7-13
Septic shock - loss of vascular tone due to release of infectious toxins in the circulatory system. (Body
responses impaired)
Cardiac shock - loss of cardiac output to sustain blood pressure. Body responses usually intact unless on
B/P medications.
Anaphylactic shock - loss of vascular tone due to an allergic reaction. Body responses impaired.
Neurogenic shock - loss of vascular tone due to impaired neural or spinal function. Body responses impaired.
Distributive shock - distribution of blood flow is impaired (pulmonary embolus - blocks blood from entering
into lungs, cardiac tamponade - mechanical impairment of the pumping action of the heart and tension
pneumothorax- loss of blood return to the thorax and heart due to pressures building in the chest cavity).
Plan:
Procedures
Essential: CONTROL ALL HEMORRHAGE. Eliminate all possible sources of ongoing intravascular volume
loss.
Once hemorrhage is controlled, initiate blood administration as soon as it can safely be accomplished.
If unable to control hemorrhage (i.e., intrathoracic/intraabdominal bleeding), urgent evacuation to a medical
facility with general surgical capability is indicated ASAP - do not delay evacuation to initiate any procedures
other than to secure the airway. Further efforts at hemorrhage control should be performed en route and
should not delay evacuation. Initiate two large bore IV infusions with appropriate fluid (saline, RL, Hespan,
etc.). If hemorrhage has been controlled, administer fluid to obtain systolic BP > 90 mm Hg (see Shock:
Fluid Resuscitation).
Recommended: For lower abdominal/pelvic bleeding and/or large thigh/buttocks wounds or femur fractures
PASG (MAST) application is reasonable and appropriate. Applying PASG when patient has uncontrolled
intrathoracic bleeding is contra-indicated (See Procedure: PASG).
Treatment
Primary:
- Control hemorrhage first! If volume loss is due to other causes, i.e., burns, diarrhea, vomiting, etc., the
same principle applies - try to prevent further loss but in these cases early aggressive fluid resuscitation is
appropriate. Measure urine output and all blood and fluid loss to insure replacement and use guidelines
such as those used to direct fluid resuscitation of burned patients to estimate volume losses. - Volume and IV fluid resuscitation is a temporizing measure, not a treatment for uncontrolled hemorrhage.
When hemorrhage has been controlled, administer sufficient fluids (po and/or IV) to maintain an hourly
urinary output of > 50 cc/hr. Attempting to maintain urinary output (and systolic pressure) of patients with
on-going, uncontrollable, blood loss may temporarily maintain their urinary output at the expense of
increasing the rate of red blood cell loss. There is no simple answer to this dilemma and the most
appropriate response probably depends upon a variety of factors, such as prior hydration and health
status, anticipated time to surgery, availability of IV fluids. - Preserve body heat by passive rewarming (by blankets, etc.). External heating (active rewarming) before
volume has been restored may produce undesired vasodilation, worsening hypotension. - Place all badly wounded patients in a position with their feet elevated about 12 inches with the head and
heart low. Utilize the head-down position unless it causes obvious distress, labored respiration or
cyanosis, even in patients with chest wounds and with head wounds as long as their systolic blood
pressure remains below 80 mm Hg. When the systolic blood pressure has risen above 80 mm Hg,
gradually start slow elevation of the head. - When hemorrhage cannot be controlled, the priority is rapid transport to a surgeon for surgery ASAP.
Attempt to control pelvic bleeding and bleeding into the thigh(s) with PASG. When bleeding is into the
chest/abdomen, limit fluid administration (see Table 7-2). - Both normal saline and Ringer’s Lactate are appropriate fluids, as is Hespan. The only resuscitation
fluid for hemorrhagic shock that is significantly better is blood- it is the only oxygen-carrying fluid available
in the field today.
NOTE: Do NOT treat bradycardia in hypovolemic patients with atropine. The appropriate treatment is to
stop further blood loss and rapidly restore intravascular volume, preferably with blood.