Principles of Management of Hemorrhagic Shock

Supplemental oxygen

Definitive airway

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  Endotracheal intubation/surgical airway

Ventilatory support

Peripheral line

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  Antecubital peripheral line

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    Two large-caliber (14–16 gauge) catheters

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    Short, large-caliber peripheral IV lines are preferred for rapid infusion of large volumes of fluid.

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    Rate of flow is proportional to the 4th power of the radius of the cannula and inversely related to the length (Law of Poiseuille).

Intraosseous (IO) access

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  The bone marrow of long bones has a rich network of vessels that drain into a central venous canal, emissary veins, and, ultimately, the central circulation, providing a noncollapsible venous access.

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  Advantages

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    Rapid access in patients with failed peripheral IV line

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    Intraosseous route has roughly the same absorption rate as intravenous route.

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    Under pressure, fluid can be infused up to 200 mL/min.

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    Any medications that can be given via IV can be given per intraosseous route.

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    Needle should be removed within 3–4 hours, but it can be maintained for 24–72 hours. In practice, IO needle should be removed once an alternative vascular access is obtained.

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    The levels of drugs, chemistries, and hemoglobin, as well as acid-base status, obtained from bone marrow are reliable predictors of serum levels.

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  Contraindications

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    Fracture at the sites of insertion

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  Relative contraindications

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    Infection at the insertion site

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    Inferior vena cava injury

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    Previous attempt on the same leg bone

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    Osteogenesis imperfecta

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    Osteoporosis

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  Complications

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    Subcutaneous or subperiosteal infiltration is most common complication.

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    Pressure necrosis of skin at insertion site

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    Epiphyseal growth plate injury in children

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    Fat embolism

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    Local hematoma

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    Compartment syndrome: if the needle passes through the opposite cortex, the infused fluid enters the muscle rather than the venous system.

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    Extravasation of hypertonic or caustic medications, such as sodium bicarbonate, dopamine, or calcium chloride, can result in necrosis of the muscle.

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    Local infection and osteomyelitis

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  Technique of IO access

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    Sites

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      Anteromedial aspect of the proximal tibia is the most common site, as it lies just under the skin and can be easily palpated and located.

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      Anterior aspect of distal femur: anterior midline 1-2 cm proximal to patella.

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      Superior iliac crest

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      Sternum

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      Proximal humerus at greater tuberosity

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    Steps of tibial IO access

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      Identify the tibial tuberosity.

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      Locate the bone 2 cm distal and slightly medial to the tibial tuberosity.

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      Support the flexed knee by placing a towel under the calf.

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      Prep and drape the patient using sterile technique.

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      If the patient is awake, inject local anesthetic (1% lidocaine) into the skin, into the subcutaneous tissue, and over the periosteum.

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      Insert the IO needle through the skin and subcutaneous tissue using automatic intraosseous device.

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      Automatic intraosseous devices

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        Quick and provides safe access

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        Deploys inject needles to a preset depth

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      Confirm the placement by aspirating bone marrow and connect the IV tubing.

Central venous access

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  Indications

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    Failed peripheral IV

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    Failed IO line

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    Need for medications that can only be delivered centrally (certain vasopressors)

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    Consider using a short, large-bore catheter (8.5 F introducer sheath) or a double- or triple-lumen 7 F catheter.

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  Locations

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    Femoral: least sterile

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    Subclavian: avoided in patients with coagulopathy

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    Internal jugular (IJ)

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  Complications

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    Correlate directly with number of sticks

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    Arterial puncture: femoral > IJ > subclavian

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    Hematoma: femoral > IJ > subclavian

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    Pneumothorax: subclavian > IJ

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    Use of ultrasound (US) guidance: increases first-attempt success, reduces access time, reduces carotid puncture in IJ access

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    Specific complications of femoral venous access

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      Deep vein thrombosis (DVT)

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      Arterial or neurologic injury

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      Infection

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      Arteriovenous (AV) fistula

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    Specific complication of subclavian/IJ venous access

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      Pneumothorax

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      Venous thrombosis

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      Arterial or neurological injury

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      AV fistula

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      Chylothorax

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      Air embolism

Limited use of crystalloids

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  Typically, normal saline (NS) or lactated Ringer’s (LR) is used for initial fluid resuscitation of the trauma patients.

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  NS and LR have equivalent effects on hemodynamics and oxygen metabolism during resuscitation.

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  Resuscitation with LR has more favorable effects on fluid overload in lungs, coagulation, and acid/base balance (pH).

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  Advanced Trauma Life Support (ATLS) recommends 1 L of crystalloid as the starting point for all fluid resuscitation.

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  In penetrating trauma with hemorrhage, aggressive fluid resuscitation should be delayed until bleeding is controlled.

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  Balanced resuscitation prevents complications due to a large volume of crystalloids.

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  Infusion of large volumes of crystalloids to achieve a normal blood pressure is not recommended. Complications from large-volume crystalloid resuscitation include:

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    Prolonged ventilator dependence.

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    Increased hospital length of stay in the adult blunt trauma population.

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    Acute lung injury.

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    Acute respiratory distress syndrome (ARDS).

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    Multiorgan dysfunction.

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    Abdominal compartment syndrome.

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    Surgical Site Infections.

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    Coagulopathy due to:

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      Dilution of coagulation factors.

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      Hypothermia due to fluid stored at room temperature.

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    Large volume of normal saline causes hyperchloremic acidosis.

Permissive hypotension:

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  Also known as hypotensive resuscitation and controlled resuscitation.

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    Goal mean arterial pressure (MAP) 40–50 mm Hg or systolic blood pressure (SBP) of 80–90 mm Hg.

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    Elevated BP causes more bleeding due to dislodgement of thrombus at the bleeding site.

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  Complications of prolonged permissive hypotension

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    Coagulation dysfunction

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    Ischemic organ dysfunction due to poor tissue perfusion

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    Mitochondrial dysfunction

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    Lactic acidosis

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  Contraindications of permissive hypotension

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    Patients with cerebrovascular disease, carotid stenosis, and compromised renal function

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    Patients with crush injury with rhabdomyolysis

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    Traumatic brain injury, and spinal cord injury. SBP >90 mm Hg is recommended in these patients.

Early use of blood and blood products

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  Early administration of red blood cells (including uncross-matched type O) to achieve a hematocrit of 25%–30%

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  Early use of plasma to maintain normal clotting factors

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  Use of cryoprecipitate in coagulopathic patients

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  Platelet transfusion if count <50,000

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  Use of a massive transfusion protocol (MTP) using a 1:1:1 product ratio or low-titer type O whole blood.

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  Use of goal-directed treatment of coagulopathy using viscoelastic assay

Advantages of balanced resuscitation over aggressive resuscitation

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  Reduces morbidity and mortality of trauma patients with hemorrhagic shock

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  Prevents lethal triad

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  Minimizes the impact of trauma-induced coagulopathy

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  Limits blood product waste

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  Reduces the complications associated with aggressive crystalloid resuscitation

Direct pressure on the bleeding wounds

Tourniquet

Local hemostatic agents

Pelvic stabilization

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  Pelvic binder

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  External fixator

Surgical hemostasis

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  External

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    Suture of bleeding laceration

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    Ligation of bleeding vessels

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    Control of bleeders with arterial clamps

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  Internal

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    Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

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    Angioembolization

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    Resuscitative thoracotomy

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    Damage-control celiotomy

Lethal triad

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  Acidosis

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  Hypothermia

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  Coagulopathy

Not a fluid of choice for initial resuscitation

More expensive than crystalloids

Small risk of anaphylaxis

No significant advantages over crystalloids in the early stages of resuscitation

May be used in later part of resuscitation after a considerable capillary leak caused by the systemic inflammatory response syndrome (SIRS)

May be associated (but no strong evidence) with less peripheral and pulmonary edema due to less capillary leak

IV albumin does not have any advantage compared to crystalloid in resuscitation of hemorrhagic shock.

No role in survival of shock

May be indicated in pH <7.0