K. John Hartman MD FACS Trauma Services Medical Director Genesis Davenport Objectives 1. Discuss tourniquet indications 2. Review Tourniquet application 3. Review Fluid 4. Assessing 5. Providing Care for Shock 4/15/2013

“Past tourniquet bad experiences are now explicable because prior science, device designs, training, doctrine and evacuation were inadequate”.

-Kragh, Use of Tourniquets and Their Effects on Limb Function… Foot Ankle Clin N Am 15 (2010) 23-40

Purpose: stop blood flow through an extremity’s arteries Main Use Scenario: stop bleeding from an injured limb

Arterial and venous blood flow in the limb is stopped. To stop bleeding so you can do something else (direct pressure “inconvenient”) Return enemy fire (military/tactical care) Solve an airway problem Attend to other injuries Attend to another casualty Extricate from current location (crushed vehicle, machinery entanglement, unsafe location) Transport to definitive care

Kragh et al. J Spec Oper Med 2011;11:30-38 Reasons to use arterial tourniquets ATo stop bleeding not amenable to direct pressure  Open fractures  Amputations  Vascular wounds  Severe soft tissue wounds  Expanding hematoma  Impaled objectImpaled object 20 of 90 IA EMTs with no military experience had used a tourniquet on a limb injury (6 more than once). Injury Sources: motor vehicle accidents (9), farm equipment (6), manufacturing equipment (4), falls through glass (2), gunshots (2), chainsaws (2), and stab (1) Tourniquet Indications: severe hemorrhage, extrication/transport time, injury access, other injuries Tourniquets Used: blood pressure cuffs (9, only 6 indicated as stopping the bleeding), other improvised (10, only 4 listed as stopping the bleeding)

Tourniquets have civilian injury relevance.

90% survival applied pre-shock (429/476) 18% survival applied after shock onset (4/22) 89% survival applied pre-hospital (374/422) 78% survival applied in hospital (59/76) 0% survival not applied for severe limb trauma (0/10)

Kragh et al. J Emerg Med 2011;4:590-597

For life threatening bleeding, don’t wait  stop the bleeding! Between the heart and the injury The presence of two long bones in the forearm and lower leg does not decrease tourniquet effectiveness for stopping arterial blood flow as compared to the single long bone in the upper arm and thigh. Tourniquet placement on a smaller circumference limb location allows easier pressure application to the underlying arteries.

Place tourniquet(s) just proximal to the injury. Tourniquet Placement on the Limb Need to stop arterial blood flow (importance of mechanical advantage) Are most life saving used before shock Should be wider than 2.5cm (wider is better so long as stop arterial blood flow, side by side is good) Should be placed close to the injury (forearm and lower leg are good tourniquet locations) Need reassessment Hartford Consensus  The American College of Surgeons brought together senior leaders from medical, law enforcement, fire/rescue and EMS communities to create a strategy to improve survival of the victims of mass casualty shooting events in April, 2013. Hartford Consensus  Threat Suppression  Hemorrhage control  Rapid Extrication to safety  Assessment by medical providers  Transport to definitive care

“Life threatening bleeding from the extremities is best controlled by early placement of a tourniquet.” “Life threatening bleeding from penetrating wounds to the chest and trunk are best addressed through rapid transport to a hospital setting.”

“Improving survival from active shooter events: The Hartford Consensus.” Journal of Trauma and Acute Care Surgery, June 2013-Volume 74-Issue6-p1399-1400 Shock Inadequate oxygen delivery to meet metabolic demands.

3 factors determine: 1. oxygen content 2. oxygen delivery 3. distribution Causes/Types of Shock

 Hypovolemic/Hemorrhagic  Septic  Cardiogenic  Neurogenic  Anaphylactic 

• If you palpate a pulse, you know SBP is at 60 least this number

70

80

90 • Non-hemorrhagic • Vomiting • Diarrhea • Bowel obstruction, pancreatitis • Burns • Neglect, environmental (dehydration) • Hemorrhagic • GI bleed • Trauma • Massive hemoptysis • AAA rupture • Ectopic pregnancy, post-partum bleeding Possible Locations of the Blood  Abdomen  Retroperitoneum •It is possible to  Pelvis exsanguinate from a  Thigh scalp laceration.  Chest •Take note and report any  Pavement saturated clothing, towels, etc. Hypovolemic Shock • ABCs • Establish 2 large bore IVs • Crystalloids • Normal Saline or Lactate Ringers • Up to 3 liters • PRBCs • O negative or cross matched • Control any bleeding Controlling bleeding

1. Direct pressure 2. If unsuccessful, and location is on extremity, apply a tourniquet.

 Tachycardic, cold/cool extremities, widened pulse pressure. • Two or more of SIRS criteria • Temp > 38 or < 36 C • HR > 90 • RR > 20 • WBC > 12,000 or < 4,000 • Plus the presumed existence of infection • Blood pressure can be normal! • Clinical signs: • Hyperthermia or hypothermia • Tachycardia • Wide pulse pressure • Low blood pressure (SBP<90) • Mental status changes • Beware of compensated shock! • Blood pressure may be “normal”  Warm, vasodilated, tachycardic

• Defined as: • Signs: • SBP < 90 mmHg • Cool, mottled skin • CI < 2.2 L/m/m2 • Tachypnea • PCWP > 18 mmHg • • Altered mental status • Narrowed pulse pressure • Rales, murmur Etiologies • What are some causes of cardiogenic shock? • AMI • Sepsis • Myocarditis • Myocardial contusion • Aortic or mitral stenosis, HCM • Acute aortic insufficiency Pathophysiology of Cardiogenic Shock

• Often after ischemia, loss of LV function • CO reduction = lactic acidosis, hypoxia • Stroke volume is reduced • Tachycardia develops as compensation • Ischemia and infarction worsens Treatment of Cardiogenic Shock • Goals- Airway stability and improving myocardial pump function • Cardiac monitor, pulse oximetry • Supplemental oxygen, IV access • Intubation will decrease preload and result in hypotension • Be prepared to give fluid bolus Treatment of Cardiogenic Shock • AMI • Aspirin, beta blocker, morphine, heparin • Dopamine – will ↑ HR and thus cardiac work • Dobutamine – May drop blood pressure • Combination therapy may be more effective • PCI or thrombolytics  Cold extremities, tachycardic, narrow pulse pressure Anaphylactic Shock • – a severe systemic hypersensitivity reaction characterized by multisystem involvement • IgE mediated • Anaphylactoid reaction – clinically indistinguishable from anaphylaxis, do not require a sensitizing exposure • Not IgE mediated Anaphylactic Shock • What are some symptoms of anaphylaxis? • First- Pruritus, flushing, urticaria appear

•Next- Throat fullness, anxiety, chest tightness, shortness of breath and lightheadedness

•Finally- Altered mental status, respiratory distress and circulatory collapse Anaphylactic Shock • Risk factors for fatal anaphylaxis • Poorly controlled asthma • Previous anaphylaxis • Reoccurrence rates • 40-60% for insect stings • 20-40% for radiocontrast agents • 10-20% for penicillin • Most common causes • Antibiotics • Insects • Food Anaphylactic Shock

• Mild, localized urticaria can progress to full anaphylaxis • Symptoms usually begin within 60 minutes of exposure • Faster the onset of symptoms = more severe reaction • Biphasic phenomenon occurs in up to 20% of patients • Symptoms return 3-4 hours after initial reaction has cleared • A “lump in my throat” and “hoarseness” heralds life- threatening laryngeal edema Anaphylactic Shock- Diagnosis • Clinical diagnosis • Defined by airway compromise, hypotension, or involvement of cutaneous, respiratory, or GI systems • Look for exposure to drug, food, or insect Anaphylactic Shock- Treatment • ABC’s • Angioedema and respiratory compromise require immediate intubation • IV, cardiac monitor, pulse oximetry • IVFs, oxygen • Epinephrine • Second line • Corticosteriods • H1 and H2 blockers Anaphylactic Shock- Treatment • Epinephrine • 0.3 mg IM of 1:1000 (epi-pen) • Repeat every 5-10 min as needed • Caution with patients taking beta blockers- can cause severe hypertension due to unopposed alpha stimulation • For CV collapse, 1 mg IV of 1:10,000 • If refractory, start IV drip Anaphylactic Shock - Treatment • Corticosteroids • Methylprednisolone 125 mg IV • Prednisone 60 mg PO • Antihistamines • H1 blocker- Diphenhydramine 25-50 mg IV • H2 blocker- Ranitidine 50 mg IV • Bronchodilators • Albuterol nebulizer • Atrovent nebulizer • Magnesium sulfate 2 g IV over 20 minutes • Glucagon • For patients taking beta blockers and with refractory hypotension • 1 mg IV q5 minutes until hypotension resolves • Occurs after acute injury • Sympathetic outflow is disrupted leaving unopposed vagal tone • Results in hypotension and bradycardia • Spinal shock- temporary loss of spinal reflex activity below a total or near total (not the same as neurogenic shock, the terms are not interchangeable) Neurogenic Shock • Loss of sympathetic tone results in warm and dry skin • Shock usually lasts from 1 to 3 weeks • Any injury above T1 can disrupt the entire sympathetic system • Higher injuries = worse paralysis Neurogenic Shock- Treatment • A,B,Cs • Remember c-spine precautions • Fluid resuscitation • Keep MAP at 85-90 mm Hg for first 7 days • Thought to minimize secondary cord injury • If crystalloid is insufficient use vasopressors • Search for other causes of hypotension • For bradycardia • Atropine • Pacemaker  Warm and dry extremities, bradycardic, usually with a mechanism of injury. Obstructive Shock • Tension pneumothorax • Air trapped in pleural space with 1 way valve, air/pressure builds up • Mediastinum shifted impeding venous return • Chest pain, SOB, decreased breath sounds

Rx: Needle decompression, chest tube Obstructive Shock • Cardiac tamponade • Blood in pericardial sac prevents venous return to and contraction of heart • Related to trauma, pericarditis, MI • Beck’s triad: hypotension, muffled heart sounds, JVD • Diagnosis: large heart CXR, echo • Rx: Pericardiocentisis Obstructive Shock • Pulmonary embolism • Virscow triad: hypercoaguable, venous injury, venostasis • Signs: Tachypnea, tachycardia, hypoxia • Low risk: D-dimer • Higher risk: CT chest or VQ scan • Rx: Heparin, consider thrombolytics The Golden Hour What should we be doing?

Rapid assessment ATLS Resuscitation and stabilization

Definitive management/Transfer The Golden Hour Rapid Resuscitation

 restores circulating volume  improves oxygen delivery  prevents cellular ischemia and tissue necrosis  prevents onset of secondary cellular injury  prevents onset of MODS The Golden Hour Shock Pathophysiology

 prolonged hypoperfusion creates a vicious cycle of ischemia and shock 2 most important steps in managing shock: 1. recognition 2. treatment Goals of Treatment

• ABCDE • Airway • control work of Breathing • optimize Circulation • assure adequate oxygen Delivery • achieve End points of resuscitation