Hemorrhagic Shock link to review paper from NEJM 1/2018
Principles
of damage control resuscitation in cases of extreme bleeding are guided by
avoiding overzealous resuscitation with crystalloid which dilute clotting factors,
and decrease oxygen carrying capacity. In addition the use of cold
fluids aggravates the loss of heat from hemorrhage, in addition to effects of
environmental exposure, and depleted energy stores leading to decreased
function of enzymes in the clotting cascade. The over administration of
acidic crystalloid solutions worsens the acidosis caused by hypoperfusion and
further impairs the function of clotting factors resulting in a “bloody vicious
cycle” of coagulopathy, hypothermia, and acidosis. Successful
resuscitation emphasizes the priorities of restoration of the intravascular
volume and control of hemorrhage.
So
principles of successful resuscitation of the bleeding patient:
-Avoid
or correct hypothermia
-Apply
direct pressure or a tourniquet proximal to the sites of hemorrhage in the
extremities; pack junctional wounds with hemostatic dressings
-Delay
fluid administration until the time of definitive hemostasis in selected
patients (penetrating trauma to the torso, short pre-hospital transport times)
-Minimize
crystalloid infusions (< less than 3 liters in the 1st 6 hours)
-Use
a massive transfusion protocol to ensure that sufficient blood products are
available
-Minimize
imbalances and plasma, platelet, and red cell transfusion order to optimize
hemostasis (1:1:1)
-Obtained
functional laboratory measures of coagulation to guide transition from
empirical transfusions to targeted therapy
-Selectively
administer pharmacologic adjuncts to reverse any anticoagulant medications can
address persistent coagulopathy
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