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SCENARIO

A 30 years old man came to the emergency roomwith ambulance. The


patient was a referral from the first clinic. From anamnesa it is known that the
patient was a victim of a traffic accident hit by a car from the front. Patients
come unconscious, breath snoring, there are some wounds in face area, right
chest and right foot. While at the first clinic received infusion therapy RL 2000cc
but the awareness and blood pressure did not improve, finally decided to be
referred to the hospital.
On the physical examination in the emergency room get: snoring,
respiration 26x/min, intercostal muscle retraction, rhonki -/- , wheezing -/-,
abdomen soepel, normal bowel sounds. Acral perfusion is cold, wet, pale. Blood
pressure 70/50 mmHg, pulse 130x / min fast, weak. Awareness of response to
pain, isokor round pupil 3/3 mm. Obtained open fractures in the right femur
and active bleeding in the right femur. Once installed catheter urine only 50cc
out of concentrated then not out of urine at all.
Identifying Difficult Word
Abdomen Soepel: Examination of palpation in abdominal wall.

Keywords
Victim of a traffic accident hit from front, unconscious, snoring,
facial lesions, right chest and left leg, infusion RL 2000cc but not
improved, RR 26x / min, intercostal muscle retraction, cold and
pale acral, BP 70 / 50 mmHg, puse 130x / min fast, awareness of
response to pain, right open femur fracture and massive
bleeding, clavicula fracture, no urine exit, fast ultrasound +, Hg
7 g / Dl, 20% hematocrit, leukocyte 21.000, ECG: sinus
Tachycardia, hypoalbumin (2.9).
Identification Of Problems
1. What is the first aid performed on the patient?
2. What is the most urgent situation to deal with? (Action
priority)
3. How is the trauma to the patient causing symptoms?
4. What are the chances that if the patient is not handled
appropriately?
Mind Map
Trauma

Rupture of blood
Open Fracture vessels

Massive bleeding

Hypovolemic Shock

First Aid Not helped

Complication

Airways Circulation Exposure

Breathing Dissability
Learning Objective
1. Can explain Basic Life Support in hypovolemic shock due to
bleeding.
2. Can explain the pathophysiology of hypovolemic shock.
3. Can explain the indication of blood transfusion-related
scenario.
4. Can explain classification and stage of Hypovolemic shock
5. Can explain the teraphy of hipovolemic shock.
6. Can explain the definition and epidemiology related scenarios.
7. Can explain complications and prognosis related scenarios.
Basic Life Support for Hipovolemic
Shock from ATLS 2008
Airway and Breathing
Ensures patent airways with adequate ventilation and oxygenation
Circulation - Bleeding Control
Priority in circulation includes clearly visible bleeding control, gain
adequate intravenous access and assess tissue perfusion. Bleeding from
external wounds can generally be controlled by a direct compression
bucket at the site of the bleeding. PASG (Pneumatic Anti Shock
Garment) can be used to control bleeding at the pelvic or lower
extremity bone Operation may be required to control internal bleeding.
Disability - Neurological Examination
A short neurologic examination can determine the level of
consciousness, eye movement and pupil response, as well as motor and
sensory function.
Basic Life Support for Hipovolemic
Shock from ATLS 2008
Exposure - Full Checkup
The patient was stripped naked and examined from head to toe
to look for the accompanying injuries.
Dilatation of the stomach - Decompression
In unconscious patients, gastric dilatation increases the risk of
aspiration of gastric contents so that gastric decompression can
be performed
Installation of Urine Catheter
Bladder catheterization is used for urine assessment of
hematuria and evaluation of renal perfusion by monitoring
urine production.
HYPOVOLEMIC SHOCK
(GELS)
LO 2. PATHOPHYSIOLOGY of
HYPOVOLEMIC SHOCK
PATHOPHYSIOLOGY
Primary pathophysiological event
(reduction of ventricular filling volumes and pressures)

compensatory phenomena macrocirculatory reaction


time

decompensatory phenomena microcirculatory reaction


Hypodynamic shock:
Macrocirculatory reaction:
sympatho-adrenergic + humoral reaction (ADH, cortizol,
SRAA)
o EFFECTS: centralisation of the circulation (compensatory effect)
worsening of tisular hypoperfusion (decompensatory
effect)
Microcirculatory reaction:
Alterations of capillary exchanges
o EFFECTS: transcapilary filling (compensatory effect)
capilary leak (decompensatory effect)
Maldistribution of blood flow
o EFFECTS: preferential renal blood flow towards medular region
(cortical vasoconstriction)
Abnormal peripheral oxygen extraction
o EFFECTS: early - increased (compensatory effect)
late - decreased (decompensatory effect)
Rheologic changes
o EFFECTS: blood viscosity, blood flow, CID
Endhotelial modifications
o EFFECTS: morpho-functional modifications
proinflamatory and procoagulatory status,
altered permeability
Indications for Blood
Transfussion
Stage and Classification of Haemorrhagic
Shock by Giesecke (1991)
Management hypovolemic shock

Airway and shock


breathing ok!!
Keep it unblock
and give oxygen

Positioned shock position


Install a large infusion x 2
Take a blood sample
For donor blood and check Hb
Stop bleeding
Give fluid infusion, 20-40 cc / kgBB fast
Definition

Hipovolemic Shock
Hypovolemic shock is a medical or surgical
condition in which rapid loss of fluid ends in the
failure of some organs, caused by inadequate
circulation volume and resulting in inadequate
perfusion. Most often, hypovolaemic shock is the
result of rapid blood loss (hemorrhagic shock).

Wijaya, 2006
Epidemiology

Hipovolemic Shock
According to WHO, injuries from accidents each
year caused 5 million deaths worldwide. Mortality in
trauma patients who experience shock in the
hospital with a complete service level reached 6%,
while in the hospital with inadequate equipment
reached 36%.
Shock also occurs in women with haemorrhagic
bleeding, shock deaths of up to 500,000 per year and
99% of those deaths occur in developing countries.
Diarrhea in infants is also one of the causes of
hypovolemic shock. According to WHO, the mortality
rate due to diarrhea with hypovolemic shock among
under-fives in Brazil reaches 800,000.
Diantoro, 2014
7. Complications and prognosis
Complications
Sepsis
Acute respiratory syndrome
Disseminated intravascular coagulation
Multiorgan failure
Death
Prognosis

Prognosis depends on several things, among


others:
The duration of shock progresses
Weighing of shock
Correct handling speed
Previous disease
Comorbidities