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Key points Resuscitation from haemorrhagic shock prove fatal through the pathophysiology of
remains one of the primary tasks of the organ system failure, beginning with the lungs
Shock is defined by clinical
traumatologist, whether practising in the and progressing to the renal, gut, immune
evidence of hypoperfusion
and a failure of adequate emergency department (ED), the operating and cardiovascular systems. Figure 1 is a
oxygen delivery to some theatre or the intensive care unit (ICU). Dia- crude representation of the shock cascade,
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Fluid management for trauma
NO REFLOW
DECREASED FLUID
VOLUME
CELL
MEDIATORS
REACTIVE CELL
(IMMUNE SYSTEM, LIVER, LUNG) CYTOTOXINS
ACTIVATED
NEUTROPHILS
AND
MEDIATORS MICROPHAGES
LUNG
LIVER BRAIN HEART
ENDOCRINE BONE
KIDNEY ORGANS MARROW
Fig. 1 The shock cascade. Ischaemia in one organ system triggers a systemic response that persists even after adequate resuscitation. This is the
pathophysiology of the multiple organ system failure that commonly follows severe haemorrhagic shock.
Once these preliminary steps are taken, the focus of care fixation of fractures will facilitate spontaneous haemostasis in the
shifts to a search for haemorrhage as the cause of circulatory associated soft tissue beds.
shock. Bleeding must be diagnosed and treated as swiftly as pos- For the patient who requires exploratory surgery, the
sible, and this priority should inform all subsequent decision- emphasis is on ‘damage control.’ While the patient is hypo-
making. Clinically significant haemorrhage occurs into one of perfused and resuscitation is under way, the goal is to perform
only five compartments: the thoracic cavity, the peritoneum, the fastest surgery possible to achieve control of haemorrhage.
the retroperitoneal space, the tissue compartments of the thigh Large vessels are ligated or shunted whenever possible, and not
and outside the body. These are investigated by direct inspection reconstructed or bypassed. Bleeding from the spleen, kidney,
of the patient, chest X-ray, abdominal sonography, pelvic lung-lobe or bowel segments is managed by excision, without
X-ray and computer tomography. External bleeding is managed anatomical reconstruction. Hepatic or retroperitoneal haemor-
by direct pressure and ligation of exposed cutaneous vessels. rhage is controlled with cautery, topical haemostatic agents
Haemorrhage in the chest is managed initially by tube thora- and packing. When haemostasis is achieved, the chest or
costomy, as bleeding from the low-pressure pulmonary circuit abdomen is drained, packed open and covered with a temporary
will usually resolve spontaneously unless a major vessel has sterile dressing. This allows monitoring of recurrent or ongoing
been injured. Bleeding in the abdomen or persistent bleeding haemorrhage, permits tissue oedema without fear of com-
in the chest is addressed by surgical exploration. Pelvic or ret- partment syndrome and offers easy access for subsequent thera-
roperitoneal haemorrhage is difficult to access surgically; where peutic or reconstructive surgery. The patient is moved through
logistically possible, angiographic embolization is the preferred theatre and angiography suite or both as swiftly as possible,
approach. Bleeding into the thigh may be substantial at the time subsequently returning to the trauma bay or ICU for completion
of injury (up to 1500 ml) but will almost always resolve spontan- of resuscitation.
eously through tamponade in the muscle compartment and vaso- Surgical strategy for managing haemorrhagic shock must be
constriction of the feeding vessels. Traction, splinting or external focused on control of haemorrhage. The same is also true of the
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 4 2006 145
Fluid management for trauma
anaesthesia plan. While not as obvious as the ligation of a Table 1 Clinical trials of deliberate hypotensive resuscitation
bleeding vessel, the actions of the anaesthetist may play just as Trial Bickell et al.4 Dutton et al.5
great a role in the patient’s survival. Fluid administration is Mechanism of injury Penetrating Blunt and penetrating
one aspect of this, titrated to maintain or improve perfusion Site of resuscitation Pre-hospital, Trauma resuscitation
while at the same time encouraging native haemostasis. Main- emergency unit, operating room
department
tenance of body temperature, blood composition, electrolyte Study mechanism No fluid given Blood pressure titration
balance, respiratory function and depth of muscle relaxation N 598 110
and anaesthesia are also critical tasks. Finally, the appearance Study Group Mortality 30% 7%
Control Group Mortality 38% 7%
in clinical practice of systemic haemostatic agents (i.e. recombin- P-value 0.04 Not significant
ant human coagulation factor VIIa) offers a new option. Most
important of all, perhaps, is the anaesthetist’s ability to facilitate
146 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 4 2006
Fluid management for trauma
Early transfusion of plasma and platelets is similarly advant- It is not unusual to see ‘overshoot’ in the vital signs
ageous, as coagulopathy complicating haemorrhagic shock is after resuscitation from severe haemorrhage, characterized by
easier to prevent than to reverse. For the patient who requires a hypertension, tachycardia, fever and other signs of a hyperdy-
transfusion of >1 blood volume (approximately 10 units of red namic circulation. While this phenomenon has been associated
blood cells) in a short period, dilutional coagulopathy is almost with improved survival from shock, attempts to artificially create
certain. Our own preference is to begin therapy with plasma it (through the use of inotropic agents) have not generally been
and platelet concentrates as soon as this need is recognized, successful. Optimal results depend on adequate fluid loading,
with maintenance over the course of early resuscitation of an with inotropes reserved for those patients who do not resuscitate
approximately 1 : 1 : 1 ratio of blood components. Once haem- (clear their lactate) despite adequate intravascular volume as
orrhage has been anatomically controlled, further transfusion measured by pulmonary artery catheter or trans-oesophageal
therapy can be managed in a much more conservative fashion echocardiography.
After definitive control of haemorrhage, the emphasis of resus- 4. Bickell WH, Wall MJ, Pepe PE, et al. Immediate versus delayed resuscitation
for hypotensive patients with penetrating torso injuries. N Engl J Med
citation shifts to the restoration of normal tissue perfusion. The 1994; 331: 1105–9
phenomenon of ‘occult hypoperfusion’ has been used to describe 5. Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitation during
patients (specially young patients) who reach the ICU with nor- active hemorrhage: impact on in-hospital mortality. J Trauma 2002; 52:
mal vital signs, but persistently elevated serum lactate.7 These 1141–6
patients are hypovolaemic owing to under-resuscitation, but 6. Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline
supporting their blood pressure on the basis of profound vaso- for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350:
2247–56
constriction. If not promptly recognized, this situation creates
7. Blow O, Magliore L, Claridge JA, et al. The golden hour and the silver day:
the potential for sustained shock, organ system failure and detection and correction of occult hypoperfusion within 24 hours
death. When receiving such a patient, it is imperative that the improves outcome from major trauma. J Trauma 1999; 47: 964–9
ICU practitioner examines the patient’s arterial blood gas and 8. Abramson D, Scalea TM, Hitchcock, et al. Lactate clearance and survival
serum lactate concentration for any evidence of persisting anaer- following injury. J Trauma 1993; 35: 584–8
obic metabolism. If present, the patient should be aggressively 9. Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant
fluid resuscitated until the lactate concentration has cleared to human activated protein C for severe sepsis. N Engl J Med 2001; 344:
699–709
normal.8 Warming to normal body temperature and adequate
systemic analgesia will also help reverse vasoconstriction. Please see multiple choice questions 4–8.
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 4 2006 147