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1、Patterns of Traumatic Injury,Penetrating injury ongoing significant blood loss is expectedBlunt injury blood loss may be occult or contained and significant or limitedHead injury maintenance of cerebral perfusion pressureOthers:pediatric and obstetric trauma,Shock,Definition:a state of reduced organ
2、 perfusion resulting in tissue hypoxia and organ dysfunctionS/S:falling of BP,tachycardia,oligouria,decreased mental status,decreased peripheral pulses,diaphoresisMain goal of therapy:rapid resuscitation with re-establishment of tissue perfusion using fluid therapy and vasoactive drugs,Hemorrhagic s
3、hock,Acute response:Increased capillary permeability Reduction in blood flow Sympathetic compensation by peripheral vasoconstrictionElevated IL-6 and TNF-alphaTissue hypoperfusion and anaerobic metabolism/acidosisAfter systemic circulation is restored,reperfusion injury due to free oxygen radicals r
4、eleased during acute hypoxic stage may occur,Traumatic hemorrhagic shock,Acute stage:hemorrhagic shockMay be accompanied with:Cardiogenic shock Neurogenic shock Obstructive shock Septic shock,Hemorrhagic shock,Traumatic hemorrhagic shock,Trauma triad of death after hemorrhagic shock:(1)Hypothermia(2
5、)Acidosis(3)Coagulopathy,Traumatic hemorrhagic shock,Phase 1:The period from injury to definite surgical care and homeostasisPhase 2:The period during and immediately after definite surgical procedurePhase 3:The period in ICU following definitive care and characterized by established critical illnes
6、s,Phase 1:pre-hospital/pre-operative fluid therapy,Traumatic hypotension without a head injury:no evidence suggest that pre-hospital fluids are beneficialDelayed fluid resuscitation has better outcome than immediate resuscitation in penetrating torso injuriesThe evidence supporting delayed or limite
7、d prehospital resuscitation in blunt trauma is less clear,Phase 2:perioperative fluid management,It is unclear whether targeting cardiac output or oxygen delivery to specific defined goals results in improved clinical outcomes Maximized stroke volume using fluids titrated against a measure of blood
8、flow is supported by limited available data,Phase 2:perioperative fluid management,The addition of inotropes to achieve specific blood flow or oxygen delivery goals may confer additional advantage but the available data is not conclusive,Phase 3:Critical care fluid management,Fluid strategies are di
9、rected at restoring organ function after the combined insult of hypovolemic hypoperfusion,surgery and trauma induced inflammatory response Maintaining a normal circulating volume(cardiac output)is a priorityTargeting oxygen delivery goals has been demonstrated to be harmful in established critical i
10、llness,Trauma Fluid Resuscitation,Severity of hemorrhagic shockAgeCo-morbid disorderInjury typesConcurrent head or spinal injuryPulmonary edema,Types of Fluid,Crystalloid solutionsColloid solutionsGelatinsDextransHydroxyethyl starches(HES)Albumin and plasma-protein fractionBlood&blood substitutes,Cr
11、ystalloids,Solutions in water of inorganic ions and small organic molecules,either glucose or sodium chloride based.,Colloids,A homogeneous,non-crystalline substance consisting of large molecules or ultramicroscopic particles of one substance dispersed through a second substancePrincipal types of se
12、misynthetic colloid molecules:gelatins;dextrans;and HESHuman plasma derivatives:albumin,FFP and immunoglobulin solutions,Colloids,Key characteristics of artificial colloids,Magnitude and duration of plasma volume expansionHemorreological characteristicsHemostatic effectsInteraction with endothelial
13、and inflammatory cellsAdverse drug reactionsCost,Gelatins,Dextrans,HES,Gelatins:prepared by hydrolysisof bovine monly available preparation-succinylated gelatin(Gelofusin)Dextrans:high-MW D-glucose polymers joined largely into linear-branched macromoleculesHES:synthesized from amylopectin,a waxy sta
14、rch derived from maize or sorghum,Albumin and plasma-protein fraction,Human albumin:a naturally occuring monodiperse colloidFFP and plasma-protein fraction:a more polydisperse human-derived colloidal solution with significant amounts of higher-MW proteins-globulins,Blood Substitutes:hemoglobulin sol
15、utions,At an early stage of development and probably some way from routine clinical use HBOC(Hemoglobic-based oxygen-carrying compounds)PBOC(Perflourocarbon-based oxygen-carrying compounds)Have a linear O2Hb dissociation profile and specific pharmacological effects,Thank you for your attention!,Hemorrhagic shock,Schematic diagram of capillary memebrane,Crystalloids,Colloids,HES solutions,HBOC,
