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Hemorrhagic Shock: the “Physiology Approach”

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Hemorrhagic Shock: the “Physiology Approach” Review Article Hemorrhagic shock: The “physiology approach” Fabrizio Giuseppe Bonanno Trauma Directorate, Chris Hani Baragwanath Hospital, Johannesburg, South Africa ABSTRACT A shift of approach from ‘clinics trying to fit physiology’ to the one of ‘physiology to clinics’, with interpretation of the clinical phenomena from their physiological bases to the tip of the clinical iceberg, and a management exclusively based on modulation of physiology, is finally surging as the safest and most efficacious philosophy in hemorrhagic shock. ATLS® classification and recommendations on hemorrhagic shock are not helpful because antiphysiological and potentially misleading. Hemorrhagic shock needs to be reclassified in the direction of usefulness and timing of intervention: in particular its assessment and management need to be tailored to physiology. Key Words: Classification, hemorrhagic shock, management INTRODUCTION management of a scenario or of a problem [Table 1]. ATLS® classification of hemorrhagic shock (HS)[1] is not sensitive It has always been puzzling trying to understand and accept the and specific enough to help decision-making in reference to rationale and benefits of the ATLS classification[1] especially after the timing of management, being based only on the amount having replaced Holcroft more sensible classification,[2] as for the of blood loss that may or may not be rightly estimated, and difficulty of practical implementation with reference to timing and it is unhelpful and difficult to apply too.[9] The previous optimal management. Both classifications were consequences of physiological classification[2] had advantages overlooked and not experiments done on animals that do not have the same adrenergic re-captured by the ATLS® one, namely the progression of the receptors distribution and amount on humans, which further varies effects of a hemorrhage on the different organs and systems, from individual to individual,[3,4] and a misinterpretation of Shires a more reliable indicator than the amount of blood itself in studies in the 1960s,[5,6] deceptively corroborated by the improvement guiding timing of intervention. Nevertheless, the physiological in renal failure statistics in the Vietnam war with the overload of classification, despite being more functional and useful does not crystalloids, incidental with a coincidental increase of ARDS.[7,8] keep in account the pre-existent different organ physiological reserves or can foresee the level at which hypotension, crucial A more useful classification of hemorrhagic shock (HS), individual parameter signaling decompensation, occurs. By recommending physiology-tailored and therapeutic/decision-making friendly, which is the fluid-load of 2 L crystalloids load for adult patients to test based on the above two classifications of shock, has been elaborated. the reliability of compensatory mechanisms, as recommended up to recently, classical ATLS® guidelines actually delay the timing of intervention as source control when testing is not CLASSIFICATION OF HEMORRHAGIC SHOCK required and more crucially end up increasing the ongoing or spontaneously stopped bleeding. The only novelty of the Classifications are meant to summarize the assessment and classification is the cutoff at 30% blood loss as level of blood loss always manifesting with hypotension, per se not enough Address for correspondence: useful information to guide decision making. Dr. Fabrizio Giuseppe Bonanno, E-mail: [email protected] The new classification [Table 2], which may well be called Access this article online the “physiological HS classification” or “therapeutical HS Quick Response Code: Website: classification’, is based on a decision-making that keeps in account www.onlinejets.org hard practice and basic physiological considerations, such as the significance of fluid-blood resistant hypotension and body DOI: natural hemostatic mechanisms, the right definition of shock 10.4103/0974-2700.102357 nonetheless the relevance that hemorrhage triggered I-R and SIR have in critical illness scenarios as secondary insult from ischemia. Journal of Emergencies, Trauma, and Shock I 5:4 I Oct - Dec 2012 285 Bonanno: Hemorrhagic shock Table 1: Classical clinical classifications of complications; improve the healthy or moderately sick patient haemorrhagic shock before surgery by optimizing or reinforcing patient physiology Holcroft* with a view to reduce or prevent complications. So, sicker the Mild <20% Skin changes patient, the earlier more rapid and aggressive the intervention Mod >20% <40% Kidney, Gut, Lung, Liver dysfunction - Hypotension has to be; the less sick the patient more time has to be taken Severe >40% Brain and Heart involvement for improvement before intervention. Patient biological and ATLS** I: blood loss <15% physiological reserves (immunity, nutrition, exercise and age- II: blood loss >15% <30% related cardiovascular reflexes and specific organs homeostatic III: blood loss >30% <40% autoregulatory compensatory mechanisms), pre-existing IV: blood loss >40% systemic diseases or derangements (chronic renal failure, *BV diverted towards noble organs in a reverse hierarchy response; **Hypotension is consistently present when > 30% TBV loss. It may or may not be present with blood hypertension, diabetes, chronic liver disease, and chronic heart loss of < 30% TBV. Hypotension signals decompensation.; ***Persisting Tachycardia with disease), and concurrent drug intake (alcohol, antihypertensive, normalised systolic after fluid load signals partial compensation (stably unstable); ****Persisting Tachycardia and hypotension after fluid load signals severe life anti-arrhythmic, β-blockers, steroids, vasodilators, inotrops, and threatening Physiology (unstably unstable); BV: Blood volume; ATLS®: Advanced trauma insulin) play different significant roles in the overall prognosis life support; TBV: Total blood volume of the critical illness by delaying detection, limiting the physiological reserve of the different organs and complicating Table 2: Therapeutical/physiological classification of recovery. HS and first line management of source control Critical HS Shock with heart and brain involvement or > 40% TBV loss Timing of intervention for source control in HS depends on (impending CV collapse) → Stand-by surgery for source the clinical severity and degree of compensation that in normal control individuals reflects the level of blood loss, and on the response Severe HS Shock with hypotension not responding to blood/fluid load-test (unstably unstable) → Rapid surgery for source control to fluids load. TBV is 70 ml/kg body weight in adults, 80 ml/kg Moderate/ Moderate shock is hypotensive shock responding with in infant age and 80–90 ml/kg in newborns. HS at the extremes Mild HS normotension and reverse tachycardia trend to blood/ of life is more serious than at the age in between as for the not fluid overload (unstably stable); mild shock is normotensive tachycardic from start → Investigate, Ponder surgery, developed (newborns and infants) or less responsive (elderly) Interventional radiology/ Non-operative intervention vascular reflexes. Elderly patients as a matter of fact can have *hypotension may occur at ≥ 20% and is always present at ≥ 30% TBV loss; **by response shock at seemingly normal blood pressure of 120 mmHg due is meant reverse tachycardia trend and normalization of pressure; HS: Haemorrhagic to atherosclerosis, hypertension, and less functional reflexes shock; TBV: Total blood volume; CV: Cardiovascular maintaining relatively high pressures for perfusion.[10,11] In “critical shock”, in fact there is no much of circulating volume, HS in pregnant women does not manifest with shock signs until and brain and heart internal circulations are barely holding as a 30–35% TBV is lost due to the increase of plasma and cardiac result of the systemic vasoconstriction from chemoreceptor and output. The supine position neutralizes the advantages of those central nervous system receptors stimulation, while in “severe preparatory changes to forthcoming intravascular volume-losses shock” there is sufficient blood volume to potentially maintain as for the uterus compressing on the IVC and impairing VR, perfusion despite endogenous compensatory capacity in terms of phenomenon avoidable by always maintaining a left-oblique vasomotion/vasoconstriction has been lost; in moderate shock positioning when lying down. compensatory capacity instead has not been lost; and mild shock indicates only some blood loss. Acute blood loss and hypotension with brain and heart disturbances or a blood loss >40% of TBV (critical HS, unstably The ‘physiological–therapeutical’ classification must be unstable) require stand-by surgery to stop bleeding; persisting distinguished from the prognostic one, i.e. reversible or hypotension not responding to blood or fluids load (severe irreversible shock and implicitly photographs the levels of shock shock) with stable normalization of systolic and reversed HR within a time-frame of reversibility. It must also not be confused trend (stably unstable), also requires emergency surgery to stop with the two hit-model of physiological deterioration either, bleeding. which describe the time-peaks of clinical downfall. Heart and brain circulation in “critical shock” are holding because RATIONALE: TIMING OF INTERVENTION—THE of still functional regional vasomotion, but they have already “RESUSCITATION PARADOX” passed the critical extraction point as by definition ischemic signs are already present. Timing
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