Refractory Shock in Trauma

OVERVIEW

• refractory shock in trauma is still most likely due to occult ongoing haemorrhage
• shock may be due to the underlying cause of trauma e.g. MI leading to car crash
• or may be a complication of trauma (e.g. neurogenic shock) or treatment that has been given (e.g. anaphylaxis to gelofusin given pre-hopsital)

CAUSES

Think PROVED?

• pump
• rate and rhythm
• obstruction
• volume
• endocrine
• distributive
• ? (error of measurement or therapy)

Hypovolaemic

• bleeding
• consider SCALPeR: scalp/street, chest, abdomen, long bones, pelvis and retroperitoneum.

Cardiogenic

• myocardial contusion, infarction or arrhythmia
• pre-existing co-morbid condition (congenital heart disease)

Obstructive

• cardiac tamponade
• tension pneumothorax
• PE (unlikely acutely)

Distributive

• unlikely
• high spinal cord injury
• anaphylaxis to drug or fluid given

Other

• technical: measurement problem, tissued IV, fluid not given
• endocrine: unlikely (Addison)
• brain death

MANAGEMENT

• as per EMST protocol
  -> primary survey with attention to life threatening injuries
  -> secondary survey with definitive treatment

• review history: mechanism of injury, documented injuries
• ensure A and B OK
• check equipment and zero and NIBP
• check IV lines

Hypovolaemic

• volume assessment
• look for bleeding (CXR, FAST, DPL, pelvic x-ray, long bones)
  -> haemostatic resuscitation
  -> FAST positive: OT
  -> pelvic #: splint + OT or angio
  -> splint limbs
  -> CXR: ICC -> thoracotomy
  -> open injuries: external pressure, reduction and surgical ligation

Cardiogenic

• look for chest pain, pericardial rub, S3, cardiac failure
• ECG: ST or T wave changes anteriorly
• ECHO: contractility, RWMA
• TNT
  -> supportive
  -> monitoring for arrhythmias
  -> replace electrolytes
  -> inotropes

Obstructive

• tension pneumothorax: hypotension, distended neck veins, tracheal deviation, decreased AE -> chest drain
• cardiac tamponade: muffled heart sounds, distended neck veins, electrical alternans, echo findings (effusion, RV collapse) -> pericardiocentesis

Distributive

• high spinal cord injury: neurology, warm skin -> supportive care, fixation
• anaphylaxis: urticaria, bronchospasm, haemodynamic instability -> fluid, adrenaline, steroid, H2 antagonists, mast cell tryptase

Other

• brain death: absent brain stem reflexes