The top culprit? Hemorrhage. It accounts for nearly 30% to 40% of trauma-related deaths. Fortunately, bleeding can be controlled with prompt management.
Join Hospital Procedures Consultants as we explore the primary treatments for administering resuscitation in shock patients.
Understanding the Grave Impact of Hemorrhagic Shock
Hemorrhagic shock is marked by a rapid loss of intravascular volume through blood loss. If left unchecked, it can result in hemodynamic instability, impaired oxygen delivery, inadequate tissue perfusion, cellular hypoxia, and ultimately organ damage.
It can be fatal—but resuscitation can help prevent and/or correct coagulopathy.
Before we look at specific strategies, it’s important to be familiar with mechanisms that contribute to trauma-induced coagulopathy (TIC): anticoagulation, consumption, platelet dysfunction, and hyperfibrinolysis.
Resuscitation 101: What You Should Know
The optimal resuscitative strategy is not clearly discussed in current medical literature, which can make it difficult to manage trauma patients with hemorrhagic shock.
But the good news is research offers a few best practices.
Fluid Therapy
In patients with traumatic shock, the first line of treatment focuses on fluid replacement for the normalization of hemodynamic parameters. However, one must look beyond blood pressure and urine output for guidance. Clinicians must also consider more sensitive markers that indicate the adequate restoration of perfusion such as Vo2 and lactate.
Crystalloids are commonly used, but in large volumes, they can make matters worse with an increased incidence of abdominal compartment syndrome and coagulopathy.
Colloids may be better options as they produce greater intravascular expansion per unit. The most sensible fluid to use in hemorrhagic shock is whole blood or O negative blood initially. Albumin, for example, can help with circulation. The use of hydroxyl ethyl starch may be up for debate though as it can result in significantly better lactate clearance and less renal injury. It can also be used with hypertonic saline for rapidly expanding blood volumes. However, it has been linked to a 3.8% chance of acute kidney injury (AKI) and a 3.2% chance of mortality.
To prepare for massive bleeding, secure a trauma line or central venous access via a cordis catheter. This is useful for large-volume fluid replacement such as massive transfusion protocol (MTP) hemodynamic monitoring, and the simultaneous administration of multiple solutions.
Alternatively, a large-bore IV peripheral cannula (14 or 16, gauge) can be considered. But, if this type of venous access is too difficult to establish during emergencies, intraosseous access can be a substitute.
Vasoactive Agents
Vasoactive agents can be employed as a pharmacological treatment to attenuate derangements in organ perfusion and oxygenation during shock. They are frequently necessary for increasing cardiac output and blood pressure while sustaining life.
Hence, a thorough understanding of vasoactive drugs is mandatory for clinicians.
Norepinephrine is the agent of choice in septic shocks. It is administered through a central catheter. Norepinephrine increases cardiac preload and contractility while improving microcirculation. An animal study also indicates that it can significantly improve survival. It should thus be used early on to quickly restore blood pressure.
Since strong vasopressors can worsen organ perfusion, clinicians should assess cardiac function during ultrasound examination while considering indications and techniques for achieving vascular access to minimize risks.
Hydrocortisone as an Adjunct
In a propensity score analysis, low-dose hydrocortisone was found to improve shock reversal irrespective of adrenal response to corticotropin. It also reduced the incidence of hospital-acquired pneumonia among intubated patients with multiple traumas.
That said, corticosteroids can bring about a multitude of side effects. They’ve been linked to significant increases in death with steroids, a relative risk of death, or severe disability. As such, it should not be routinely used.
Objectives of the Resuscitation in Shock Patients
Mean arterial pressure (MAP) is an important physiologic variable for effective hemodynamic monitoring which aims to maintain adequate tissue perfusion.
In patients with severe hemorrhage, early fluid administration could limit tissue hypoxia and reduce the risk of death. That said, studies (such as Bickell et al.) call for restricting IV fluid resuscitation until operative intervention. This is likely because animal studies have found an increased risk of death from aggressive resuscitation in cases where the hemorrhage is less severe.
Even then, blood transfusion must be considered for early goal-directed therapy protocols to improve cell respiration since the administration of oxygen-carrying red blood cells can improve tissue oxygenation and microcirculation. In fact, it is said to be indispensable when the hemoglobin level is below 7 g/dL.
If the availability of blood products is a concern, hemoglobin-based oxygen carriers (HBOCs) may be used as a substitute. But they should only be employed when modified with polyethylene glycol (PEG) since HBOCs are known to cause oxidative damage to tissues.
Ensure Better Outcomes With HPC
Hemorrhagic shock is the second leading cause of traumatic fatalities among patients aged 1 to 46 in the US. As a clinician, your goal is to use optimal resuscitative strategies to control bleeding while monitoring the effectiveness of therapy with thromboelastography. Ultimately, these measures help reduce blood transfusion requirements.
In addition to educating one’s self about resuscitation in shock, it helps to become familiar with the intubation of patients with varying levels of consciousness and patients who cannot protect their airways. You can learn all about the indications, contraindications, and best practices of airway management with our Glidescope Intubation and Endotracheal Intubation courses.
Hospital Procedures Consultants also provides intraosseous line and arterial line courses to help you maximize your chances of first-pass success. Visit the HPC website for the full list of courses.
Resources:
Jones, D. G. Nantais, J. Rezende-Neto, J. B. Yazdani, S. Vegas, P. Rizoli, S. Crystalloid resuscitation in trauma patients: deleterious effect of 5L or more in the first 24h. BMC Surg. 2018; 18: 93. 2018 Nov 6. doi: 10.1186/s12893-018-0427-y
James, M. F. M. Michell, W. L. Joubert, I. A. Nicol, A. J. Navsaria, P. H. Gillespie, R. S.Resuscitation with hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma) Randomized Controlled Trial Br J Anaesth. 2011 Nov;107(5):693-702. doi: 10.1093/bja/aer229
Patil, V. Shetmahajan, M. Massive transfusion and massive transfusion protocol. Indian J Anaesth. 2014 Sep-Oct; 58(5): 590–595.doi: 10.4103/0019-5049.144662
Mapstone, J. Roberts, I. Evans, P. Fluid resuscitation strategies: a systematic review of animal trials. Review J Trauma. 2003 Sep;55(3):571-89. doi: 10.1097/01.TA.0000062968.69867.6F.
Luo, J. Chen, D. Tang, L. Deng, H. Zhang, C. Chen, S. Chang, T. Dong, L. Wang, W. Xu, H. He, M. Wan, D. Yin, G. Wu, M. Cao, F. Liu, Y. Tang, Z.-H. Multifactorial Shock: A Neglected Situation in Polytrauma Patients. J Clin Med. 2022 Nov; 11(22): 6829.2022 Nov 18. doi: 10.3390/jcm11226829
Bouglé, A. Harrois, A. Duranteau, J. Resuscitative strategies in traumatic hemorrhagic shock. Ann Intensive Care. 2013; 3: 1. 2013 Jan 12. doi: 10.1186/2110-5820-3-1