Shock is defined as an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. In simple terms it means that tissues are not getting adequate blood perfusion and oxygenation.
Persistent shock leads to cellular metabolic dysfunction and organ failure. In trauma patient the cause of shock is loss of blood following injury. This kind of shock is called hypovolemic shock . Acute hemorrhage is the primary cause of the intravascular volume depletion associated with hypovolemic shock.
In the orthopaedic trauma patient, hemorrhage from fractures and severe soft tissue contusions may be a source of severe hypovolemia The loss could be external which is obvious and visible, or internal which is concealed and could be overlooked easiliy if one is not alert enough.
It is essential to treat shock early and aggressively with emphasis on controlling hemorrhage, increasing oxygen carrying capacity, and improving perfusion pressure to vital organs.
Management of Hemorrhagic Shock
The initial management of hemorrhagic shock involves controlling active bleeding with the application of external pressure compression dressings and the splinting of fractures.
At the same time, fluid resuscitation to restore adequate intravascular volume and tissue oxygen delivery is undertaken
The response to the initial fluid resuscitation serves as a guide to further therapy
- A rapid response to initial fluid therapy with hemodynamic stability indicates minimal blood loss with no indication for further resuscitation.
- Transient improvement in hemodynamics followed by deterioration after initial fluid therapy. this indicates ongoing blood loss or inadequate resuscitation. These patients would require additional fluid resuscitation, blood transfusion, and possibly surgical intervention to control hemorrhage.
- Minimal or no response to fluid and blood administration. This indicates ongoing, severe hemorrhage with the need for continuous, aggressive fluid and blood transfusion and emergent surgical intervention to prevent exsanguination.
Goals of Resuscitation
The primary goal of resuscitation is, by definition, restoration of adequate organ perfusion and tissue oxygenation.
Treatment strategies to restore intravascular volume, optimize oxygen delivery, and correct tissue acidosis continue until clinical evidence indicates resuscitation is complete.
Clinical parameters include normalizing vital signs with a stable mean arterial pressure and heart rate. Adequate urine output indicates good renal perfusion in the absence of renal failure. Invasive monitoring demonstrates improved trends in cardiac filling pressures and oxygen transport parameters. The patient should be warm with good peripheral perfusion and distal capillary filling. Conscious patients usually demonstrate appropriate or improving mental status
However, the presence of physiologic compensatory mechanisms decreases the utility of these measures alone to assess the complete resuscitation from shock.
The arterial base deficit, easily available from an arterial blood gas, and the serum lactate are better indicators of severity of hemorrhagic shock and the response to resuscitation. These variables are good markers of the adequacy of tissue perfusion.
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