1. Evaluation of Shock Dr. Chew Keng Sheng Professor/Emergency Physician,
Faculty of Medicine and Health Sciences,
Universiti Malaysia Sarawak

2. Case 1
A 30-year-old man is brought in to your ED due to motor- vehicle accident one hour ago sustaining intra-abdominal injuries, closed mid-shaft femoral fracture and a deep lacerated scalp wound that is continuously oozing. His urine output is 50 ml since the last one hour, and the urine appears concentrated.

3. Case 2
A 22-year-old man fell while riding his motorcycle and suffered an open fracture of his left femur and severe lacerations and crushing injury to the thigh. Immediate operation was performed with the fracture reduced and wounds debrided.
The immediate postoperative course was uneventful, but 24 hours later, pain started to develop in the thigh. Patient was drowsy. Pain and swelling of the thigh increased rapidly. BP 90/60 mmHg, Temperature 39ºC, pulse rate 120/min, respiratory rate 30/min.

4. Case 3
An 40-year-old construction worker fell down a flight of stairs, complaining of back pain. Pulse rate is 64 bpm, blood pressure 90/60 mmHg, and a respiratory rate of 18/min. He complained of numbness from mid-trunk and below and unable to move both his lower limbs.

9. Pitfall: Shock may occur in normal vital signs
Young, healthy patients - compensatory mechanisms
Bradycardic rather than tachycardic response to penetrating intraperitoneal injury (Vayer et al. Ann Emerg Med. 1988)
Triad of bradycardia, hypotension and peripheral vasodilation, think of neurogenic shock
Elderly patients – polypharmacy (eg, beta blockers)
Always interpret vital signs with the patient's baseline in mind!
Redefining hypotension in the elderly? Normotension may not reassuring.
Optimal BP to define hypotension: 85 mm Hg (18 to 35 years); 96 mm Hg (36 to 64 years, and 117 mm Hg for elderly patients (Oyetunji et al Arch Surg. 2011)

10. Pitfall: AMS can be caused by many things
AMS: head injuries? hypoperfusion? Drug or alcohol intoxication?
Think of AEIOU TIPS
Deterioration of conscious level in the absence of head injuries – think of cerebral hypoperfusion
In young, healthy patients – can be subtle
Agitation, confusion, irritability, indifference to surroundings, or inattention to instructions

12. Trauma Triad of Death

13. Why Coagulopathy In Trauma?
Dilutional effect of IV fluids
A qualitative platelet defect (particularly after traumatic brain injury [TBI])
Diffuse endothelial cell injury
Depletion of coagulation factors and platelets through hemorrhage and deposition into injuries
Consumption of platelets and coagulation factors secondary to DIVC
(Pohlman et al, 2015):

14. Why Is Acidemia Bad?
Diminishes enzymatic activity of coagulation factors
Depletes fibrinogen and reduces the number of circulating platelets.
Decreases cardiac contractility, causes dysrhythmias
Desensitizes peripheral vasculature adrenergic receptors to endogenous catecholamines
Decrease immunologic response
(Pohlman et al, 2015):

15. Why hypothermia is bad?
Affect enzymatic activity of coagulation factors and platelet functions
Coagulation factor activity is reduced approximately 10%– 15% for each 1 °C drop in temperature
(Pohlman et al, 2015):

16. Initial Fluid Resuscitation
Colloid vs crystalloid?
Infusions of large volumes of NS can lead to the development of a nonanion gap hyperchloremic metabolic acidosis.
Aim for penetrating trauma:
mean arterial pressure (MAP) 65 mmHg or
systolic blood pressure (SBP) around 90 mmHg
Neal et al (2012) - Crystalloid resuscitation in a ratio greater than 1.5:1 per unit of PRBCs transfused was independently associated with a higher risk of MOF, ARDS, and ACS.

17. Massive Transfusion
requirement for >10 units of PRBCs within the first 24 hours of injury.
transfusion of >4 RBC units in 1 h with anticipation of continued need for blood product support
replacement of >50% of the TBV by blood products within 3 hours
Pham, H. P., and B. H. Shaz. Update on massive transfusion. BJA 111.suppl 1 (2013): i71-i82.

18. Massive Transfusion Protocol
The optimal fixed ratio of units of plasma, platelets and RBCs for non-military DCR remains incompletely defined, although likely falls between 1:1:3 and 1:1:1 (plasma: platelets: RBCs)
The physiology supporting the 1:1:1 (FFP:platelets:PCs) approach is because of the risk of dilutional coagulopathy with conventional transfusion especially so associated with crystalloid (3:1).

19. Massive Transfusion Protocol
Holcomb et al (2015) - RCT (n = 680 with major traumatic bleeding) FFP: platelets: PC of 1:1:1 vs 1:1:2.
No significant differences in terms of mortality
at 24 hours (12% in 1:1:1 vs 17% in 1:1:2) or
at 30 days (22% vs 26% respectively) but
patients given 1:1:1 were significantly more likely to have adequate hemostasis (86% vs 78%) and had fewer exsanguination deaths at 24 hours (9% vs 15%).
Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA 2015;313(5): Epub 2015/02/04.