CLINICAL CARE Fluid Resuscitation Therapy for Hemorrhagic Shock Joseph R. Spaniol vides a review of the 4 types of shock, the 4 classes of Amanda R. Knight, BA hemorrhagic shock, and the latest research on resuscita- tive fluid. The 4 types of shock are categorized into dis- Jessica L. Zebley, MS, RN tributive, obstructive, cardiogenic, and hemorrhagic Dawn Anderson, MS, RN shock. Hemorrhagic shock has been categorized into 4 Janet D. Pierce, DSN, ARNP, CCRN classes, and based on these classes, appropriate treatment can be planned. Crystalloids, colloids, dopamine, and blood products are all considered resuscitative fluid treat- ment options. Each individual case requires various resus- ■ ABSTRACT citative actions with different fluids. Healthcare Hemorrhagic shock is a severe life-threatening emergency professionals who are knowledgeable of the information affecting all organ systems of the body by depriving tissue in this review would be better prepared for patients who of sufficient oxygen and nutrients by decreasing cardiac are admitted with hemorrhagic shock, thus providing output. This article is a short review of the different types optimal care. of shock, followed by information specifically referring to hemorrhagic shock. The American College of Surgeons ■ DISTRIBUTIVE SHOCK categorized shock into 4 classes: (1) distributive; (2) Distributive shock is composed of 3 separate categories obstructive; (3) cardiogenic; and (4) hemorrhagic. based on their clinical outcome. Distributive shock can be Similarly, the classes of hemorrhagic shock are grouped categorized into (1) septic; (2) anaphylactic; and (3) neu- by signs and symptoms, amount of blood loss, and the rogenic shock. type of fluid replacement. This updated review is helpful to trauma nurses in understanding the various clinical Septic shock aspects of shock and the current recommendations for In accordance with the American College of Chest fluid resuscitation therapy following hemorrhagic shock. Physicians and the Society of Critical Care Medicine in August of 1991,2 sepsis was described as an infection- ■ KEY WORDS induced syndrome characterized by an inflammatory cas- Advanced Trauma Life Support, Hemorrhagic shock, cade that is activated within a patient. This cascade leads Resuscitative fluids to a reaction in the body with 4 main areas being affected. When 2 of the 4 areas of the body become exces- he leading cause of death with regard to civilian and sively inflamed, the systemic inflammatory response syn- Tmilitary traumas is hemorrhagic shock.1 Since hemor- drome is triggered. These 4 parameters and their rhagic shock has a high mortality rate, research is crucial respective in finding the most effective treatment. The article pro- ■ Body temperature higher than 38°C or lower than 36°C; ■ Heart rate more than 90 beats per minute (bpm); ■ Joseph R. Spaniol is research assistant, Amanda R. Knight, BA, Respiratory rate more than 20 breaths per minute; is research assistant, Jessica L. Zebley, MS, RN, is graduate and student, Dawn Anderson, MS, RN, is graduate student, and ■ White blood cell count more than 12,000/mm or Janet D. Pierce, DSN, ARNP, CCRN, is Professor, University lower than 4,000/mm or with more than 10% of Kansas Medical Center, Kansas City. bands.3,4 Corresponding Author: Janet D. Pierce, DSN, ARNP, CCRN, School of Nursing, University of Kansas Medical Treatment of septic shock includes multiple modalities. Center, 3901 Rainbow Blvd, Mail Stop #4043, Kansas City, KS A protocol was published in the New England Journal of 66160 ([email protected]). Medicine in 2001 and termed the early goal-directed 152 Journal of Trauma Nursing • Volume 14, Number 3 July–September 2007 therapy. The advantages of recommended therapy was 3- pumping blood throughout the body.19 One common cir- fold: (1) early recognition of patients with potential sep- cumstance that may cause cardiac arrest is cardiac tam- sis; (2) early broad-spectrum antibiotics; and (3) a rapid ponade in which the pressure of the blood within the crystalloid fluid bolus.5,6 pericardium greatly decreases its venous return to the The early goal-directed therapy includes an algorithm heart. Other causes may be a tension pulmonary that depends on the patient response. For instance, if tis- embolism pneumothorax or a tumor.20,21 The obstruction sue hypoperfusion results when persistent hypotension is must be removed to reverse the obstructive shock. The not controlled despite fluid resuscitation, there are possi- treatments differ according to the initial cause of the ble treatment modalities.7 Vasopressive drugs including obstruction. dobutamine, dopamine, and, possibly, packed red blood In a case where a pulmonary embolism exists, result- cells (PRBCs) may be administered to the patient in sep- ing in interference of ventricular emptying, a thrombec- tic shock.8 tomy may be necessary, which has been shown to improve hemodynamics as well as lowering the critically Anaphylactic shock high pulmonary pressures.22 The most common method This form of shock is due to the body’s response to an of treatment of cardiac tamponade is removal of the fluid allergen, antigen, drug, or a foreign protein that causes (usually around 50 mL) by syringe.23 Pneumothoraces call the release of histamine. Histamine systemically causes for a variety of procedures, which usually involve rapid and widespread vasodilation of blood vessels, lead- catheter placement within the chest cavity to remove the ing to hypotension and increased capillary permeability.9 lung-collapsing agent.24 Rapid constriction of the airway (angioedema), urticaria, and bronchospasm also occurs with anaphylactic shock.10 ■ CARDIOGENIC SHOCK According to the Advanced Trauma Life Support (ATLS) Cardiogenic shock occurs when the ventricles are unable guidelines, the priority in treating anaphylactic shock is to function effectively, resulting in inadequate circulation to maintain a rapid airway patency, which might include due to decreased cardiac output. Much like other types of endotrachial intubation.11 Rapid infusion of a crystalloid shock, there are classic symptoms of cardiogenic shock. solution and intravenous epinephrine may also be neces- These symptoms include decreased urine output, altered sary. Inhaled ␤-agonists and antihistamines may be useful mentation, and hypotension. Symptoms specific to car- in opening the compromised airway and other symp- diogenic shock consist of jugular venous distention, car- toms. To treat the bronchospasm, corticosteroids may be diac gallop, and pulmonary edema. A study by Muhlberg administered intravenously.12 and Ruth-Sahd in 2004 defined the existence of cardio- genic shock as systolic blood pressure of less than 90 mm Neurogenic shock Hg for longer than 30 minutes and evidence of tissue Neurogenic shock is the least occurring type of shock hypoperfusion with left ventricular filling pressure observed and is typically caused by trauma to the spinal remaining adequate.25 This tissue hypoperfusion is mani- cord or brain.13 This type of shock leads to the immediate fested in patients with symptoms such as cold peripheral loss of autonomic and motor reflexes below the location tissues, oliguria (Ͻ30 mL/h), or the two combined of the injury. The inability of the sympathetic nervous sys- (Table 1).26–29 tem to stimulate the vessel walls causes them to relax. When treating cardiogenic shock, clinicians focus on Relaxation of these walls leads to rapid and widespread targeting the underlying cause, early diagnosis, and pre- vasodilation and hypotension. The classic presentation of vention of further ischemia. Intravenous fluids, vasopres- neurogenic shock is hypotension without tachycardia or sors, vasodilators, analgesics, phosphodiesterase enzyme cutaneous vasoconstriction.11 One suggested treatment is inhibitors, diuretics, and natriuretic peptides may all be placing the patient in the Trendelenburg position, with used for treatment depending on the clinical signs and the the head lower than the pelvis, to increase blood flow to cause of such shock.28,30,31 the brain. However, this treatment has not been shown to be successful in multiple studies.14–17 Using vasopressors ■ HEMORRHAGIC SHOCK such as intravenous dopamine or dobutamine may be Hemorrhagic shock is generally precipitated by a trau- more appropriate and efficacious in forcing blood flow matic event that results in an acute loss of blood from the and volume to increase, thus reversing shock.18 intravascular space. Patients who experience hemor- rhagic shock severely impair their ability to provide ade- ■ OBSTRUCTIVE SHOCK quate tissue perfusion and oxygenation after blood loss.32 In obstructive shock, blood flow is reduced and thus pre- Loss of circulating volume leads to a decrease of venous vented from entering the heart. This lack of blood flow return to the heart and reduces end-diastolic volume (pre- leads to circulatory arrest, causing the heart to stop load). This reduction in preload decreases the myocardial July–September 2007 Journal of Trauma Nursing • Volume 14, Number 3 153 TABLE 1 Causes of Cardiogenic Shock ■ Acute myocardial infarction ■ Myocardial contusion ■ Aortic stenosis ■ Myocarditis ■ ␤-Blocker or calcium channel blocker overdose ■ Respiratory acidosis ■ Coarctation of the aorta ■ Restrictive cardiomyopathies ■ Endocarditis ■ Rupture of the free wall ■ Hypertrophic cardiomyopathy ■ Rupture of the inter ventricular septum ■ Hypocalcaemia, hypophosphatemia ■ Septic shock with severe myocardial depression ■ Malignant hypertension