The first step in treating shock, is to identify its presence.

-ATLS

Shock is poor perfusion to the tissue, not able to get enough oxygen-carrying blood to vital organs. which further leads to anaerobic respiration

• The first step in treating shock is to identify its presence
• The second step is to identify probable cause and prompt intervention.
• The most common cause of shock in trauma – Hemorrhagic (until proven otherwise)
• Other causes may be – cardiogenic, Neurogenic, obstructive and very rarely septic
• Definitive haemorrhage control and maintaining adequate circulatory volume is the goal of the treatment

Vasopressors are contraindicated in traumatic shock because they worsen tissue perfusion.

• All Unstable should be immediately rushed to Operation Room for definitive haemorrhage control
• Stable or borderline line managed with haemorrhage control, fluid and blood transfusion.
• after stabilization of vitals – the patient should be evaluated with CT or other necessary investigations
• Overzealous fluid kills patients faster than under-fluid resuscitation.
• Blood and blood products are preferred over fluid resuscitation.
• Lactated Ringer (RL) is the preferred fluid or fluid of choice in trauma patients
• The patient should not receive more than 1 litre of fluid in any situation – it further leads to hemodilution and trauma-induced coagulopathy.
• In case, a patient needed more fluid volume resuscitation replaced with blood, plasma, and platelets (1:1:1:).
• Any trauma patient presented in emergency with Systolic Blood Pressure(SBP) less than 90mmHg. consider immediate blood transfusion (Avoid fluid more than 1 litre)
• Activate Massive Transfusion Protocol (MTP)if the patient doesn’t respond to the fluid consider definitive haemorrhage control in the operation room.

Assessment of Blood Loss in Trauma victims

Blood loss may be visible or concealed

• The patient may have both or either
• Visible blood loss – due to external injury will be visible e.g. mangled extremity, laceration or amputated stump. visible blood loss can be very well controlled or managed in an emergency with good team efforts.
• Concealed blood loss – which is not visible can be very well evaluated clinically by eFAST or clinical examination.
• Most lethal concealed blood loss – 1. Abdomen, 2. Thorax 3. Pelvis. and 4 Long Bones fracture

Blood on Floor & Four more – Source of Bleeding

– Look for bleeding in all trauma victims (ATLS)

• eFAST is the clinical examination that should be done at the bedside by a trauma surgeon or emergency physician.

eFAST (Extended Focus Assessment sonography for Trauma)

1. Pericardial Window – the first window to examine & see pericardial fluid.
2. Right Hypocondrial Window (Hepatorenal Window) – to evaluate the free fluid in Morrisons Pouch
3. Left Hypochonrial Window (Splenorenal Window) – to examine free fluid in splenorenal space.
4. Hypogastric window – to see free fluid around the urinary bladder.
5. Examination of the right lung – to evaluate free fluid in the right pleural cavity and free air.
6. Examination of the left lung – to evaluate free fluid in the left pleural cavity and free air.

FAST is ‘Focused Assessment Sonography in Trauma’ – where examination of lung is excluded, pericardial, and abdominal free fluid examined.

• Colloids are contraindicated in traumatic shock and associated with higher mortality in trauma due to acute kidney injury.
• Balanced resuscitation should be followed for a better patient outcome that includes PRBC:FFP: Platelets – 1:1:1
• Pelvic trauma associated with higher mortality rate – Pelvic binder should be applied immediately in all polytrauma patients. The binder should be removed as soon as possible once the diagnosis is made or hemodynamically stabilized.

Class of Hemorrhagic shock

• Blood in the adult – 7% (5L)of body weight and in children 8-9% (70-80ml/kg)of their body weight.
• Grade IV Shock (>40%) blood loss is considered a preterminal condition – unless aggressively treated. for non-compressible bleeding mortality goes to 80% or more.
• A well-equipped and prepared trauma can only save such patients.
• The patient can be divided into three categories depending on fluid response – 1. Rapid responder 2. Transient Responder or 3. Non-responder.

Rapid Responders

• These patients have lost blood but the bleeding has been controlled now – most of these patients are well-managed non-operatively (Until Bowel or vascular injury is present)

• can be established and evaluated with CT

Transient Responders

• These patients have lost blood but they respond to fluid resuscitation. Once the patient returned to his normal blood pressure they started rebleeding. Such patients usually required definitive haemorrhage control.

Non-Responders

• Usually presented in hypotension and doesn’t respond to fluid resuscitation. Non-responders should immediately be rushed to the operation room (usually within 10min). Only Saline cross-match blood is needed MTP should be activated and transfusion started along with definitive haemorrhage control.

• The source may be thorax or abdomen or both so Trauma Crash Laparotomy is indicated in such patients for good exposure to rapid haemorrhage control.
• Most of the patients already have lost more than 30% or more blood.
• An operation room is the best place for immediate resuscitation of such patients with a trauma surgeon, trauma nurse, anesthesiologist and technicians with other support staff.

Permissive Hypotension

Also called “Controlled Resuscitation” “Balanced Resuscitation” “Hypotensive Resuscitation” and “Permissive Hypotension.”

In blunt trauma – fluid resuscitation and avoidance of hypotension are important principles in initial management.

In Penetrating trauma – delaying aggressive fluid resuscitation until definitive haemorrhage will prevent excessive blood loss and maintain permissible hypotension.

Permissive Hypotension is a bridging resuscitation strategy for definitive haemorrhage control.

In Grade III & IV shock – early blood and blood product transfusion (PRBC, FFP, & Platelets) in the ratio of 1:1:1 or a low ratio of Blood and FFP & platelets (which means more blood products) reduces the chances of trauma-induced coagulopathy.

Before definitive haemorrhage control, maintain systolic blood pressure <90 mmHg with blood & blood products.

Overzealous crystalloids and vasopressors kill patients sooner or later.

Colloids are contraindication is traumatic shock or any shock and are associated with higher mortality and acute kidney injury.

Permissive hypotension is maintaining low blood pressure in penetrating or selected blunt trauma patients (except head injury) to prevent excessive blood loss before definitive haemorrhage control.

Use of Vasopressors in Trauma

Trauma is unlike other illnesses. The most common cause of shock in trauma is haemorrhage.

Vasopressor use in severely injured trauma patients is discouraged due to concerns that vasoconstriction will worsen organ perfusion and result in increased mortality and organ failure in hypotensive trauma patients. Richards JE, et al 2021

Can we use vasopressors in traumatic shock for resuscitation to increase blood pressure?

Answer – No

Few may think – ohh why “No”, I have used it many times and patients responded well.

then again you need to remind, how many patients finally survived after reaching to trauma ICU?

may not find a satisfactory answer – because Vasopressor kills trauma patients faster without achieving definitive haemorrhage control.

Reasons

1. Vasopressors cause peripheral vasoconstriction which again leads to poor perfusion and shock. temporarily you may notice a rise in blood pressure but finally, your patient will land up into shock and lactic acidemia & metabolic acidosis. which is associated with a higher mortality rate in trauma patients.
2. As soon you give vasopressors it will increase the patient’s blood pressure – the patient will rebleed or increases total blood loss, which further aggravates shock and finally death.
3. If the patient has already lost blood – due to lack of preload cardiac strain will increase and the patient may develop myocardial infarction and sudden death.

Never use vasopressors in Traumatic Shock without definitive haemorrhage control

Now again a question

Q: Should we never use vasopressors in trauma?

Answer – We can use it in trauma victims only after definitive haemorrhage control and after the adequate restoration of body volume. Lactic acidemia is a good indicator of body perfusion.

Inotropes only useful in post-resuscitation or in Trauma ICU (Sepsis)