1) Shock in trauma patients can result from hemorrhage, cardiac issues, tension pneumothorax, or other causes like sepsis. Initial treatment involves rapid fluid resuscitation and identifying the source of shock. 2) For hemorrhagic shock, the most effective treatment is stopping the source of bleeding through surgery or other interventions, while restoring volume through fluid and blood product administration. 3) Non-hemorrhagic shock requires identifying the specific cause like cardiac tamponade and treating it through methods like drainage, while continuing fluid resuscitation and monitoring the patient's response. Teamwork and following ATLS principles are important for managing profound shock.

1. Shock in Trauma patient
Dr. Varun Bansal
MEM –GW USA 2nd year
Guide -
Dr. Ritu Sabharwal
Head Emergency department

2. Definition
An abnormality of circulatory system that results in inadequate
organ perfusion and tissue oxygenation

4. Two Critical steps in the management
Step one
Recognize its presence – Initial diagnosis is based
on clinical appreciation of the presence of
inadequate tissue perfusion and oxygenation

5. Step two
Identify the probable causes of the shock state.
 – Hemorrhage (most common cause)
 – Cardiogenic
 – Neurogenic
 – Obstructive -Tension pneumothorax-
-Cardiac tamponade
 – Sepsis

6. The response to initial treatment couples with the
finding during the primary and secondary patient
surveys, usually provides sufficient information to
determine the cause of the shock state.

7. Hemorrhagic shock
Blood Loss Pathophysiology
Early circulatory responses to blood loss are compensatory and
include progressive vasoconstriction of cutaneous, muscular, and
visceral circulation to preserve blood flow to the kidneys , heart,
and brain.

10. blood is lost into the site of injury, particularly
in major fractures
 Example –
 a fractured tibia or humerus can result in the loss of up to 750 mL of
blood.
 Twice that amount, 1500 mL, is commonly associated with femur
fractures
 several liters of blood can accumulate in a retroperitoneal hematoma
associated with a pelvic fracture

11. Earliest clinical signs
• Tachycardia - the earliest measurable circulatory sign of
shock
• Increased Diastolic blood pressure
• Reduced Pulse Pressure

13.  The most effective method of restoring adequate
cardiac output, end-organ perfusion, and tissue
oxygenation is to restore venous return to normal
by locating and stopping the source of bleeding.
Volume repletion will allow recovery from the
shock state only when the bleeding has stopped

14.  Physical examination
 Diagnostic adjuncts to primary survey
Chest X-ray
Pelvic X-ray
FAST(Focused Assessment with Sonography in Trauma)
DPL(Diagnostic Peritoneal Lavage)

15. Using ultrasound (FAST) to search for the cause
of shock

16. Non-hemorrhagic Shock
 cardiogenic shock
 cardiac tamponade
 tension Pneumothorax
 neurogenic shock
 septic shock

17. Cardiogenic Shock
Myocardial dysfunction can be caused by blunt cardiac
injury, cardiac tamponade, an air embolus, or, rarely,
myocardial infarction. Suspect a blunt cardiac injury when
the mechanism of injury to the thorax
All patients with blunt thoracic trauma need continuous
electrocardiographic (ECG) monitoring to detect injury
patterns and dysrhythmias

18. Cardiac Tamponade
 Tachycardia, muffled heart sounds, and dilated , engorged neck veins with
hypotension and insufficient response to fluid therapy suggest cardiac
tamponade.
Beck’s Triad

19.  Tension pneumothorax can mimic cardiac tamponade, with findings of
distended neck veins and hypotension in both. However, absent breath
sounds and hyperresonant percussion are not present with tamponade

20. Septic Shock
 Shock due to infection immediately after injury is
uncommon; however, it can occur when a patient’s arrival
at the ED is delayed for several hours.
 Patients with early septic shock can have a normal
circulating volume, modest tachycardia, warm skin, near
normal systolic blood pressure, and a wide pulse pressure

22. Treatment goals
 Volume restoration
 Control hemorrhage
 Assess response to the initial therapy

24. Management strategy
• Assess and manage “ABC”
• Establish “IV -Oxygen –Monitors”
• Insert “2 large bore” cannulae in peripheral Veins(minimum of
18-gauge in an adult)
• Infuse “large volume” of warm crystalloids (1liter) rapidly
• Insert NG tube and bladder catheter

27.  Early resuscitation with blood and blood products must be
considered in patients with evidence of class III and IV
hemorrhage. Early administration of blood products at a
low ratio of packed red blood cells to plasma and
platelets can prevent the development of coagulopathy
and thrombocytopenia
 replacement during resuscitation should produce a urinary
output of approximately 0.5 mL/kg/hr in adults, whereas
1 mL/kg/hr is adequate urinary output for pediatric
patients. For children under 1 year of age, 2 mL/kg/hr
should be maintained

29. Fluid of choice
• Ringer’s lactate is the initial fluid of choice
• Normal saline is the second choice
• Blood and blood components as required

32.  Surgical consultation and evaluation are necessary during initial assessment
and treatment of rapid responders, as operative intervention could still be
necessary.
 Failure to respond to crystalloid and blood administration in the ED dictates
the need for immediate, definitive intervention (i.e., operation or
angioembolization) to control exsanguinating hemorrhage

33. Blood Replacement
 Patients who are transient responders or nonresponders
require pRBCs, plasma and platelets as an early part of
their resuscitation

34.  If crossmatched blood is unavailable, type O pRBCs
are indicated
 massive transfusion, most often defined as > 10 units of
PRBCs within the first 24 hours of admission or more than
4 units in 1 hour
 Administration of pRBCs, plasma, and platelets in a
balanced ratio to minimize excessive crystalloid
administration may improve patient survival

35.  One of the most challenging situations a trauma team
faces is managing a trauma victim who arrives in profound
shock. The team leader must direct the team decisively
and calmly, using ATLS principles
 The team leader ensures that the areas of external
hemorrhage are controlled and determines when to
perform adjuncts such as chest x-ray, pelvic x-ray, FAST,
and/or diagnostic peritoneal lavage (DPL). Decisions
regarding surgery or angioembolization should be made as
quickly as possible and the necessary consultants involved
Team work

36. https://www.facebook.com/TheLancet
MedicalJournal
• CRASH-2: tranexamic acid and trauma patients
• Published March 24, 2011
• Executive summary
• A new analysis of the 2010 CRASH-2 study shows that tranexamic acid should
be given as early as possible to bleeding trauma patients; if treatment is not
given until three hours or later after injury, it is less effective and could even
be harmful. In this new analysis, the CRASH-2 investigators analysed subgroups
of patients who had received tranexamic acid less than one hour after injury;
between one and three hours after injury; or more than three hours after
injury

37. conclusion
• Trauma shock management is challenge
• Protocol based approach is the best way to
solve puzzle
• Early surgical involvement is one of the corner
stones

38. THANK YOU