Shock refers to an
improper tissue perfusion due to the disparity between tissue demand for oxygen
and the capacity of the body to supply it. The consequence of the shock is
hypoperfusion of the global tissue which is associated with a reduced amount of
venous oxygen and metabolic acidosis (lactic acidosis). Conventionally, there's
four shock categories: hypovolemic, cardiogenic, obstructive, and distributive.
Hypovolemic shock happens when intravascular volume is decreasing to the extent
of cardiovascular failure [7,8].
The hypovolemic shock
may result from extreme dehydration by a variety of mechanisms or from lack of
blood. Haemorrhage is the most common source of shock following damage and
there is a degree of hypovolemia in nearly any case with multiple injuries.
Hence, where there are symptoms of shock, care is usually administered as
though the patient is hypovolemic. Nevertheless, before instituting care, it is
necessary to recognise the limited number of patients whose shock has a
specific origin (e.g., a secondary disorder such as cardiac tamponade, tension
pneumothorax, spinal cord damage, or blunt heart injury), which complicates
haemorrhagic shock presentation [8].
Four of these six
requirements will be met: Empirical standards for the treatment of circulatory
shock irrespective of cause [9] (Table 1).
·
Ill
appearance or altered mental status.
·
Heart
rate >100 beat/min
·
Respiratory
rate >20 cycle/min. or paco2 <32 mmhg
·
Serum
lactate level >4 mmol/L
·
Arterial
base deficit ?-4meq/L
Table 1: Signs and symptoms
of hemorrhage by class [8].
|
PARAMETER
|
CLASS I
|
CLASS II (MILD)
|
CLASS III (MODERATE)
|
CLASS IV (SEVERE)
|
|
Approximate
blood loss
|
<15%
|
15–30%
|
31–40%
|
>40%
|
|
Heart
rate
|
?
|
?/?
|
?
|
?/??
|
|
Blood
pressure
|
?
|
?
|
?/?
|
?
|
|
Pulse
pressure
|
?
|
?
|
?
|
?
|
|
Respiratory
rate
|
?
|
?
|
?/?
|
?
|
|
Urine
output
|
?
|
?
|
?
|
??
|
|
Glasgow
Coma Scale score
|
?
|
?
|
?
|
?
|
|
Base
deficita
|
0 to –2 mEq/L
|
–2 to –6 mEq/L
|
–6 to –10 mEq/L
|
–10 mEq/L or less
|
|
Need
for blood products
|
Monitor
|
Possible
|
Yes
|
Massive Transfusion Protocol
|
|
A Base excess is the sum of base (HCO3–,
in mEq / L) over or below the standard body range. A negative value is
considered a deficiency basis (or base deficit) and demonstrates metabolic
acidosis.
|
Description of a
problem, a lack of knowledge on a certain topic or a segment on WHY this is a
problem
However,
there are such medical problems which are might be faced during the emergency
room when dealing with patients who are suspected to have a shock. For example,
diagnosis of circulatory shock or other
type of shock can be missed because of depending on only a single parameter which
is like a blood pressure. As an example, hypertensive emergencies with a
compromised cardiac output can include blood pressure normal or elevated.
Another one is when there is unobvious
bleeding source (internal bleeding) and the unstable patient need CT scan to
localise the source of bleeding. Moreover, the physicians on emergency room may they are not aware about specific
consideration in shock detection and care involves discrepancies in the
responses to extreme age shocks, fitness, pregnancy and the involvement of
other drugs [8].
WHY this study is
necessary
The
goal of studying and addressing these problems is to improve healthcare,
decreasing the mortality rate, and highlight some of the wrong approaches
applied by a physician in emergency cases. Any delay or missing diagnosis of a
shock will have a dramatic effect on the patient’s health and it can be led to
death especially the patient with unobvious internal bleeding. Also, Physicians
on emergency room should be aware about the special consideration or type of
patient when they are trying to resuscitate them (This topic will be discussed
below). Therefore, it is very important to apply the right approach of ATLS
when dealing with such suspicion patients have signs and symptoms of shock [9].
Aim of study
This
is a review study Aim to decreasing the mortality rate, improve the healthcare
and highlight some of the wrong approaches applied by a physician in emergency
room in aspect of traumatic haemorrhagic shock.
Study question
·
How
can we correct and prevent using of the single parameter (such as blood
pressure) as not missing the diagnoses of shock?
We can correct and
prevent this by [8]
Ø
Application
of all clinical knowledge regarding breathing rate, pulse rate, skin perfusion
and mental status.
Ø
If
available, ask for pH, pO2, PCO2, oxygen levels and base
deficiency measures of the arterial blood gas.
Ø
End-tidal
CO2 and serum lactate tests may provide valuable diagnostic details.
·
In
case of unstable polytrauma patient with unobvious internal bleeding what
should we do to detect the source of bleeding?
Ø
The
ER doctors can't move the patient to a CT scan in this situation, since the
individual is unstable. Hence, rapid ultrasound in shock and hypotension (RUSH)
is the most effective method when working with unstable polytrauma patients
with unobvious internal bleeding. This shows that the classification of
unstable polytrauma patients was 94.2 percent sensitive; the precision of RUSH
in shock patients was 95.2 percent. However, it is highly operator dependent
and need expert. As well as Portable chest and pelvic X-ray should be used
[10].
·
What
are the special considerations and types of patients that the ER physicians
should know? And why?
The special types of
patients and consideration are advance age, athletes, pregnancy, and
Medications.
For advancing age, the
ageing process causes a significant reduction in sympathetic function in the
cardiovascular system. Therefore, cardiac compliance reduces with age, and in
comparison to younger patients, older patients are reluctant to raise their
heart rhythm or myocardial contraction capacity while distressed by lack of
blood flow. Furthermore, the atherosclerotic vascular occlusive disorder allows
certain important organs highly susceptible to even the smallest drop in blood
flow. Additionally, often elderly patients suffer pre-existing volume loss
attributable to long-term diuretic usage or slight malnutrition. For these
factors, the elderly trauma patients display poor resistance to secondary blood
loss hypotension. For e.g. in an elderly patient, a systolic blood pressure of
100 mm Hg may constitute a shock [8]. For athletes, Rough
athletic fitness workouts change physiological processes of those patients.
Blood volume will increase from 15% to 20%; cardiac output will raise 6-fold;
stroke rate will rise by approximately 50%; and resting pulse may increase by
an average of 50 BPM. The bodies of highly qualified athletes have a tremendous
capacity to compensate for loss of blood, and even with substantial blood loss,
the normal reactions to hypoperfusion will not be manifested [8].
For pregnancy, the
normal hypervolemia that happens throughout pregnancy suggests that the
development of mother's perfusion defects requires a greater volume of blood
loss and can even be reflected in decreased fetal perfusion [8]. For Medications,
Specific drugs can affect a patient's reaction to the shock. For eg,
ß-adrenergic receptor blockers and calcium channel blockers could drastically
influence a patient's hemodynamic response to haemorrhage. Insulin toxicity may
be the cause of hypoglycaemia, which could have led to the injury event.
Long-term diuretic therapy may be causing unidentified hypokalaemia, and
non-steroidal anti-inflammatory drugs (NSAIDs) that adversely influence the
function of platelets and can speed up bleeding [8].
Describe steps of the
right technic of this method point by point [8].
Initial Management of Haemorrhagic Shock: The detection and management of shocks
will actually occur nearly simultaneously. Clinicians begin therapy in most
trauma cases as though the patient were experiencing a haemorrhagic shock, unless
another source of shock becomes apparent. The fundamental concept of management
is to control bleeding, then replace the lack of volume.
