Article Type : Review Article
Authors : Adel Hamed Elbaih and Emad Amjad Abou
Keywords : Haemorrhagic shock, Emergency physicians; Skill approach; Management
Background:
Trauma continues to be the leading cause of death; responsible for more than 5
million deaths worldwide each year. Uncontrolled hemorrhage is the leading
cause of preventable death in such cases, attributing about 50% of trauma-related
deaths within 24 h of injury. Deaths from haemorrhage represents a substantial
global problem, with more than 60,000 deaths per year in the United States and
an estimated 1.9 million deaths per year worldwide, 1.5 million of which result
from physical trauma. Therefore, we aim to look into the common pitfalls that
both medical students and new physicians face in the recognition, diagnosis,
and Emergency Traumatic Haemorrhagic Shock Resuscitations.
Targeted
population: Haemorrhagic Shock patients who are
requiring urgent management in the ED, with Emergency Physicians for teaching
approach protocol.
Aim
of the study: Appropriate for assessment and
priorities for Haemorrhagic Shock Patients Resuscitations by training protocol
to Emergency Physicians. Based on Resuscitations guidelines by applying the
ATLS protocol in traumatic Haemorrhagic shock.
Methods:
Collection of all possible available data about the haemorrhagic patients’
therapy in the Emergency department. By many research questions to achieve
these aims so a midline literature search was performed with the keywords
“critical care”, “emergency medicine”, “principals of urgent therapy in
haemorrhage", "Resuscitations and ATLS”. All studies introduced that
the initial diagnosis of hypovolemia is a serious condition that face patients
of the emergency and critical care departments. Literature search included an
overview of recent definition, causes and recent therapeutic strategies.
Conclusion:
Haemorrhage is the cause of shock in most trauma patients and Treatment of
these patients requires immediate haemorrhage control and ?uid or blood
replacement. Initial assessment of a shocked patient involves careful physical
examination, finding signs of life-threatening problems and other causes of
shock. In case of, Shock does not respond to initial crystalloid fluid bolus.
Think about an internal bleeding or a non-Haemorrhagic source of shock.
Trauma remains the leading cause of death; responsible for more than 5 million deaths per year worldwide. For these cases, uncontrolled haemorrhage is the main cause of preventable mortality, attributing nearly 50 percent of trauma-related mortality within 24 h of damage. A trauma center recorded 62.2 per cent over one year of massive transfusions in trauma settings. The remaining cases are classified into emergency surgery, critical care, cardiology, obstetrics, and general surgery, with injuries in excess of 75% of blood supplies used [1,2]. Road traffic accidents are in the top ten worldwide causes of death and the leading cause of death for people who are younger than 45 years. Furthermore, haemorrhage fatalities pose a significant global epidemic with more than 60,000 fatalities per year in the United States and an estimated 1.9 million deaths per year globally, of which 1.5 million are the consequence of physical injuries. Moreover, bleeding is one of the most important causes of early death following an accident. Trauma became the third leading cause of death overall in the United States in 2001, with heavy rates of haemorrhage being the primary cause of death among people aged 1 to 44 years [1,2]. Despite considerable improvement in haemorrhage treatment, post-traumatic bleeding is the leading cause of preventable death (40 per cent of trauma-related deaths). Furthermore, approximately 25 percent of the critically injured trauma patients who suffered extreme haemorrhage associated with acute traumatic coagulopathy (ATC) are present. These patients have a 5-fold greater chance of mortality within the first 24 hours; even survivors are at risk of contracting organ failure and sepsis, indicated by a mortality rate of up to 67 percent associated with factors other than the original critical bleed. Survival of these patients requires intensive management to correct hypovolemic shock and prevent ATC [3-6].
Shock refers to an
improper tissue perfusion due to the disparity between tissue demand for oxygen
and the capacity of the body to supply it. The consequence of the shock is
hypoperfusion of the global tissue which is associated with a reduced amount of
venous oxygen and metabolic acidosis (lactic acidosis). Conventionally, there's
four shock categories: hypovolemic, cardiogenic, obstructive, and distributive.
Hypovolemic shock happens when intravascular volume is decreasing to the extent
of cardiovascular failure [7,8].
The hypovolemic shock
may result from extreme dehydration by a variety of mechanisms or from lack of
blood. Haemorrhage is the most common source of shock following damage and
there is a degree of hypovolemia in nearly any case with multiple injuries.
Hence, where there are symptoms of shock, care is usually administered as
though the patient is hypovolemic. Nevertheless, before instituting care, it is
necessary to recognise the limited number of patients whose shock has a
specific origin (e.g., a secondary disorder such as cardiac tamponade, tension
pneumothorax, spinal cord damage, or blunt heart injury), which complicates
haemorrhagic shock presentation [8].
Four of these six
requirements will be met: Empirical standards for the treatment of circulatory
shock irrespective of cause [9] (Table 1).
·
Ill
appearance or altered mental status.
·
Heart
rate >100 beat/min
·
Respiratory
rate >20 cycle/min. or paco2 <32 mmhg
·
Serum
lactate level >4 mmol/L
· Arterial base deficit ?-4meq/L
PARAMETER |
CLASS I |
CLASS II (MILD) |
CLASS III (MODERATE) |
CLASS IV (SEVERE) |
Approximate
blood loss |
<15% |
15–30% |
31–40% |
>40% |
Heart
rate |
? |
?/? |
? |
?/?? |
Blood
pressure |
? |
? |
?/? |
? |
Pulse
pressure |
? |
? |
? |
? |
Respiratory
rate |
? |
? |
?/? |
? |
Urine
output |
? |
? |
? |
?? |
Glasgow
Coma Scale score |
? |
? |
? |
? |
Base
deficita |
0 to –2 mEq/L |
–2 to –6 mEq/L |
–6 to –10 mEq/L |
–10 mEq/L or less |
Need
for blood products |
Monitor |
Possible |
Yes |
Massive Transfusion Protocol |
A Base excess is the sum of base (HCO3–,
in mEq / L) over or below the standard body range. A negative value is
considered a deficiency basis (or base deficit) and demonstrates metabolic
acidosis. |
Description of a
problem, a lack of knowledge on a certain topic or a segment on WHY this is a
problem
However,
there are such medical problems which are might be faced during the emergency
room when dealing with patients who are suspected to have a shock. For example,
diagnosis of circulatory shock or other
type of shock can be missed because of depending on only a single parameter which
is like a blood pressure. As an example, hypertensive emergencies with a
compromised cardiac output can include blood pressure normal or elevated.
Another one is when there is unobvious
bleeding source (internal bleeding) and the unstable patient need CT scan to
localise the source of bleeding. Moreover, the physicians on emergency room may they are not aware about specific
consideration in shock detection and care involves discrepancies in the
responses to extreme age shocks, fitness, pregnancy and the involvement of
other drugs [8].
WHY this study is
necessary
The
goal of studying and addressing these problems is to improve healthcare,
decreasing the mortality rate, and highlight some of the wrong approaches
applied by a physician in emergency cases. Any delay or missing diagnosis of a
shock will have a dramatic effect on the patient’s health and it can be led to
death especially the patient with unobvious internal bleeding. Also, Physicians
on emergency room should be aware about the special consideration or type of
patient when they are trying to resuscitate them (This topic will be discussed
below). Therefore, it is very important to apply the right approach of ATLS
when dealing with such suspicion patients have signs and symptoms of shock [9].
Aim of study
This
is a review study Aim to decreasing the mortality rate, improve the healthcare
and highlight some of the wrong approaches applied by a physician in emergency
room in aspect of traumatic haemorrhagic shock.
Study question
·
How
can we correct and prevent using of the single parameter (such as blood
pressure) as not missing the diagnoses of shock?
We can correct and
prevent this by [8]
Ø
Application
of all clinical knowledge regarding breathing rate, pulse rate, skin perfusion
and mental status.
Ø
If
available, ask for pH, pO2, PCO2, oxygen levels and base
deficiency measures of the arterial blood gas.
Ø
End-tidal
CO2 and serum lactate tests may provide valuable diagnostic details.
·
In
case of unstable polytrauma patient with unobvious internal bleeding what
should we do to detect the source of bleeding?
Ø
The
ER doctors can't move the patient to a CT scan in this situation, since the
individual is unstable. Hence, rapid ultrasound in shock and hypotension (RUSH)
is the most effective method when working with unstable polytrauma patients
with unobvious internal bleeding. This shows that the classification of
unstable polytrauma patients was 94.2 percent sensitive; the precision of RUSH
in shock patients was 95.2 percent. However, it is highly operator dependent
and need expert. As well as Portable chest and pelvic X-ray should be used
[10].
·
What
are the special considerations and types of patients that the ER physicians
should know? And why?
The special types of
patients and consideration are advance age, athletes, pregnancy, and
Medications.
For advancing age, the ageing process causes a significant reduction in sympathetic function in the cardiovascular system. Therefore, cardiac compliance reduces with age, and in comparison to younger patients, older patients are reluctant to raise their heart rhythm or myocardial contraction capacity while distressed by lack of blood flow. Furthermore, the atherosclerotic vascular occlusive disorder allows certain important organs highly susceptible to even the smallest drop in blood flow. Additionally, often elderly patients suffer pre-existing volume loss attributable to long-term diuretic usage or slight malnutrition. For these factors, the elderly trauma patients display poor resistance to secondary blood loss hypotension. For e.g. in an elderly patient, a systolic blood pressure of 100 mm Hg may constitute a shock [8]. For athletes, Rough athletic fitness workouts change physiological processes of those patients. Blood volume will increase from 15% to 20%; cardiac output will raise 6-fold; stroke rate will rise by approximately 50%; and resting pulse may increase by an average of 50 BPM. The bodies of highly qualified athletes have a tremendous capacity to compensate for loss of blood, and even with substantial blood loss, the normal reactions to hypoperfusion will not be manifested [8].
For pregnancy, the normal hypervolemia that happens throughout pregnancy suggests that the development of mother's perfusion defects requires a greater volume of blood loss and can even be reflected in decreased fetal perfusion [8]. For Medications, Specific drugs can affect a patient's reaction to the shock. For eg, ß-adrenergic receptor blockers and calcium channel blockers could drastically influence a patient's hemodynamic response to haemorrhage. Insulin toxicity may be the cause of hypoglycaemia, which could have led to the injury event. Long-term diuretic therapy may be causing unidentified hypokalaemia, and non-steroidal anti-inflammatory drugs (NSAIDs) that adversely influence the function of platelets and can speed up bleeding [8].
Describe steps of the
right technic of this method point by point [8].
Initial Management of Haemorrhagic Shock: The detection and management of shocks
will actually occur nearly simultaneously. Clinicians begin therapy in most
trauma cases as though the patient were experiencing a haemorrhagic shock, unless
another source of shock becomes apparent. The fundamental concept of management
is to control bleeding, then replace the lack of volume.
Physical examination
concentrates on the rapid treatment of life-threatening conditions and the
evaluation of ABCDEs. Baseline assessments are important for evaluating the
patient's responsiveness to care, and frequent examinations of vital signs,
urinary output, and awareness level are necessary [9].
The
first priority is the establishment of a patented airway with adequate
ventilation and oxygenation. Provide enough oxygen to preserve oxygen
saturation at more than 95 percent [10].
·
Priorities for maintaining circulation include preventing apparent
bleeding, securing adequate intravenous access, and evaluating tissue
perfusion.
·
Bleeding from external wounds in the extremities may typically be
managed by direct pressure to the bleeding location, while severe extremity
blood loss can involve a tourniquet.
·
Bleeding from pelvic fractures could be controlled with a sheet or
pelvic binder.
·
Internal haemorrhage may need surgical or angioembolization to
control.
· The priority is not to quantify the amount of fluid loss, but to control the bleeding.
In patients with proof
of Class III and IV haemorrhage, early resuscitation of blood and blood
supplies needs to be addressed.
·
Early
administration of blood transfusions at a low ratio of red blood cells to
plasma and platelets may prevent the production of coagulopathy and
thrombocytopenia [11].
Uncontrolled high
blood loss can result in patients receiving antiplatelet or anticoagulant
medicine. Prevented by:
·
Get the list of medications as quick as possible.
·
Administer reversal drugs at the earliest moment.
·
Where available, observe coagulation with thromboelastography (TEG)
or rotational thromboelastometry (ROTEM).
·
Consider prescribing the transfusion of platelets, also with
regular platelet levels.
European and American
military studies show increased recovery after tranexamic acid (TXA) is given
within 3 hours of damage within 10 minutes.
·
Follow
up infusion TAX 1 gram over 8 hours at the hospital while needed in the field
[12].
For emergency patient, the endpoints of fluid resuscitation are when heart rate, blood pressure, distal pulses and capillary refill, urinary flow, mental state return to regular level. As well as decrease of base deficit and lactate level.
In case of, Shock does not respond to the initial bolus of crystalloid fluid.
·
Check
for a continuing cause of blood loss: (abdomen / pelvis, retroperitoneum,
thorax and limbs).
·
Think
of a non-haemorrhagic shock trigger.
·
Start
replacing the blood and plasma elements.
·
Obtain
surgical consultation on precise management of haemorrhage [13].
Massive transfusion
·
Massive
transfusion, most generally described during the first 24 hours of admission as
> 10 units of pRBCs or more than 4 units in 1 hour.
·
Early
and effective administration of balanced-ratio pRBCs, plasma, and platelets may
enhance patient longevity to reduce unnecessary crystalloid administration.
·
This
technique has been called resuscitation "balanced,"
"haemostatic" or "damage control."
Simultaneous measures are particularly necessary
in these patients for rapid management of bleeding and the adverse consequences
of coagulopathy, hypothermia and acidosis [14].
A simple neurological
evaluation can evaluate the state of consciousness of the patient that is
helpful in determining brain perfusion. Alterations in CNS function in patients
with hypovolemic shock do not generally mean severe intracranial damage and may
represent insufficient perfusion. Repeat neurological examination following the
restoration of perfusion and oxygenation [15].
·
After outlining life-saving priorities, fully undress the patient
and closely check the patient from head to foot for possible injuries.
·
That's also necessary to avoid hypothermia, a disease that may
intensify blood loss by leading to coagulopathy and increasing acidosis when
introduced to the patient [16].
· To prevent hypothermia, always use fluid heaters and the additional passive and active heating techniques.
·
Gastric distention raises the possibility of aspiration of gastric
material in unconscious patients, and is a possibly lethal complication [17].
·
Start decompressing the stomach by
inserting a nasal or oral hose in and suctioning it.
·
Be conscious that careful positioning of
the tubes will not reduce the possibility of aspiration.
·
Continuous
renal perfusion measurement is made possible by controlling urinary production.
·
Blood
in the urethral meatus or perineal hematoma / bruise may imply urethral injury
and may contraindicate the insertion of a transurethral catheter without
radiographic confirmation of an intact urethra [18].
·
For emergency cases haemorrhage is by far the most frequent cause
of shock.
·
The haemorrhage classes and the approach to treatments act as a
resuscitation guide.
·
The fundamental concept of management is to control bleeding, then
replace the lack of volume.
·
In the ED, inability to respond to crystalloid and blood
administration determines the need for urgent, conclusive action (i.e.,
operation, or angioembolization) to manage exsanguinating haemorrhage.
·
Coagulopathy, hypothermia, and deteriorating metabolic acidosis are
deadly triads that trauma victims need to look out for.
·
The choice to trigger the treatment for massive transfusion should
be made early in order to avoid the fatal triad of coagulopathy, hypothermia
and acidosis.
·
If clinically suggested, negative FAST scan, this can't fully
eliminate the risk of serious intraabdominal injury.
·
CT scan is a gold standard for diagnosing intraabdominal injuries
in patients with hemodynamically stable status.
· For emergency patient, the endpoints of fluid resuscitation are when heart rate, blood pressure, distal pulses and capillary refill, urinary flow, mental state return to regular level. As well as decrease of base deficit and lactate level.