विवरण
The inability of the circulatory system to supply tissue oxygenation and organ perfusion necessary to meet cellular metabolic demands is known as shock. Although non-haemorrhagic shock, such as cardiogenic or neurogenic shock, can occur after trauma, hemorrhage is more frequently linked to trauma-related shock. Evidence gathered over the past ten years has shown that trauma patients suffer from acute traumatic coagulopathy (ATC), which is brought on by the actual process of injury. Damage control resuscitation (DCR), the current method for managing acute shock, was developed with this as a key component. Haemostatic resuscitation, which uses blood products as the main resuscitative fluid, permissive hypotension, and damage control surgery are the three main resuscitative techniques included in DCR.
सारांश
- Circulatory shock in trauma is defined as an abnormality of the circulatory system resulting in inadequate organ perfusion and tissue oxygenation. Hemorrhage is the most common cause in trauma patients. Initial management involves recognizing the presence of shock and identifying its cause, such as hypovolemic, cardiogenic, neurogenic, or septic shock. Hypovolemic shock due to blood or plasma loss is the most frequent type in trauma.
- The pathophysiology of shock involves blood loss leading to inadequate perfusion and cellular hypoxia, initiating aerobic and then anaerobic metabolism, ultimately resulting in lactic acidosis and cellular edema. The body's compensatory mechanisms, triggered by baroreceptor reflexes, activate the sympathetic nervous system, increasing heart rate, contractility, and peripheral vasoconstriction.
- The ATLS protocol guides initial assessment with the ABCDE approach: Airway, Breathing, Circulation, Disability, and Environment. Signs and symptoms of shock include altered mental status, tachycardia, cool and clammy extremities, prolonged capillary refill time, narrow pulse pressure, decreased urine output, and hypotension. The ATLS classification of hemorrhagic shock ranges from Class 1 (minimal blood loss) to Class 4 (severe blood loss).
- Patients respond to fluid resuscitation differently: rapid responders, transient responders, and non-responders. Systolic blood pressure drop is a late sign of shock. The shock index (heart rate divided by systolic blood pressure) can raise early suspicion of hypovolemia. Urine output is monitored to assess organ perfusion.
- Lab values significant in hemorrhagic shock include hemoglobin, arterial pH, lactate, and base deficit. Treatment of hemorrhagic shock involves establishing a patent airway, controlling hemorrhage, and administering warm isotonic crystalloid solutions. A balanced resuscitation approach, or permissive hypotension, aims to balance organ perfusion with the risk of rebleeding.
- Massive blood transfusion (MBT) is defined by a large volume of red blood cell units administered within a short period. MBT protocols typically involve transfusing packed RBCs, plasma, and platelets in a 1:1:1 ratio. Recombinant factor 7A is used for refractory bleeding, and tranexemic acid can reduce mortality. Damage control resuscitation includes permissive hypotension, hemostatic resuscitation, and damage control surgery.
- Key considerations in the ED include identifying at-risk patients (high shock index, low systolic BP, acidosis, hypothermia, elevated INR, elevated lactate) and promptly initiating appropriate interventions. The target systolic blood pressure is generally 80-90 mmHg in patients without traumatic brain injury, and above 90 mmHg in those with TBI. The ultimate goal is to stop the bleeding and correct the underlying causes of shock.
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