Reposição Volemica No Trauma

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Reposio Volemica No Trauma

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  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Reposio Volmica no TraumaProf Dr Fabrcio Bastos

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Cenrio domingo e passa um pouco do meio-dia. O dia est ensolarado e a temperatura 18C. Ao sair do carro no estacionamento de um shopping, voc ouve um grande estrondo. Virando-se, v um motociclista voando e caindo na frente de um carro parado.

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *CenrioAparentemente o carro estava parado, esperando para entrar no estacionamento, quando a moto bateu na sua lateral a cerca de 70 km/h. O motociclista foi ejetado e caiu na frente do carro.

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Cenrio: Exame PrimrioAlerta, agitado, demora para responderEst tremendo, plidoFreqncia respiratria um pouco acima do normalPele fria; pulso radial acima de 100 bpm

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Cenrio: Exame PrimrioH evidncias de choque?Classificao do Choque Hemorrgico

    Classe IClasse IIClasse IIIClasse IVQuantidade de sangue perdido(% do volume total de sangue)< 750 mL(15%)750 1500 mL(15% - 30%)1500 2000 mL(30% - 40%)> 2000 mL (>40%)Freqncia cardaca (bpm)Normal ou pouco aumentada> 100> 120> 140Freqncia ventilatria (vpm)Normal20 3030 40> 35Presso arterial sistlica (mm Hg)NormalNormalDiminudaMuito diminudaDbito urinrio (mL/hora)Normal20 - 305 15MnimoModificado de American College of Surgeons Committee: Advanced Trauma Life Support for doctors, student course manual, 7th ed., Chicago, 2004, ACS.

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Cenrio: Pensamento CrticoO que est acontecendo com esta vtima?

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *ChoqueEstado de hipoperfuso celular generalizada, que leva a oxigenao celular inadequada para as necessidades metablicasTolerncia dos rgos isquemia

    rgoTempo de isquemia quenteCorao, crebro, pulmes4 6 minutosRins, fgado, trato gastrointestinal45 90 minutosMsculo, osso, pele4 6 horas

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *HipoperfusoA vtima est perdendo sanguePerder sangue significa ter menos hemcias circulando pelos leitos capilares, para levar oxignio s clulasA falta de oxignio prejudica o metabolismo

    Cada hemcia importante!

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Cenrio: Pensamento CrticoO que est acontecendo com esta vtima?O uso de ATP (energia) produz calorComo tem falta de ATP (energia), a vtima no produz tanto calorMesmo com temperatura amena, a vtima est perdendo calor para o ambiente e no pode compensar a perdaA vtima est usando o pouco ATP (energia) que produz para tremer e est produzindo cido ltico, pelo metabolismo anaerbicoA hipotermia prejudica a coagulao sangunea

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Cenrio: Pensamento CrticoO que est acontecendo com esta vtima?Est entrando numa espiral descendentePrecisa de sua ajudaO que voc pode fazer por esta vtima, enquanto no chega o resgate?

    Tolerncia dos rgos isquemia

    rgoTempo de isquemia quenteCorao, crebro, pulmes4 6 minutosRins, fgado, trato gastrointestinal45 90 minutosMsculo, osso, pele4 6 horas

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Fisiopatologia do ChoqueAlteraes da microcirculaoPrecoces: os esfncteres pr- e ps-capilares fecham-se, causando isquemiaCom o aumento da acidose: os esfncteres pr-capilares relaxam, mas os esfncteres ps-capilares permanecem fechados, causando estagnaoFinalmente: os esfncteres ps-capilares tambm relaxam, ocorrendo a depurao (washout), com liberao de micrombolos e agravamento da acidose

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Cenrio: Exame SecundrioChegou ao local uma equipe de suporte bsicoAchadosFC = 124 bpmFR = 28 vpmPA = 124/86 mm HgDeformidadesFmur bilateralmero direito

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Tratamento do ChoqueQuatro questes ajudam a orientar a reanimaoQual a causa de choque nesta vtima?Qual o tratamento para este tipo de choque?Onde pode ser feito esse tratamento?O que pode ser feito at que a vtima chegue ao local de tratamento definitivo?Um pescador foi atingido por uma lancha e teve leso grave de membros inferiores. A sua vida foi salva por um socorrista que aplicou torniquete em ambas as coxas.

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Circulao: Reposio VolmicaPor qu repor volume?Controvrsias e desvantagensreas de investigao

    Trade letal:HIPOTERMIAACIDOSECOAGULOPATIA

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Circulao: Reposio VolmicaRecomendao atualChoque classes II, III e IVAdministrao inicial rpida de 1000 a 2000 mL de Ringer lactato aquecido a 39C ***Vtimas que recebem grandes volumes de cristalide necessitam de maiores quantidades de CH na cirurgia????Hipotenso Permissiva - Manter a PA sistlica entre 85 e 90 mm Hg

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Consideraes sobre o TransporteTransporte rpido no significa pegar de qualquer jeito e sair correndo (scoop and run)A temperatura ambiente na cabine deve ser 29CTransporte prolongado

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Cenrio: ReavaliaoA caminho do pronto-socorro, os socorristas puncionaram uma veia. A presso arterial subiu com um soro rpido, mas caiu logo a seguirQual o significado desta resposta?

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *ReavaliaoA reposio volmica pode ter trs tipos de resposta:RpidaTransitriaMnima ou nenhuma

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Reposio VolmicaControle de Danos alternativa em casos de perda sangunea macia? 2002

    Uso de soluo de NaCl hipertnica? 2005

    Reposio 1:1:1? CH: CP: PFCGuia para o Uso de Hemocomponentes, MS. 2008

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Reposio VolmicaRessuscitacao com formula 1:1:1 CH:CP:

    Fibrinogenio ao inves de plasma

    Protocolos para transfusao macica

    Anti fibrinoliticos cido Tranexmico (Transamin) em substituio ao PFCNASCIMENTO, B.; CALLUM, J.; RIZOLI, S.

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Cenrio: EvoluoAvaliao no pronto-socorroTrauma ortopdicoLeso de rim e de bao de tratamento no operatrioCirurgia ortopdicaRecuperao sem complicaes

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide *Reposio VolmicaAinda um assunto polmico e com diversas controvrsias.

    NO TEMOS UM VENCEDOR NESTA ARENA AINDA!!!

    Copyright 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

  • Slide *Obrigado pela Ateno!!!fabriciojsbastos@yahoo.com.br

    ****Key Points:Additional information not obvious from the video clip:Breathing is slightly faster than normalSkin is coolRadial pulse is faster than 100*Key Points:Assessment is a process of seeking evidence of potential problems, including evidence of shock. Participants should note the following:The patient is awake and able to speak (LOC, airway, breathing)The patient has been described as shivering (general impression)The patient is pale (general impression)The patient is agitated and slightly confused (LOC)While these findings could have alternative explanations, based on the mechanism of injury, shock is extremely likely and will kill the patient more quickly than any other potential cause. The patient should be assumed to be in shock at this point.*Key Points:Understanding what is happening to the patient is critical to understanding how shock kills and what EMS providers must do to intervene in the process. Signs and symptoms of shock are related to the pathophysiological process of shock and the bodys attempt to compensate for the pathophysiological changes.

    Transition:Discussion of pathophysiology follows.*Instructor Notes:It is critical that participants understand this basic definition of shock.

    Key Points:The patient is in shock. This means that his cells are not receiving enough oxygen to produce an adequate amount of energy for them to function.*Key Points:Loss of blood volume means oxygen cannot be delivered to the cells.Inadequate cellular oxygenation impairs metabolism.*Key Points:Blood loss is also heat loss. Without ATP the patient cannot produce heat to balance the heat loss associated with blood loss and the normal loss of heat to the environment. The bodys attempts to maintain its temperature is increasing the need for oxygen and resulting in increased anaerobic metabolism and worsening acidosis.Hypothermia impairs the ability of the blood to clot so that hemorrhage continues. The on-going hemorrhage worsens hypothermia and acidosis.

    *Key Points:Keeping the patient warm is critical, but often overlooked.Transition:A discussion of classifications of shock follows.*Key Points:There are three phases of shock at the capillary level: ischemic, stagnant, and washout.Blood flow to the tissues is controlled by sphincter muscles at both ends of the capillary beds that perfuse the tissues.The precapillary sphincter controls the flow of blood into the tissues. The postcapillary sphincter controls the flow of blood out of the tissues.Early in shock, both sphincters constrict to divert blood away from peripheral tissues into the core of the body in order to perfuse vital organs.This causes ischemia (lack of blood flow) in the tissues, which must then produce energy anaerobically.The acidosis produced by anaerobic metabolism causes the precapillary sphincters to fail so that blood flows into the capillary bed, but cannot flow out. The blood is then stagnant in the capillary bed.Finally, as acidosis increases, the post-capillary sphincter also fails and the accumulated acidotic blood and microemboli (small blood clots formed in the stagnant blood) are released into the circulationSystemically, this increases acidosis and causes infarction of organs by microemboli*Additional information:The patients breath sounds are equal bilaterally and his abdomen is soft and nontender. His pelvis is stable. The patient is experiencing significant pain in the areas of deformity. This information is important in determining the cause of shock in this patient.

    Key Points:The patients vital signs provide important information about the amount of blood loss and where the patient is in the shock continuum.The presence of multiple major fractures is significant for hemorrhage.Absence of significant findings in the chest and abdomen and the fact that the patient has intact sensation make distributive and cardiogenic causes of shock unlikely.*Key Points:Four critical questions guide shock resuscitation.Assessment should simultaneously provide evidence that the patient is in shock and clues about what type of shock the patient is suffering from.Hemorrhagic shock is most common in trauma.*Key Points:Prehospital fluid resuscitation seems to make sense.Increased circulatory volume should improve circulation.But there is no evidence that fluid therapy in the prehospital setting improves survival.Moderate hypotension may be beneficial in reducing bleeding.Hemodilution and increased blood pressure may impair clotting.Transport is not delayed to gain vascular access and administer fluids.Blood is the fluid of choice, but impractical in prehospital care.AlternativesIsotonic crystalloidsShort-term volume expandersLactated Ringers preferredTraditionally, a 3:1 ratio of crystalloid solution to the amount of blood loss has guided resuscitation, but the end-points of prehospital resuscitation are not known.Hypertonic crystalloidsNo improvement in survival rate over isotonic crystalloidsAdvantageous in military settings where large volumes of fluid cannot be carriedSynthetic colloidsLarge protein molecules help maintain vascular volumeDrawbacks: cost, allergic reactions, interference with blood typing, transmission of infectious diseasesBlood substitutesClinical trials show promise, but there are drawbacks*Key Points:RecommendationsAdult patients in Classes II, III, or IV shock should receive an initial rapid bolus of 1000 to 2000 mL of warmed lactated Ringers solution.Ideal fluid temperature is 102 F (39 C)Pediatric patients should receive 20 mL/kgMaintain systolic blood pressure at 85 to 90 mm Hg or MAP of 60 to 65 mm Hg

    *Key Points:Patients must receive appropriate management without delay in transporting.The temperature of the patient compartment must meet the needs of the patient, not necessarily the needs of the crew.*Instructor Notes: Solicit responses from participants.*Key Points:A rapid return to normal vital signs and stabilization of the patients condition usually indicates that the patient has lost up to 20% of his blood volume but that hemorrhage has stopped. Surgery may still be necessary.An initial improvement followed by deterioration indicates 20% to 40% volume loss and on-going hemorrhage. The patient requires rapid surgical intervention.No change in condition after a rapid infusion of 1000 to 2000 mL of fluid indicates massive exsanguinating hemorrhage and the need for immediate surgical intervention to prevent death.*Key Points:A rapid return to normal vital signs and stabilization of the patients condition usually indicates that the patient has lost up to 20% of his blood volume...