Resuscitative strategies in traumatic hemorrhagic shock

Abstract

Managing trauma patients with hemorrhagic shock is complex and difficult. Despite our knowledge of the pathophysiology of hemorrhagic shock in trauma patients that we have accumulated during recent decades, the mortality rate of these patients remains high. In the acute phase of hemorrhage, the therapeutic priority is to stop the bleeding as quickly as possible. As long as this bleeding is uncontrolled, the physician must maintain oxygen delivery to limit tissue hypoxia, inflammation, and organ dysfunction. This process involves fluid resuscitation, the use of vasopressors, and blood transfusion to prevent or correct acute coagulopathy of trauma. The optimal resuscitative strategy is controversial. To move forward, we need to establish optimal therapeutic approaches with clear objectives for fluid resuscitation, blood pressure, and hemoglobin levels to guide resuscitation and limit the risk of fluid overload and transfusion.

Figure 1

Flowchart of initial management of traumatic hemorrhagic shock. In the acute phase of traumatic hemorrhagic shock, the therapeutic priority is to stop the bleeding. As long as this bleeding is not controlled, the physician must manage fluid resuscitation, vasopressors, and blood transfusion to prevent or treat acute coagulopathy of trauma. AP, arterial pressure; SAP, systolic arterial pressure; TBI, trauma brain injury; Hb, hemoglobin; PT, prothrombin time; APTT, activated partial thromboplastin time.

Figure 2

The main pathophysiological mechanisms involved in acute traumatic coagulopathy and transfusion strategy. SAP, systolic arterial pressure; RBC, red blood cells; FFP, fresh-frozen plasma.