CHAPTER 53

Shock

53.1 Four kinds of shock

There are several kinds of shock, but the nal mechanism in all of them is a fall in a patients cardiac output which reduces the supply of blood to his brain, kidneys, gut, liver, lungs, and muscles. His brain is the most sensitive of these organs. Hypovolaemic shock is our main concern here. A patients blood volume can fall because of. (1) Sudden bleeding, either external or internal. (2) The slow loss of plasma from his circulation due to burns or peritonitis. (3) The loss of extracellular uid as the result of vomiting, diarrhoea, intestinal obstruction or stulae. In theory, the treatment of all these kinds of shock is straightforwardrestore his blood volume with balanced electrolyte solutions or whole blood as appropriate. Section 14.3 of Primary Anaesthesia describes the treatment of surgical dehydration. Vasovagal shock or neurogenic shock is the result of a strong sensory or emotional stimulus which causes widespread vasodilation and bradycardia. Trauma, either severe or trivial, is one such stimulus. The patient may yawn, feel hot, sweat, and then lose consciousness. He breathes with slow deep sighs, he becomes cold and pale, his blood pressure falls, and he has a slow pulse. If he lowers his head or lies down, he rapidly recovers. Vasovagal attacks are common and normally harmless, but they can be important because: (1) Their symptoms can be added to those of hypovolaemic shock and make a patient seem worse than he really is. The critical sign is his pulse. If this is slow, suspect that there is a strong vasovagal component to his symptoms. (2) If vasovagal shock is added to hypovolaemia, he may collapse suddenly during the induction of anaesthesia. (3) Vasovagal shock can complicate such procedures as the manipulation of fractures. (4) If he remains seated upright during a vasovagal attack, his brain becomes anoxic and he may die. Septic shock is caused by bacteria releasing endotoxins which cause circulatory collapse, especially when antibiotics kill them in large numbers in a patients circulation when he is septicaemic. Although this might logically be considered in Volume One, with the surgery of sepsis, it is more conveniently included here. Cardiogenic shock has many medical causes, the most important one being cardiac infarction. There are also two important surgical causesbruising of the heart and cardiac tamponade (65.9), due to blood in the pericardial cavity.

This is rare but it is important because you can treat it. Dont transfuse a patient if he is in cardiogenic shock, unless there are other reasons for doing so. More uid in his circulation can weaken myocardial contractility and add to the work of his heart. There are difculties in diagnosing and managing hypovolaemic shock: (1) Diagnosing internal bleeding may not be easy, so (a) remember the possibility of an ectopic pregnancy, and (b) dont forget that shock developing after trauma may be due to bleeding into a patients peritoneal cavity or behind it, into his pleural cavities (65.4), or into the muscles round frac tures, particularly those of his pelvis or femur. He can die from bleeding into any of these places, without any blood appearing on the surface. (2) Shock is not the only cause of reduced consciousness in an injured patienthe may be drunk, drugged, concussed, hypoxic or hypoglycaemic; he may also be suffering from a head injury. Sometimes he is unconscious for more than one of these reasons-the combination of a head injury and abdominal bleeding is common. Finally, (3) dont diagnose an infarct without some positive evidence for it, such as precordial pain and no signs of any other cause of shock.

53.2 Hypovolaemic shock after an injury

A patient in hypovolaemic shock is intensely pale with cold extremities. The rst signs to suggest that insufcient blood is reaching his brain are drowsiness and withdrawal from his environment, although he can be deceptively alert and euphoric. As shock deepens he becomes agitated, delirious, and nally comatose. His pulse is rapid, and his blood pressure low. When you pinch one of his nails, its bed empties of blood and takes a long time to ll up. His breathing is fast and rapid. He is thirsty and acidotic, and he passes little urine. He has two main ways of compensating for the blood he loses: (1) He immediately constricts the vessels in his skin and gut. About 75% of the blood is in the veins, so venous constriction is particularly effective. (2) Later, he slowly absorbs the extracellular uid from his tissues, with the result that his skin loses its elasticity, and his eyes sink into their sockets. Although this maintains his blood volume, it dilutes his remaining red cells, so that his haemoglobin falls and he becomes anaemic over several days. Both these mechanisms have their limits. A normal adults blood volume is 80 ml/kg or about 5.5 litres. 1

53 Shock

THE VOLUME IN CHILDREN THEBLOOD BLOOD VOLUME IN CHILDREN

from nozzle
50

160 140 120 100 80

to succer

A
1213 yrs. 1011 yrs. 69 yrs.

25

35 yrs.
10

23 yrs. 1 yr.

B
60 610 mths. 40 20

These figures are approximate only, each bottle is 500 ml

Fig. 53.1: Fig. 53-1 THE BLOOD VOLUME IN CHILDREN. A, when you operate on a child, put a graduated test tube in your suction line. B, the loss of even a little blood can cause severe shock in a small child. Each one of these bottles contains 500 ml. After Brenda Vaughan.

Whether he goes into shock, or not, depends on how much blood he loses. If he loses 10% of it (500 ml) he is unlikely to show signs of shock, but if he loses 20% of it (a litre) he almost certainly will. Provided he loses less than a third of his blood volume (2 litres), he can usually maintain his blood pressure above 100 mm. If he loses half of it (about 3 litres) for more than a few minutes, he dies. So a shocked adult needs a transfusion of at least a litre, and if he is severely shocked he may need 3 litres. If he continues to bleed, he may need much more. A child has a smaller blood volume, so that a given loss is proportionately more serious in him.
BEWARE OF A CHILDS SMALL BLOOD VOLUME

When you try to decide how shocked a patient is, remember that: (1) His condition is never static. From moment to moment he will be getting better or worse. (2) Shock usually develops slowly over several hours, although it can develop rapidly. (3) A single sign may not be reliable, so use several. (4) His symptoms may be out of proportion to the volume of blood he has lost. A small loss may occasionally cause severe shock and vice versa. (5) A falling blood pressure is an unreliable sign, and occurs late. For example, the blood pressure of a child or young adult may not fall at all, until it nally falls catastrophically, when he has lost a third or more of his blood volume. Try to restore the blood volume before this happens. A rising pulse rate is an earlier and more reliable sign than a falling blood pressure. But even the pulse may not rise until late, particularly if the patient is old. A good pulse volume, a warm pink skin (if he is Caucasian), well lled veins, and a good urine output, are better signs of an adequate blood volume than a normal blood pressure. If a patients systolic blood pressure falls below 100 mm after an injury, he needs an infusion. If it falls below 80 mm he needs it urgently.
IN HYPOVOLAEMIA THE BLOOD PRESSURE MAY FALL LATE

Electrolyte solutions are useful replacements for lost blood. If a patient can only maintain his cardiac output, he can meet the oxygen demands of his tissues even if his haemoglobin falls as low as 8 g/dl. He is only likely to need a blood transfusion if: (1) He has lost 1000 ml of blood or more. Or, (2) his haemoglobin later falls below 10 g. If an adult is in severe hypovolaemic shock, give him a large volume (23 litres) of an electrolyte solution fast, preferably Ringers lactate, but if necessary 0.9% saline, or glucose saline. Then assess his needs by evaluating his clinical response. Unfortunately, these solutions will leave his circulation in an hour or two. Colloids like dextran stay in it longer; you can give him dextran 70 in 0.9% saline to replace up to 30% of his blood volume, or up to about 2 litres if he is an adult. Giving more may damage his kidneys. If possible, try to stop him bleeding, then restore his blood volume, and then operate on him. If he is bleeding externally, this it should not be difcult (55.1). If he is bleeding internally, resuscitate him as best you can, and then operate. He will probably need a laparotomy. He will not die from anaemia while you do this, but he may die from hypovolaemia. His blood pressure should be over 80 mm before surgery starts. Ideally, it should have remained over 100 mm for at least 20 minutes. But, if he does not respond to resuscitation, an immediate laparotomy is his only hope. For example, if he has ruptured his spleen, try to get your hand on his splenic pedicle as soon as you canbold action may save his life. You are like a person who is trying to ll a bath without rst putting in the plug. Somehow, you will have to put in the plug. Restoring a patients blood pressure is not a sufcient aim in itself. A good pulse volume, warm extremities, and a systolic pressure of only 70 mm, are better than a normal systolic pressure, cold extremities, and a rapid pulse. The surest way to know if you have given a patient enough uid is to put a catheter in his bladder, and to monitor his urine output. The common mistake is to underestimate the volume of blood that a patient has lost, and so to give him too little uid too slowly. You are unlikely to give a young healthy person too much uid before you realize that his circulation is normal. But in an old hypertensive or cardiac patient, be more cautious. You can precipitate cardiac failure before you have corrected his hypovolaemia. Ideally, such a patient needs a CVP monitor (A 19.2). Anaesthesia is dangerous if a patient is severely shocked (16.7), because he is only maintaining his blood pressure by severe vasconstriction; a general anaesthetic abolishes this, so does subarachnoid (spinal) anaesthesia in the lower half of the body. If he is desperately ill, local inltration anaesthesia may be best (A 5.4, A 6.7).
WHEN IN DOUBT INFUSE. OPERATE AS SOON AS A PATIENT IS FIT FOR SURGERY. THE COMMON MISTAKE IS NOT TO GIVE ENOUGH FLUID.

HYPOVOLAEMIC SHOCK This extends Section 51.3 on the care of a severely injured patient. You have diagnosed shock, and have already inserted an intravenous line.

53.2 Hypovolaemic shock after an injury

GRADING SHOCK

Degree of Shock None Slight Blood Pressure Normal To 20 per cent decrease Decreased 20 per cent to 40 per cent Decreased 40 per cent to non recordable Pulse Quality Normal Normal Temperature

Skin
Colour Circulation

Thirst Urine Output Normal Normal Mental state Normal Clear and distressed

Normal Cool

Normal Pale

Normal Denite slowing Denite slowing

Normal Normal

Moderate

Denite decrease in volume Weak to imperceptible

Cool

Pale

Denite

Reduced

Clear and some apathy unless stimulated Apathetic to comatose; little distress except thirst

Severe

Cold

Ashen to cyanotic mottling

Very sluggish

Severe

Oliguria

Fig. 53.2: GRADING HYPOVOLAEMIC SHOCK Dont rely on one sign only, use as many as you can. Measure the patients blood pressure, and the rate and quality of his pulse; assess the colour of his skin; ask him if he is thirsty, assess his mental state. Later, his urine volume will be the best guide. From the Field Surgery Pocket Book, with the kind permission of Guy Blackburn.

MINIMIZING SHOCK These things make hypovolaemic shock worse, so try to avoid them: (1) Rough handling. (2) Prolonged or rough operating, including (a) the repeated vigorous manipulation of fractures, (b) the prolonged handling of gut through too small an incision, (c) too many operations on the day of the injury. (3) Ignoring intraoperative bleeding by failing to use warm packs, or to tie or clamp bleeding vessels. (4) Associated dehydration due to severe vomiting, diarrhoea, or sweating. (5) Warming a patient with hot water bottles or shock cradles. Warmth may overcome the vasoconstriction that he needs to maintain his circulation, so dont let a shocked patient get too warm. Instead, put a blanket over him to prevent him losing heat and actually getting cold. SOME INJURIES DO NOT CAUSE SHOCK, so that if a patient has one of them and is shocked, suspect that it is not the cause of his shock and that he has some other injury also, probably an abdominal one. Injuries which do not by themselves cause shock include: (1) Any minor injury. (2) Head injuries. (3) Maxillofacial injuries. IMMEDIATE TREATMENT Raise the patients legs at right angles to his body. The blood in them will give him an autotransfusion and increase the venous return to his heart. Dont tilt him with his head down because: (1) It is uncomfortable. (2) It causes cererebral congestion, and (3) it impairs the movement of his diaphragm. HOW SHOCKED IS HE? Dont rely on one sign only, use as many as you can. Apply the rules Fig. 53-2. Measure his blood pressure, and the rate and quality of his pulse; assess the colour of his skin; ask him if he is thirsty, assess his mental state. Later, his urine volume will be the best guide. Feel the warmth and wetness of his forehead and hands. Are his hands or his nose cold? If his feet are cold, how far

up his legs does the coldness go? If he is cold below the knee, he has lost 30% of his blood volume. How full are his peripheral veins? Judge this from two signs: (1) Empty any convenient supercial vein by pressing it between two of your ngers. Remove your distal nger, and see how fast the empty vein lls up. (2) Look at the veins on the dorsum of his ankle. If they are invisible through a white skin, he is likely to be in hypovolaemic shock. This sign is less valuable in a dark one. What is the capillary pressure in his nail beds? Press the blood out of one of them. How quickly does it ll up? What is the pressure of his interstitial uid? Look for: (1) sunken eyes, (2) loss of skin elasticity, (3) lowered eyeball tension, and (4) in severe cases, a Hippocratic facies. These are late signs. If his respiration is shallow and rapid (air hunger), he is severely shocked. If possible, and if you are sufciently skilled, insert a central venous line (A 19.2) and measure his central venous pressure (CVP). This will be useful for monitoring treatment. CAUTION! (1) A falling blood pressure is a late sign of increasing shock. (2) Dont give him vasopressor drugs. HOW MUCH BLOOD HAS HE LOST EXTERNALLY? A patients history will be of some help. On the oor or on his clothes 100 ml of blood covers about a thousand square centimetres, or one square foot. A litre covers about a square metre (or square yard). HOW MUCH BLOOD HAS HE LOST INTERNALLY? The volume of your st is about 500 ml (one unit of blood or uid). For each mass of soft tissue swelling equal to this, he needs a unit of replacement uid. Fractures cause approximately the following blood loss. Upper limb fractures 1 unit. Tibia and bula 2 units. Femur 1.5 units. Pelvis or multiple fractured ribs 2 to 6 units. For each rib fracture you can see on the Xray, estimate 100 ml. If a fracture is open, add another 0.5 to 1 unit. A patients abdomen or thorax can hold 3 litres 3

53 Shock

of blood or more. If he has multiple injuries he can thus lose much blood. CAUTION! (1) Lost blood need not reach the surface. (2) The loss of only a few hundred millilitres may be fatal in a small child, as in Fig. 53-1.

DOES THE SEVERITY OF HIS SHOCK MATCH THE VOLUME OF BLOOD HE HAS LOST? Perhaps the patient has a fractured forearm and a fractured femur with an average sized haematoma, yet a litre of blood does not resuscitate him. He probably lost more blood externally at the site of the accident, or he has lost it into his abdomen or chest. If he has a fast pulse and a low blood pressure with only a small wound, suspect that he has some serious internal injury, or, if a day or two has passed since the accident, some massive infection or gas gangrene.

BLOOD TRANSFUSION If you are fortunate enough to be able to give more than 4 units, warm them. The only safe way to do this is to t two drips sets together and lead the cooled tubes through a water bath at 37 C measured with a thermometer. Too much cold blood may cause ventricular brilation. After you have given 12 units of blood, give him 5 ml of a 10% solution of calcium chloride, or 10 ml of a 10% solution of calcium gluconate for every 3 or 4 units of blood you transfuse.

FLUID BALANCE CHART Start this (A 15.5).

WHEN HAVE YOU GIVEN ENOUGH FLUID TO A SEVERELY SHOCKED PATIENT? (1) Monitor his skin temperature. If you have transfused him adequately, his skin will become warm, dry, and pink (of he is Caucasion), instead of being cold, damp and white. His nail beds now ll up again after you have emptied them and his nose becomes warm. These signs may sometimes be delayed, even if transfusion is satisfactory. (2) A normal blood pressure is a good sign, but perfusion can be inadequate, even if it is normal. (3) An adults urine ow should be at least 20 ml/hour, and preferably 30 to 60 ml (1 ml/kg hour).

THE MANAGEMENT OF A PATIENT IN HYPOVOLAEMIC SHOCK This follows on from Section 51.3. You have taken blood for cross matching, and set up at least one good intravenous line, by the methods in A 15.2. If the patient is bleeding externally, you have controlled it (55.1). He is receiving oxygen. His management during (A 4.4) and after the operation (A 4.5), or when burns (58.4) or dehydration (A 15.3) are causing his shock, are described elsewhere.

CATHETER Insert an indwelling catheter and attach it to a urine bag. Or, collect his urine in a 250 ml plastic measuring cylinder. If you suspect a urethral injury, insert the catheter suprapubically (68.1). An adequate urine output will be the most useful indication that you have treated his hypovolaemic shock adequately. Examine the rst urine from this catheter. Look especially for blood, and if possible culture it. If, later, no urine appears in the bag, make sure: (1) that the catheter is not kinked, and (2) that the inlet spigot has been removed from the bag. If the catheter only produces a little urine and some blood, suspect that he has a bladder or urethral injury (68.1).

ESTIMATING ESTIMATING ESTIMATING BLOOD LOSS BLOOD LOSS BLOOD LOSS

2 ll 0.5 l 0.5

thevolume the volume of your fist of your fist is about is about 500 ml 500 ml
2l 2

250 250 ml ml

1.5 l 1.5

HOW MUCH FLUID SHOULD YOU GIVE HIM AND HOW FAST? A severely shocked patient must have an effective intravenous line (A 15.2), if necessary, from two drops. If possible, replace the volume of blood you calculate he has lost. In very severe hypovolaemia give him a litre in 5 minutes. If he is shocked enough to have air hunger and a blood pressure less than 60 mm, he will need 2 or 3 litres. If he is reasonably young, transfuse him at the most rapid convenient rate until the signs of shock go. If he is old, or hypertensive, or has vascular or coronary disease, give him repeated rapid transfusions of about 100 ml, watching his jugular venous pressure carefully between each transfusion. Do this until there are signs that his cardiac output is normal. A change in his JVP or CVP is more important than its absolute value. Listen to the bases of his lungs for crepitations. 4

100 ml of blood 100 ml of blood cover an area cover an area of floor floor about of about 30 square 30cm cm square

1 ll

Fig. 53.3: ESTIMATING BLOOD LOSS. When you examine an injured patient, try to estimate how much blood he has lost. The volume of your st is about 500 ml (one unit of blood or uid). For each mass of soft tissue swelling equal to this, he needs a unit of replacement uid. For each rib fracture you can see on the Xray, estimate 100 ml. If a fracture is open, add another 0.5 to 1 unit. A patients abdomen or thorax can hold 3 litres 0f blood or more. If he has multiple injuries he can thus lose much blood. After Hamilton Bailey, with the kind permission of Hugh Dudley.

53.3 Renal failure after an injury

If you have transfused him adequately, it should reach this value very soon after the injury. CAUTION! Watch for: (1) A rose on his jugular venous pressure. (2) Basal crepitations.

53.3 Renal failure after an injury

If you dont transfuse a patient in severe hypovolaemic shock rapidly and adequately, he either dies immediately, or the cortices of his kidneys necrose so that his kidneys fail. Posttraumatic renal failure is thus the major complication of hypovolaemic shock. Although a period of acute hypovolaemia can injure his lungs, his heart or his liver, it is its effect on his kidneys that is so marked and so preventable. The more severe his hypovolaemia and the longer it lasts, the more likely are his kidneys to stop working and shed their tubular cells. If they do, days or weeks may elapse before they start working again. During this time he can die from uraemia, potassium intoxication, or infection. Prevent these disasters by treating hypovolaemic shock quickly. In good units post traumatic renal failure has almost disappeared, but preventing it may require 50 units of blood. It can also complicate extensive burns, crush injuries, severe muscle wounds (especially if they are heavily infected), or transfusion reactions. If a patient passes no urine, suspect that his catheter is kinked or blocked, or that his urinary tract is obstructed. If he passes less than 20 ml an hour (for a child, see Fig. 586), suspect that he has post traumatic renal failure. Before diagnosing it, consider these other possibilities: (1) He may still be hypotensioe due to hypovolaemia. If his blood pressure is still below 80mm, or his peripheral circulation is still severely constricted, his glomerular ltration rate will be low. If you correct his hypovolaemia and restore his blood pressure, his urine output may increase, but only provided that hypotension has not lasted long enough to damage his kidneys. (2) He is showing the metabolic response to injury. If his urine output is low, look for signs of hypovolaemia and renal failure. If you have excluded these, his urine output may be low because of the metabolic response to trauma due to increased antidiuretic hormone secretion. This may reduce his urine output for 836 hours. Dont rely on this diagnosis unless his condition is stable in other respects, his urine is chemically normal and its specic gravity is high. The practical consequence of this is that you should not infuse more uid to increase his urine output if all other signs are satisfactory. If you have excluded these two conditions, and a patient has passed less than 20 ml/hour of urine for 12 hours, he probably has acute post traumatic renal failure. Diagnose it early, before his blood urea starts to rise, by monitoring his urine output. His kidneys are probably failing if: (1) The specic gravity of his urine is less than 1016 in the absence of glycosuria or albuminuria, or (2) there is pigment or protein in his urine, whatever its specic gravity. If he recovers, he will go through two phases: (1) An oliguric phase during which his kidneys cannot correct for his water and electrolyte intake, so you will have to restrict these for him. While he is oliguric, one of his dangers is that too much potassium will enter his plasma from dead or dying tissues, so try to minimize this. Unfortunately, you cannot diagnose the earlier phases of hyperkalaemia clinically. Dont give him potassium containing solutions such as Darrows solution or Ringers lactate in this phase. It may be followed gradually or suddenly by the next one. (2) A phase of diuresis, during which he may pass 6 to 9 litres of urine a day, regardless of his uid intake. While 5

IF YOU ARE MONITORING A PATIENTS CVP, when he is oligaemic, you can give him uid safely and rapidly until it rises 12 cm of water. If his CVP is over 15 cm, you are overtransfusing him, or he has a failing heart. If his CVP rises, but his blood pressure and peripheral circulation do not improve, give him isoprenaline 0.5 to 10 micrograms/minute by intravenous infusion.

METABOLIC ACIDOSIS If a patient is severely shocked he will be acidotic. So give an adult 100 mmol of sodium bicarbonate, and another 50 mmol an hour or two later if necessary (A 15.1).

HOW WELL DOES THE PATIENT RESPOND TO TRANSFUSION? Shock from a fractured femur or a bleeding limb responds rapidly. If a patients shock does not respond, suspect an abdominal or thoracic injury.

LATER MANAGEMENT For the care of hypovolaemia during and after the operation, see Primary Anaesthesia 5.4 and 5.5.

DIFFICULTIES WITH HYPOVOLAEMIC SHOCK If you are in DOUBT AS TO THE CAUSE OF A PATIENTS SHOCK, and he is t enough, prop him up with his legs horizontal and his trunk at 45 . His neck veins should not be visibly distended. If they are, his jugular venous pressure is raised. He probably has some medical condition, or a bruised heart, or cardiac tamponade, or overtransfusion. If you can see an upper level on the blood on his neck veins, estimate how many centimetres it is above his sternal angle. If his BLOOD PRESSURE FAILS TO RISE: (1) You have probably failed to give him enough uid. (2) He may have been on shock too long. (3) He may have acute adrenocorticosteroid lack due to previous steroid therapy. Thos will weaken the response of his adrenal cortex to stress. Or, he may have some other cause of adrenocortical insufency. If his VENOUS PRESSURE AND HIS PULSE RATE RISE, he has BASAL CREPITATIONS, PERIORBITAL OEDEMA AND A HEADACHE, you have given him too much uid. The more usual mistake is to give him too little. Slow down the infusion, give an adult 40 to 80 mg of frusemide intravenously. If his kidneys are working normally, he will then have a massive diuresis. If necessary repeat the frusemide after 6 hours.

A SHOCKED PATIENT MUST HAVE A CATHETER IN HIS BLADDER

53 Shock

this phase lasts, he is in danger of losing electrolytes. So replace them, and the water he loses. One difculty is knowing when to stop giving him large volumes of uid. If you go on giving them, he has to go on excreting them, so you wont know if he needs them or not!

OTHER MEASURES Give him 20 ml of 50% glucose with 10 units of soluble insulin into a large vein, preferably his vena cava, repeated 6 hourly (19.2). THE DIURETIC PHASE OF POST TRAUMATIC RENAL FAILURE Every 24 hours during this phase give him 1500 ml of uid plus his urine output for the previous 24 hours. Give him a litre of 0.9% saline and a litre of 5% dextrose and the balance as half strength Darrows solution. This contains 17 mmol/l of potassium. The normal potassium requirements are about 35 mmol/daily. He may need 6 to 10 litres of uid a day. If his urine specic gravity is still very low at 4 days, you are probably keeping his diuresis going by overinfusing him. Try cautiously reducing his uid intake. CAUTION! Dont start protein feeding until he is passing at least 1500 ml of urine a day, and his blood urea is below 25 mmols (250 mg/dl). Starting it too early increases the danger of uraemic complications.

POST TRAUMATIC RENAL FAILURE

If possible, refer the patient. If you cannot refer him, treat him like this. THE OLIGURIC PHASE OF POST TRAUMATIC RENAL FAILURE CORRECT THE CAUSE For example, correct any hypovolaemia, treat a burn, or severe muscle injury. Even if you can refer him, do this rst. CORRECT HIS INITIAL WATER AND ELECTROLYTE DEFICIT Chart the water and electrolytes he has lost and those he has been given. Correct his calculated water and electrolyte decit before you start the period of uid restriction. RESTRICT HIS WATER AND ELECTROLYTES Give him his measured output of water, plus an estimate of his insensible loss. Give it as water by mouth, or intravenously as 5% dextrose. Dont give him any solutions containing electrolytes, except those necessary to replenish his losses, because he cannot excrete them. His measured output is the total volume of his urine, and any vomit, or watery diarrhoea. His insensible loss in a temperate climate will be about 500 ml, in the tropics it may be 1000 ml or more. CAUTION! (1) Dont include blood, plasma, or plasma substitutes in these estimates. (2) Dont allow his thirst to inuence the volume of his intake. Watch that he does not over hydrate himself. (3) The dose of many antibiotics, especially gentamicin, needs to be modied in the presence of renal failure. (4) Dont give him diuretics. WEIGH HIM If possible, do this daily. He should lose about 500 g daily after his initial uid replacement. If he gains weight, he is retaining uid and is being over hydrated. MINIMIZE THE RISE OF HIS PLASMA POTASSIUM (1) Remove all dead and dying tissue with a really thorough wound toilet. (2) Avoid hypoxia. If he needs an anaesthetic, try to use local anaesthesia. (3) Dont give him potassium in any form. There is potassium in milk and orange juice, barrows and Ringers lactate, in soup and meat, and in many drugs. (4) Minimize catabolism with a high energy no protein diet. HIGH ENERGY NO PROTEIN DIET If he has no nausea, gastric suction, or intestinal lesions, try to to give him at least 400 g of glucose or lactose, or, failing these, sucrose, daily by mouth or by nasogastric tube. This will give him 6.7 MJ (1,600 kcal). 6

53.4 Septic shock

Although septic shock might be considered out of place in a system of traumatology, it is more conveniently discussed with other kinds of shock, than with the surgery of sepsis. This is the draining of pus from the many sites in which it can collect, and is described in Chapters 5 to 8 of Volume One. Septic shock is a common cause of surgical death. Once it has developed, a patient has a 50% chance of death, even in a good unit. His outlook is better if he is young and his history is short. It is the result of the release of endotoxins from lysed bacteria, especially Gram negative bacilli, into his circulation. It is not the same as septicaemia caused by intact living bacteria. Provided the bacteria remain intact, a patient can be septicaemic without being shocked. Septic shock usually starts suddenly. The drop in a patients blood pressure may be castastrophic. He may be disoriented, confused, delirious, or comatose. He breathes rapidly. His blood pressure is low. He is always febrile, and his pulse is fast. A characteristic sign is a high rectal (or vaginal) temperature and cold extremities. A patient in septic shock is acidotic and breathes deeply and rapidly. He may have diarrhoea and ileus simultaneously. He is usually jaundiced, is often anaemic, and passes little or no urine (a bad sign). He may develop DIC (disseminated intravascular coagulation), and bleed from a wound, from his nose, or his gut, or into his urine. His heart, lungs and kidneys may fail, causing pulmonary oedema and oliguria. There are two kindswarm and cold; the cold may follow the warm: (1) In the less common, less lethal warm kind, typically caused by Gram positive cocci, the patient has warm, pink (if he is Caucasian) extremities, a large pulse pressure and a bounding pulse. (2) In the more common and even more dangerous cold kind, usually caused by Gram negative bacilli, he has cold and clammy extremities. Suspect that a patient is in septic shock if he is already infected and suddenly becomes severely ill and hypotensive. The source of his infection can be peritonitis (6.2), septic abortion (16.3), infected bums (58.23), the transfusion of infected blood, pyaemia, or the instrumentation of an infected

53.4 Septic shock

bladder (22.8). Or, his infection may be hidden, and make diagnosis difcult. Treatment is urgent. The rst consideration is to give him uids, and to adjust the volumes you give to his urine output. Measuring his CVP is not useful, even if you can measure it, because he can develop pulmonary oedema when it is in the normal range. SEPTIC SHOCK Take blood cultures, and culture pus from any septic lesion. OXYGEN Give the patient oxygen through a mask. NURSING Tepid sponging will comfort him. Dont let him develop hyperpyrexia. ANTIBIOTICS Give him large doses of not less than three bactericidal antibiotics, if possible intravenously, as a bolus injection. Choices include: (1) Benzyl penicillin 510 megaunits 4-hourly with chloramphenicol 1 g 6-hourly, or streptomycin 500 mg 6-hourly. (2) Gentamicin 2 to 5 mg/kg daily by intramuscular or slow intravenous injection in divided doses every 8 hours. In renal failure increase the interval between the doses. (3) Methicillin 1 g by intramuscular or slow intravenous injection 4 to 6 hourly. (4) Kanamycin 1530 mg/kg daily by slow intravenous injection in divided doses every 812 hours. (5) Cephaloridine 0.51 g every 812 hours by intramuscular or slow intravenous injection. The maximum dose is 6 g daily, or 4 g in patients over 50 or within 2 days of surgery. Give children 20 to 40 mg/kg daily in divided doses, to a maximum of 4 g. (3) Metronidazole for anaerobes. By mouth 400 mg 8-hourly. By rectum 1 g 8hourly for 3 days then 1 g 12-hourly. Intravenously give 500

mg 8 hourly up to 7 days. Give a child 7.5 mg/kg 8-hourly by any route. WHICH INTRAVENOUS FLUID? Be guided by his serum electrolytes. If you cannot measure these, give him 0.9% saline, 5% dextrose in 0.9% saline, Ringers lactate, or Darrrows solution. Hyponatraemia is common, so 5% dextrose alone is unsafe. He would probably also benet from a colloid such as dextran. HOW MUCH FLUID? He may need as much as 50 ml/kg/24hrs in addition to his normal daily water requirements in Fig. 58.6. An adult may need 6 litres in 24 hours. Be guided by his hourly urine output. Aim for a urine output of at least 30 ml/hr. If he develops pulmonary oedema, give him frusemide 100200 mg two or three times daily. If possible, watch his sodium and especially his potassium level and correct them If he develops into acute left ventricular failure, give him digoxin 0.5 mg, repeated as necessary. If an electrocardiogram is available, use it as a guide to therapy. If not, count his pulse and apex beat together. If he has a pulse decit, you are over digitalizing him. OTHER DRUGS After you have given him adequate uids, consider giving him the following drugs, they are not so important as giving him adequate uids. Dopamine which will increase his cardiac output and tissue perfusion. Give him 1 to 4 micrograms/kg/min. To give this dissolve 4 mg in 500 ml of uid. Chlorpromazine which may relieve his peripheral vasoconstriction. If his extremities are cold and clammy give him chlorpromazine 0.5 mg/kg. Steroids are of doubtful value. Give him dexamethazone 50 mg (or its equivalent) intravenously, and repeat this every 46 hours. DRAIN PUS if you can drain the septic focus, do so. Timing is important: he must be t enough to stand the procedure, so overcome shock rst. Do the simplest possible operation. This will need courage because he will be very ill, and he may not survive it. It may however save his life. You may need to evacuate a septic abortion, drain a pelvic or subphrenic abscess, or re-explore his abdomen.

SEPTIC SHOCK
fever deep rapid breathing

burns

peritonitis

septic abortion

catheter warm bounding pulse

Fig. 53.4: SOME SITES OF INFECTION IN SEPTIC SHOCK. Septic shock usually starts suddenly. The drop in a patients blood pressure may be castastrophic. He (or she) may be disoriented, confused, delirious, or comatose. A patient in septic shock breathes rapidly, his blood pressure is low, he is always febrile, and his pulse is Fast. Kindly contributed by Samiran Nundy.