVF. Prehospital intravenous fluid is associated with increased survival in trauma patients. Hampton DA, Fabricant LJ, Differding J.Shreier, MA J Trauma Acute Care Surg (2013 Jul) 75(1 Suppl 1):S9-15

44 PreHospital Fluid Resuscitation When? What? How much?

45 Pump

46 Broken Pump

47 Energy Ficke Principle Delivery Process Fluid - Blood Pump Heart Pipes Vessels Oxygenation Off Loading

48 RBC Monro-Kellie hypothesis Off Loading Oxygen hemoglobin dissociation curve Capillary flow Arterial input flow Venous output flow Capillary volume External tissue pressure Chemical reduction of flow Vascular/tissue cell separation Edema fibrosis

49 Energy Ficke Principle Oxygenation Delivery Process Fluid - Blood Pump Heart Pipes Vessels Energy Krebs cycle

50 Aerobic 38 ATP Metabolism ATP = Energy 2 ATP Anaerobic Metabolism

51 Triangle of Death Acidosis Energy Coagulopathy Hypothermia

52 Assessment for Life vs Death (Shock)

53 Primary Survey Assessment Rapid 15 seconds Simultaneously Overview of everything Gross/subjective Eyes Fingers Ears

54 Assessment Look for signs of decreased perfusion (1) Distal is the first to go Skin perfusion Color Temperature Flow (capillary refilling time) Peripheral pulses Character Radial Femoral Carotid

55 Assessment Signs of decreased energy production/perfusion (2) Mental function Alertness LOC Acidosis Increased ventilatory rate CO 2 blow off Hypothermia Shivering (35 -> 33) Muscle contractions to produce energy/heat Complains of being cold This is late. Bad sign

56 Assessment Skin Perfusion Capillary refilling time Decreased skin perfusion does not define shock nor is it definitive of shock Can come from a variety of causes Hypovolemia Hypothermia Vascular obstruction Very important sign

57 Lord, Sir William Thomson, Kelvin when you..can express it in numbers, you know something about it; when you cannot measure [and].express it in numbers, your knowledge is of a meagre and unsatisfactory kind.pla, vol. 1, "Electrical Units of Measurement",

58 Secondary Survey Details of everything Objective Measurements with numbers Think and understand

59 Vital Functions Signs Cardiac rate Ventilatory rate Temperature Mental function GCS Blood pressure Urinary output Physiology Oxygen debt Lactate Hemoglobin Hematocrit ph PaCO 2 PaO 2

60 Summary

61 Shock management Stop deterioration Restore/maintain energy production Damage control resuscitation Restore O2 delivery to tissues Restore clotting Maintain oncotic pressure

62 Shock management Stop deterioration Hemorrhage control External Pressure on injury Vascular isolation Internal In proving clotting Hypotensive reduction of blood loss Rapid assess to Factor XIV Damage control surgery

63 Hypothermia is a symptom not a disease The disease is anaerobic metabolism Acidosis is a symptom not a disease The disease is anaerobic metabolism

64 Resuscitation Think Energy production q Stop anaerobic metabolism q Control hemorrhage

65 Shock made Simple Deliver oxygen to the lungs Ventilation Deliver oxygen to the periphery Pumping system Aerobic Metabolism Deliver oxygen to the cells Aerobic metabolism Control hemorrhage tourniquet = Energy Production Replace blood loss Whole blood

66 Aerobic 38 ATP Metabolism ATP = Energy 2 ATP Anaerobic Metabolism

67 ? Questions?? Comments?? Paranoid Outbreaks? Norman McSwain, MD FACS, NEMT-P Professor Tulane University, Surgery Clinical professor, LSU, Surgery Clinical professor, USUHS, Surgery Medical Director PreHospital Trauma Life Support Trauma Director Spirit of Charity Trauma Center

68 Resuscitation Do no further harm Delay causes harm Stop RBC loss Restore energy production Delay Prehospital Emergency Department Operating Room

69 Time is cri>cal ED efficiency is just as critical as is EMS 50 cc/min blood loss is 3 liters/hr (60% of total blood volume) PreHospital time = ½ hr Access ~ 8 minutes Field care ~ 10 minutes Transportation ~ 8 minutes

70 Time is cri>cal ED efficiency is just as critical as is EMS efficiency ED efficiency & organization Each person should have a job Don t procrastinate Move out of the Resuscitation room (10 min) Do not get unnecessary studies Mortality in the death ray department is high

71 Time is cri>cal The patient continues to bleed while the abdomen is closed and clamp is not placed on the open vessel Don t procrastinate TO the OR IN the OR OR efficiency is just as critical as is EMS or ED efficiency Rapid review of the OR equipment and supplies Rapid prep of the patient Rapid incision Two motions of the scalpel Skin & fat down to the fascia Through the linea alba into the abdomen Tear/cut the peritoneum The Bovie is slow don t use it Find the hemorrhage Pressure control the hemorrhage Clamp the bleeding vessel

72 Factor XIV Suture Ligature Hemostat

73 Large Volume Resuscitation Extensive study by Tom Shires, MD Viet Nam war 3 liters Crystalloid : 1 Litter blood Misinterpreted to huge amounts of crystalloid Outcome was fluid overload Michelin Man ARDS De Nang lung Renal failure Abdominal compartment syndrome Dilution of clotting products => blood loss

74 Volume Resuscitation popularized by Dr Tom shires Pressure 2 o to blood loss Blood loss from vascular injury Crystalloid resuscitation Hct Blood pressure Blood loss from injury Blood pressure Hemorrhage Crystalloid resuscitation Hct Blood pressure Cycle repeats and RBC mass continues to

75 Hypertonic Resuscitation Studied by Holcroft and Jelenko Hypertonic fluids 7.5% saline Colloid Restoration of blood pressure Outcome = intracellular and interstitial dehydration Discarded by American Burn Association

76 Hypertonic Resuscitation Popularized by Holcroft and Jelenko Hemorrhage Blood pressure drops Hypertonic fluid administration Fluid transferred to vascular space from interstitial space Hct drops Blood pressure increases Hemorrhage increases Cycle repeats Red cell mass drops Outcome = dehydrated patient with reduced RBC mass

77 Low Volume Hypertonic Resuscitation Juan Duchesne, et al Am Surg

78 Juan Duchesne, et al Am Surg

79 Volume Restricted Resuscitation (popularized by Dr Mattox) Hemorrhage Blood pressure decreases Maintain oxygen perfusion Hemorrhage slows Gradual continuation of hemorrhage At reduced rate without increasing intra-luminal pressure Hemorrhage control in OR Full complete resuscitation

80 Fluid Resuscitation Replace what is lost with what is lost

81 Resuscitation If Blood is lost replace blood Carries oxygen Maintains oncotic pressure Restores lost clotting factors If Crystalloid is lost replace crystalloid If Presser agents are lost replace pressor agents

82 Next best option - Reconstitute blood - Packed Red Blood Cells Plasma Frozen Liquid Platelets Cryoprecipitate 1:1:1 Resuscitation & Management

83 Whole blood no longer available in United States Fractionated by the blood banking industry

84 Think Energy production

85 Shock Made Simple? Questions?? Comments?? Paranoid outbreaks? Norman McSwain, MD FACS, NREMT-P Professor, Tulane University, Surgery Clinical Professor, LSU, Surgery Clinical Professor, USUHS, Surgery Trauma Director, Spirit of Charity Trauma Center Medical Director, PreHospital Trauma Life Support

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88 Hemorrhage Control

89 Bernoulli Equation Q = AP + 2V E Q- rate of leakage A area of the laceration P transmural pressure Intraluminal pressure Extra luminal pressure V velocity of the blood flow E viscosity of blood

90 Bernoulli Equation Blood runs out of a vessel related to size of the hole in the vessel wall pressure in the vessel pressure surrounding the vessel Blood loss

91 Size of the hole Push sides together Plug up the hole Outside Finger in hole Gauze in hole Pressure to hold plug in place Inside Blood clots Clotting factors Dilution problem» EMS treatable Replacement

92 Reduction of transmural pressure Pressure in the vessel Pressure surrounding the vessel = Rate of Blood loss Reduce intravascular pressure Increase extra vascular pressure

93 Intravascular pressure reduction Restricted prehospital fluid resuscitation Systemic Maintain systolic pressure < 90 mmhg No crystalloid Colloid (hetastarch only) No blood flow to damaged extremities Local Tourniquet

94 Phases of Trauma Related Hemorrhage Dilutional Loss of RBC Loss of Plasma Loss of platelets Trauma induced hemorrhage Protein C Fibrinolysis inappropriate breakdown of clots Intravascular thrombosis DVT PE