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

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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