Definition of shock:

Shock:
A severe condition that occurs
when not enough blood flows
through body, causing very low
blood pressure, a lack of urine
and or tissue damage.
 causes:
A- Shock is caused by any condition
that dangerously reduces blood flow
including heart problems ( such as
MI or heart failure ). Or changes
blood vessels, changes in blood
volume or injures.
types of shock :
Hemorrhagic shock: caused by severe loss of blood .
Anaphylactic shock caused by allergy .
Septic or bacteremic shock associated infections .
Cardiogenic shock: associated with heart disorders .
Hypovolemic shock caused by inadequate blood volume
Diabetic shock .
 general signs & symptoms of shock
: fatigue
general discomfort, , or ill feeling ( malaise )
nervousness
irritability
trembling
headache
hunger
cold sweats
rapid heart rate
blurry or double vision
confusion
convulsions
come
 HEMORRHAGIC SHOCK
Hemorrhagic shock is the most common cause of
shock after injury ( in the trauma patient )
Virtually all patients multiple injuries have an
element of hypovolemia

Definition of hemorrhage :
An acute loss of circulating blood volume.
Note(1): Normal Adult blood volume is
approximately 7% of body weight ( e.g A 70
kilogram Man has a circulating blood volume
of approximately 5 liters) .
Note(2): The blood volume of obese adults is
estimated based on their ideal body weight.
Calculation based on actual weight may result
in overestimation..
Note(3): The blood volume for a child is
calculated as 8% to 9% of the body weight
( 80-90 ml/kg).
Class I: Hemorrhage: Blood volume loss of up
to 15%:
The clinical symptoms of this volume loss are
minimal.
In uncomplicated situations minimal
tachycardia occurs.
No measurable changes occur in BP, pulse
pressure, or respiratory rate.
Transcapillary refill and other compensatory
mechanisms restore blood volume within
24hours.
Class II: Hemorrhage: 15% to 30% Blood
volume loss:
In a 70kg male, this volume loss represents 750ml to
1500ml of blood (e.g. # humerus or tibia patient loss 1.5
unit of blood= 750ml.
Fracture of femur=1500ml
clinical symptoms include tachycardia
heart rate >100 bpm in an adult
tachypnea
Decrease in pulse pressure primarily related to a rise in
the diastolic component due to an increase in circulating
catecholamines and therefore decrease in peripheral
vascular tone and resistance. Cont.
It’s very important to evaluate pulse pressure
rather than systolic pressures.
Despite the significant blood loss and
cardiovascular changes urinary out put is only
mildly affected
Other pertinent clinical findings with this
degree of blood loss include subtle C.N.S
changes such as anxiety, fright, or hostility.
Some of these patients may eventually require
blood transfusion, but can be stabilized
initially with crystalloid solutions.
Class III: Hemorrhage- 30% to 40%Blood
volume loss:

This amount of blood loss (=2000ml in an

Adult ). Can be devastating.
Patients almost always present with the classic
signs of inadequate perfusion including
marked tachycardia and tachypnea.
Patients with this degree of blood loss almost
always require transfusion.
 Class IV: Hemorrhage- more than 40% of Blood volume loss:

* It is an immediate life threatening.

* Symptoms include marked tachycardia,
a significant depression in systolic blood pressure.
Avery narrow pulse pressure
unobtainable diastolic pressure
urinary out put is negligible
mental status is markedly depressed
the skin is cold and pale.
** these patients frequently require rapid transfusion and
immediate surgical intervention.
 Initial management of
hemorrhagic shock
The basic management
principle is to stop bleeding and
replace the volume loss
A- Physical Examination

Assessment of :
* Vital signs .
* Level of consciousness
* Urine out put.
 Assessment of the ABCDE(s):
<* Airway and Breathing supplementary oxygen is supplied
to maintain O2 saturation at greater than 95%.
<* Circulation: Hemorrhage control

* Control of obvious bleeding .

* Obtain adequate IV access
* PASG ( pneumatic antishock garment) may be used
to control bleeding from pelvic or lower extremity
fractures.
* Assess tissue perfusion
* Rapid reestablishment of intravascular volume by
IV fluid infusion
<* Disability- Neurological Examination

Conduct brief neurological examination that

determines :
* level of consciousness .
* Eye motion and pupillary response.
* Best motor function
* Degree of sensation.
Note(1): this information is useful in assessing cerebral
perfusion.
Note(2): restoration of cerebral perfusion + oxygenation
must be achieved as early as possible.
<* Exposure- Complete examination

After addressing the life- saving priorities the

patient must be completely undressed and
carefully examined from “head to toe” as part
of search for associated injuries.

Note (preventing hypothermia is essential.

<* Gastric dilatation - Decompression

Note(1): Gastric dilatation occurs in the trauma

patients ( especially in children ) and may cause
unexplained hypotension or cardiac dysrhythemia,
usually bradycardia from excessive vegal
stimulation.
Note)2): Gastric distention makes shock difficult to
treat.
Note(3): Gastric distention in the unconscious
patient increase the risk of Aspiration of gastric
contents.
<* Management
Gastric decompression must be accomplished
by intubating the stomach by a nasogastric
tube attached into a suction to evacuate gastric
contents.
<* urinary catheter insertion:
bladder catheterization allows for the
assessment of urine for hematuria and
continuous evaluation of renal perfusion.
B- vascular access lines:
The most desirable sites for peripheral,
percutaneous IV lines in the ADULT are
forearm or antecubital veins.
As IV lines are started, blood samples are
drawn for type & cross match, appropriate
lab analyses, toxicology studies and listing of
all females of childbearing age for
pregnancy.
ABGs analysis should be obtained.
C- Initial fluid therapy:
Isotonic electrolyte solutions are used for
initial resuscitation to provide for transient
intravascular expansion and further
stabilizes vascular volume.
Ringer’s lactate solution is the initial fluid of
choice.
Normal saline is the second choice but it has
a potential to cause hyperchloremic acidosis
in patients with renal function impairment.
Cont.
An initial fluid bolus is given as rapidly as
possible.
The usual dose is 1-2 liters for an adult.
20ml/kg for a pediatric client .
( 3 for 1) rule ( for replacement ) this rule
derives from empiric observation that most
patients in hemorrhagic shock require as
much as 300ml of electrolyte solution or
crystalloid for each 100ml of blood loss.
Evaluation of fluid resuscitation and
organ perfusion
The return of normal blood pressure, pulse
pressure and pulse rate are positive signs. That
suggest perfusion.
The most important evidence of enhanced
perfusion are the improvements in the C.N.S
status and skin circulation.
The volume of urinary output is reasonably
sensitive indicator of renal perfusion.
Note(1): Adequate volume replacement
should produce a urinary out put of
approximately 0.5ml/kg/hour in the
Adult.
Note(2): 1ml/kg/hour is an adequate
urinary output for the pediatric patient
Note(3): for children under 1year of age
2ml/kg/hour should be maintained
 BLOOD REPLACEMENT
Either whole blood or packed RBCs can be used. The main
purpose in transfusing blood is to restore the oxygen-
carrying capacity of the intravascular volume.
Fully crossmatched blood is preferable
Type- specific blood can be provided by most blood banks
that is compatible with ABO and RH blood types but
incompatibilities of other antibodies may exist.
If type-specific blood is unavailable type O packed cells are
indicated.
To avoid sensitization & future complications Rh- negative
cells are preferred for females of child bearing age.
Management Of Hemorrhagic Shock By
Using The Hydroxy Ethyl Starch (Haes)

Haes steril 6% iso- oncotic infusion is specifically

designed for:

Preclinical emergency care

Pre, intra, and post routine surgery
Preoperative hemodilution
Haes Steril 10% Is Specifically Designed For
Patients With Low Cardiac Output And High
Oxygen Demand In:

Sepsis
Multiple trauma
Multiple organ failure
 Advantages Of Haes – Steril

1-No histamine release

2-No preformed antibodies
3-No influence on blood matching
4-No impairment of renal function
5-No capillary leakage
6-No risk of tissue edema
 THANK YOU
Dr. Munir Arabiat