HWN Suggests

Hemorrhagic shock: The “physiology approach”

The standard ATLS classification of HS is unhelpful, confusing and misleading as it focuses on the amount of blood loss instead of individual physiological response to hemorrhage, which is the core by definition of the derangement we call ‘shock’. A new classification was needed and centered on physiology like the classical classification of Holcroft emphasized.

The era of flat anesthetics and surgery is over and it is time we go toward a tailored-to-individual physiology restoration and reprioritize all critical illness management from the microcirculation stand-point.

Fluids as first modality of treatment, particularly in excess as recommended till recently, are deleterious…

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  Ten (Trauma Resuscitation) Commandments

There is no question that concept of balanced blood product administration based on set ratios has become the dominant paradigm in modern trauma resuscitation. The idea stems from research in battlefield medicine, where it seemed (albeit retrospectively) that transfusing an equal ratio of plasma to red blood cells was associated with improved survival.

  Hemorrhagic Shock Resuscitation

The resuscitation fluid for trauma is equal parts PRBC and FFP.

  The general approach to the patient in shock

"Permissive hypotension" in trauma: Principle that guides the fluid resuscitation of traumatic patients who arrive hypotensive to stay somewhat hypotensive until blood loss is source-controlled.

 Optimal Fluid Therapy for Traumatic Hemorrhagic Shock

The resuscitation of traumatic hemorrhagic shock has undergone a paradigm shift in the last 20 years with the advent of damage control resuscitation (DCR). Major principles of DCR include minimization of crystalloid, permissive hypotension, transfusion of a balanced ratio of blood products, and goal-directed correction of coagulopathy. In particular, plasma has replaced crystalloid as the primary means for volume expansion for traumatic hemorrhagic shock. Predicting which patient will require DCR by prompt and accurate activation of a massive transfusion protocol, however, remains a challenge.

 Why Was This Teenager Bleeding So Excessively?

Patients with H.H.T. tend to have frequent, even daily, nose bleeds — as this girl did — and can experience blood loss through the stomach or other parts of the gastrointestinal tract, in their lungs or even in their brains.

Articles of Interest

Impact of transfusion of fresh-frozen plasma and packed red blood cells in a 1:1 ratio on survival of emergency department patients with severe trauma.

Three retrospective registry reviews with suboptimal methodologies and one prospective cohort study provide inadequate evidence to support or refute the use of a high FFP:PRBC ratio in patients with severe trauma.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy.

Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial

Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours.

Transfusion Strategies for Acute Upper Gastrointestinal Bleeding

Our results suggest that in patients with acute gastrointestinal bleeding, a strategy of not performing transfusion until the hemoglobin concentration falls below 7 g per deciliter is a safe and effective approach.

Resources

FP Notebook

Hemorrhage should be replaced with blood products...Massive hemorrhage with administration of more than 4 units requires matching blood products.

Life in the Fastlane

An easy way to remember the categories is to think of the scores in a game of tennis: Love – 15 – 30 – 40 — game over (>40).

StatPearls

Though most commonly thought of in the setting of trauma, there are numerous causes of hemorrhagic shock that span many systems. Blunt or penetrating trauma is the most common cause, followed by upper and lower gastrointestinal sources. Obstetrical, vascular, iatrogenic, and even urological sources have all been described.

The Young Orthopod

The traditional ATLS approach for trauma circulation resuscitation, is to site two large-bore IV cannulae and administer an initial bolus of 2 L of warmed Ringer’s lactate or Hartmann’s solution. This is certainly successful in improving perfusion in bleeding patients, but is now not recommended for pre-hospital use where haemorrhage cannot be surgically controlled and blood is not available for transfusion.