10th edition %% Lon Setnik dates:: 2022-11-08 %% _The first step in the initial management of shock is to recognize its presence._ 1. The basic management principle is to stop the bleeding and replace the volume loss.  2. The goal of resuscitation is to restore organ perfusion and tissue oxygenation 3. Identifying and controlling the site of hemorrhage with simultaneous resuscitation involves coordinating multiple efforts. The team leader must ensure that rapid intravenous access is obtained even in challenging patients. The decision to activate the massive transfusion protocol should be made early to avoid the lethal triad of coagulopathy, hypothermia, and acidosis. The team must be aware of the amount of fluid and blood products administered, as well as the patient’s physiological response, and make necessary adjustments.  4. The most effective method of restoring adequate cardiac output, end-organ perfusion, and tissue oxygenation is to restore venous return to normal by locating and stopping the source of bleeding. Volume repletion will allow recovery from the shock state only when the bleeding has stopped.  5. Definitive control of hemorrhage and restoration of adequate circulating volume are the goals of treating hemorrhagic shock.  6. In most adults, tachycardia and cutaneous vasoconstriction are the typical early physiologic responses to volume loss.  7. Any injured patient who is cool to the touch and is tachycardic should be considered to be in shock until proven otherwise.  8. Hemorrhage is the most common cause of shock after injury, and virtually all patients with multiple injuries have some degree of hypovolemia.  9. It is dangerous to wait until a trauma patient fits a precise physiologic classification of shock before initiating appropriate volume restoration. Initiate hemorrhage control and balanced fluid resuscitation when early signs and symptoms of blood loss are apparent or suspected—not when the blood pressure is falling or absent. Stop the bleeding.  10. Volume: 1 liter for adults and 20 mL/kg  11. Persistent infusion of large volumes of fluid and blood in an attempt to achieve a normal blood pressure is not a substitute for definitive control of bleeding.  12. Balancing the goal of organ perfusion and tissue oxygenation with the avoidance of rebleeding by accepting a lower-than-normal blood pressure has been termed “controlled resuscitation,” “balanced resuscitation,” “hypotensive resuscitation,”  13. Failure to respond to crystalloid and blood administration in the ED dictates the need for immediate, definitive intervention (i.e., operation or angio- embolization) to control exsanguinating hemorrhage.  14. Consider collection of shed blood for autotransfusion in patients with massive hemothorax. This blood generally has only low levels of coagulation factors, so plasma and platelets may still be needed.  15. An increase in blood pressure should not be equated with a concomitant increase in cardiac output or recovery from shock. For example, an increase in peripheral resistance with vasopressor therapy, with no change in cardiac output, results in increased blood pressure but no improvement in tissue perfusion or oxygenation.  16. Constant reevaluation, especially when a patient’s condition deviates from expected patterns, is the key to recognizing and treating such problems as early as possible. %% tags: #note/idea | #note/quote | #ATLS %% ## Sources: ATLS - 10th edition