Other considerations

Most of the above pertains to the most common cause of shock in a trauma patient, haemorrhagic shock. Other causes include cardiogenic shock, neurogenic

TABLE 3 Circulation and shock

Circulation: knowledge & skills

Facility level

Assessment and external control of haemorrhage

Basic

GP

Specialist

Tertiary

Assessment of shock

E

E

E

E

Compression for control of haemorrhage

E

E

E

E

Arterial tourniquet in extreme situations

E

E

E

E

Splinting of fractures for haemorrhage control

E

E

E

E

Deep interfascial packing for severe wounds (e.g. landmine)

D

E

E

E

Pelvic wrap for haemorrhage control

D

E

E

E

Fluid resuscitation

Knowledge of fluid resuscitation

D

E

E

E

Peripheral percutaneous intravenous access

D

E

E

E

Peripheral cutdown access

D

E

E

E

Central venous access for fluid administration

I

D

E

E

Intraosseous access for children under 5 years

D

D

E

E

Transfusion knowledge and skills

I

E

E

E

Monitoring

Knowledge of resuscitation parameters

D

E

E

E

More advanced monitoring (central venous pressure)

I

D

D

D

More advanced monitoring (right heart)

I

I

D

D

Other

Differential diagnosis of causes of shock

D

E

E

E

Use of pressors in neurogenic (spinal) shock

I

D

D

D

Use of fluids and antibiotics for septic shock

I

E

E

E

Recognition of hypothermia

E

E

E

E

External rewarming in hypothermia

E

E

E

E

Use of warmed fluids

I

D

E

E

Knowledge of core rewarming

I

D

E

E

TABLE 3 Continued

Circulation: equipment & supplies

Facility level

Assessment and external control of haemorrhage

Basic

GP

Specialist

Tertiary

Clock or watch with second hand

E

E

E

E

Stethoscope

E

E

E

E

Blood pressure (BP) cuff

E

E

E

E

Gauze and bandages

E

E

E

E

Arterial tourniquet in extreme situations

E

E

E

E

Fluid resuscitation

Crystalloid

D

E

E

E

Colloids

D

D

D

D

Blood transfusion capabilities

I

E

E

E

Intravenous infusion set (lines and cannulas)

D

E

E

E

Intraosseous needle or equivalent

D

D

E

E

Central venous lines

I

D

E

E

Monitoring

Stethoscope

E

E

E

E

Blood pressure (BP) cuff

E

E

E

E

Urinary catheter

D

E

E

E

Electronic cardiac monitoring

I

D

D

D

Monitoring of central venous pressure

I

D

D

D

Right-heart catheterization

I

I

D

D

Laboratory facilities for haemoglobin or haematocrit

D

E

E

E

Laboratory facilities for electrolytes, lactate and arterial blood gases

I

D

D

D

Other

Pressors (for neurogenic/spinal shock)

I

D

D

D

Nasogastric (NG) tube

D

E

E

E

Thermometer

E

E

E

E

Fluid warmers

I

D

D

D

Weighing scale for children

D

E

E

E

(or spinal) shock and septic shock. The ability to recognize these other causes of shock is deemed essential at all hospital levels. Cardiogenic shock is covered further under chest injuries. The ability to treat neurogenic shock appropriately with fluid resuscitation and pressors is deemed desirable at all hospital levels. It is not deemed essential because of the infrequency of neurological/spinal injury and because of the cost needed to adequately train both medical and nursing staff in the safe administration of pressors by continuous IV drip. The ability to treat septic shock with antibiotics, fluid resuscitation and other supportive care is deemed essential at all hospital levels. Appropriate treatment of source of infection and underlying injury is covered further in several of the following sections.

Many patients in shock develop an ileus and are at risk of vomiting and aspiration of gastric contents. Hence, the availability of nasogastric (NG) tubes and the skills to insert them are deemed essential at all hospital levels.

Hypothermia is a frequent complication of shock. The ability to recognize this and to treat it with external rewarming is deemed essential at all levels. Capabilities to provide warmed fluids and gases, as well as other means of rewarming the body core, such as lavage via urinary catheters, nasogastric tube or intraperi-toneal catheter, are considered desirable at all hospital levels.

Weighing scales for children, in order to more accurately calculate fluid requirements, are considered essential at all hospital levels and desirable at the basic level.

0 0

Post a comment