Snap Shot A 29-year-old male is brought to the ED following a motor vehicle accident. His blood pressure is 70/40 and he is tachycardic with cool extremities. His blood pressure improves only slightly with 2 L Ringer's lactate infusion. Introduction Most common cause of shock in a trauma patient Decreased blood volume (preload) leads to decrease in cardiac output Class I Class II Class III Class IV Blood loss (ml) <750 750-1500 1500-2000 >2000 % blood loss <15% 15-30% 30-40% >40% Pulse <100 >100 >120 >140 BP >100 >100 Decreased Decreased Pulse Pressure Decreased Decreased Decreased RR 14-20 20-30 30-40 >35 Urine >30 20-30 5-15 None CNS Slighty anxious Slighty anxious Anxious, confused Confused, lethargic Fluids Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood Presentation Physical exam hypotension tachycardia cool extremities tachypnea anxiety/confusion Evaluation Filling Pressure(RA and PCWP) Cardiac Output Vascular Resistance Septic shock Low Increased Low Cardiogenic High Low High Hypovolemic Low Low High Cardiac tamponade High Low High Papillary muscle rupture High Low High Evaluation/Treatment Primary survey (ABC) establish airway (A) if patient can speak airway is fine methods used in order of urgency from least to most includes oropharyngeal airway, intubation, cricothyroidotomy assess for breathing (B) assess for bilateral breath sounds and chest rise do not miss a hemo/pneumothorax or single lung intubation place two large bore IVs (C) replace fluid (3 liters to every liter of blood lost) prepare for transfusion if patient does not respond to 2 L IV fluids Secondary survey (DE) check neurologic function - disability (D) calculate with Glasgow Coma Scale (GCS) identify source of bleeding and other injuries - exposure (E) remove patient's clothes perform complete examination stomach - gastric tube abdomen - US / CT / Digital rectal exam diagnostic peritoneal lavage no longer used retroperitoneal - US / CT bleeding into the abdomen should be treated with exploratory laparotomy bleeding into the pelvis should be treated with angiographic embolization place foley most accurate indicator of fluid resusitation contraindications blood at urethral meatus high riding, mobile, nonpalpable prostate