Although shock has been recognised for over 100 years, a clear definition of this complex event

has emerged slowly. Since 1872 many definitions of shock have been offered.
The inadequate organ perfusion and tissue oxygenation is now recognised as the definition of
shock.
The first step in the evaluation of the trauma patient is to recognise the shock condition; there are
no laboratory tests, no instrumental aids that allow this diagnosis in the first minutes.
The diagnosis of shock must be based on clinical findings.
All types of shock can be present in the trauma patient, and the identification of what type of
shock is taking place, is another fundamental step.
In the trauma patient the vast majority of the shock condition are hypovolemic, but also
cardiogenic or tension pneumothorax must be considered in the trauma victims.
The only conditions that does not result in shock condition are the isolated head injuries.
CATEGORY OF SHOCK
HAEMORRHAGIC SHOCK
The haemorrhagic (hypovolemic) shock is due to the acute blood loss or fluids. The amount of
blood loss after trauma is often difficult to determine. Particular attention in the clothes of the
patients or in what reported by the prehospital personnel may aid in the determination of the
blood lost.
The haemorrhage after a blunt trauma is often underestimated. A femoral not open fracture, in
example, may loose to 1 up 2 litres of blood, a pelvic fracture can loose more than two liters of
blood while a simple rib fracture can arrive up to 125 ml.
The abdominal cavity may contains large amount of blood without distension occurs; initially the
blood does not irritate the peritoneum, making the diagnosis of haemoperitoneum difficult to
establish. The diagnostic studies for the abdominal trauma are listed in chapter The trauma of
abdomen..
The most rapid evaluation of the patient suspicious for shock consists of in the determination of
the heart rate (together with the capillary refilling, pulse presence and character, patient
temperature), the blood pressure and respiratory rate. Anyway keep in consideration that in the
trauma victim the heart rate may be increased because of anxiety, and the blood pressure change
with the age (a systolic blood pressure of 85 mmHg may be normal in a child, while a systolic
blood pressure of 120 mmHg may represents hypotension in the elderly people).
CARDIOGENIC SHOCK
This type of shock is usually due to an insufficient pump function of the heart.The insufficient
pump may be due to penetrating wound of the heart, myocardial contusion, cardiac tamponade,
tension pneumothorax, diaphragmatic rupture.
The evaluation of the jugular vein is a foundamental step to recognize this type of shock (jugular
vein flatted or distended).
In the old patient a myocardial infarction should be suspected following a cardiac hypoperfusion
after major trauma, but myocardial infarction may be the cause of the trauma itself. The
distended neck veins may be absent in case of severe hypovolemia. The EKG monitoring is
essential to detect any dysrhytmias that can occur after trauma.
When a cardiac tamponade exists a needle pericardiocentesis, performed by a skilled surgeon, is
mandatory.
NEUROGENIC SHOCK
In this situation there is an increased vascular system with a secondary reduction of the
circulating fluids. The neurogenic shock is due to the loss of sympathetic tone (spinal cord
injury). The classical picture of this type of shock is hypotension without tachycardia or
cutaneous vasoconstriction.
SEPTIC SHOCK
Is uncommon immediately after trauma. It may occur if the patient arrive at the emergency room
many hours after trauma. This type of shock is common for the penetrating injury, especially the
abdominal injury with contamination of the peritoneal cavity by the bowel contents. Septic shock
(with multi organ failure syndrome) is a leading cause of death in the trauma patient after the
first weeks.
SIGN AND SYMPTOMS
The signs of the shock (hypovolemic shock) are usually easy to recognize when established.
These signs are indicative of low peripheral blood flow and sympatheticoadrenal activity excess.
The patient in shock condition appear to be restless, anxious, and fearful. This restless may vary
to aphaty; in this situation the patient seems sleepy. After a while, if untreated or if the blood loss
is understimated, the patient will complain chilly sensation and at this time the aphaty rapidly
progress to coma.
The most common and important signs are:
changes in blood pressure (arterial and venous blood pressure are decreased), nausea, vomiting,
tachycardia (as compensatory process marked by the amount of blood loss; but tachycardia may
be influenced by anxiety, fear so more the heart rate it is important to record every changes in the
heart rate), vasoconstriction (in this case is an effort to compensate the reduced cardiac output. In
haemorragic shock the heart may receive 25% of the total cardiac output versus the normal 5-
8%).
These vascular responses depend on the activation of the sympathetic and adrenal medullar
systems.
Other signs include pale and cold skin, tachypnea and all the bloods changes as hemodiluition,
hormonal changes, pH changes, renal dysfuction ecc.
MANAGEMENT OF THE SHOCK
The primary goal of shock resuscitation is to restore adequate tissue oxygen delivery and to treat
the underlying pathology to prevent recrudescence of the shock state or the death of the patient.
Hypotension, tachycardia, hypothermia, pallor, cool extremities, cyanosis, decreased capillary
refill, diaphoresis and oliguria are physiologic signs suggestive of hypovolemic shock.
Treatment of the blood pressure, heart rate, and other clinical signs and symptoms of
hypoperfusion is directed toward restoration of cellular perfusion.
Since the primary defect during shock is hypovolemia, volume infusion must be the primary
therapy. Adequate volume loading is initiated after adequate vascular access is obtained, which
usually requires the insertion of at least two large bore venous catheter (14 - 16 G). Catheter may
be inserted percutaneously in an arm vein or/ and in the femoral vein.
If vasoconstriction is significant or the patient is obese, peripheral cut-down (saphenous vein,
cephalic vein) become necessary.
The central venous line should be used only as monitor for the CVP and not as route of infusion
in the trauma victims.
Immediately warmed Ringer's Lactate (or others plasma expanders) solution should be
administered at the rate of 1 liter every 3 minutes (to prevent iatrogenic hypothermia that can
leads with massive transfusion to coagulopathy. Coagulability of the blood is maintained by
administering fresh frozen plasma and platelets.).
If two or three litres of Ringer's Lactate are not successful in reversing the shocklike state, blood
should be administered. When possible type specific cross matched blood should be
administered; however if the patient has persistent haemodinamic instability and the type specific
cross matched is not available, type 0 negative packed red blood cells are an ideal replacement
(only if cross matched blood is not available ).
0 positive RBC with low antibody titers are acceptable in males or females except for the 0
negative female of child-bearing age where there is a risk of sensitisation and the subsequent
development of erythroblastosis fetalis.
It is dangerous wait for a precise diagnosis of shock before initiating aggressive treatment.
Fluid replacement must be initiates when early symptoms of shock are recognised or suspected.
The American College of Surgeons propose the following categorisation of the haemorrhage:
1) Class I 15 % blood volume loss.
This is a minimal haemorrhage, uncomplicated, no changes occur in heart rate, blood pressure or
respiratory rate.
2) Class II 15-30 % blood volume loss.
Tachycardia, tachypnea, anxiety, decreased pulse pressure are present (difference between the
systolic and diastolic pressure). Because the systolic pressure changes minimally in the early
phases of the shock, the pulse pressure evaluation becomes important. Urinary output is only
minimally affected.
3) Class III 30-40 % blood volume loss.
Very dangerous haemorrhage. Classic signs of shock are present with changes in mental status
and significant fall in systolic blood pressure. Transfusion is indicated (according to the fluid
therapy scheme).
4) Class IV > 40 % blood volume loss.
It is life threatening situation. No urinary output is detected. Deep depression of the mental
status. Immediate surgical intervention is necessary
Another simple scheme that try to quantify the shock is the Alghevar Scheme
This scheme consider the systolic blood pressure and heart rate ratio; if this ratio is more than 1
the patient is not yet in a manifest hypovolemic shock, while if the ratio is less than 1 the patient
is in a clear shock condition.
Sumber
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