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Clinical Hot Topics: Hypotensive Resuscitation in Hemorrhagic Shock: The Science So Far

Posted on Wed, Nov 12, 2014
Clinical Hot Topics: Hypotensive Resuscitation in Hemorrhagic Shock: The Science So Far

Hosted by Al Sacchetti, MD, FACEP as moderator, Don’t Blink or You Will Miss It - Clinical Hot Topics can feel much like the “speed dating” of training presentations. The 12 hyper-paced presentations covered a wealth of information for the 2014 EmCare Leadership Conference attendees.  Each week, we’ll publish highlights from select clinical hot topics presented at the conference.

Hypotensive Resuscitation in Hemorrhagic Shock: The Science So Far
by Matthew M. Carrick MD, FACS

“Shock” has been called the “Rude Unhinging of the Machine of Life” (Samuel V. Gross, 1892).

Hemorrhagic shock is a leading cause of death following trauma. (Kauvar DS et al. Impact of Hemorrhage on Trauma Outcome: An Overview of Epidemiologic, Clinical, and Therapeutic Considerations: J Trauma 2006; 60: S3‐S11)

So, it’s pretty bad. What do we do?

In 1918, Walter Cannon stated “inaccessible or uncontrolled sources of blood loss should not be treated with intravenous fluids until the time of surgical control.” With each new generation of physicians and technology, the recommendations changed based on new theories. The process of aggressive crystalloid resuscitation began around the time of the Vietnam era. However, the effects of aggressive fluid resuscitation exacerbated the “Lethal Triad” – Acidemia, Hypothermia and Coagulopathy. Over time, it was learned that the effects of resuscitation were not as clear cut as previously thought. All currently available fluid preparations contribute in varying degrees to the development of MSOF and ARDS. At elevated blood pressures, blood clots become dislodged.

How does the clinician balance the risk of resuscitation with the risk of circulatory collapse? Can we withhold all fluid resuscitation?

Dr. Carrick provided data as the participants compared clinical trials on animals testing the approach of fluids versus no fluids for a massive hemorrhage and then for a small volume hemorrhage. (Mapstone J et al., Fluid Resuscitation Strategies: A systemic Review of Animal Trials. J Trauma. 2003; 55:571‐589) Among the human patients who received delayed fluid resuscitation, 70 percent survived as compared with 62 percent who received immediate fluid resuscitation (P = 0.04).
So what’s the verdict?

Ultimately the current conclusion is that for hypotensive patients with penetrating torso injuries, delay aggressive fluid resuscitation until operative intervention improves the outcome.

It seems the recommendations have gone full circle leaving Mr. Cannon to respond simply… “told you so!” 

  1. Cannon W.B, Faser J., Collew E.M: The preventive treatment of wound shock. JAMA 47. 618.1918.
  2. Matthew M. Carrick MD FACS International Symposium on ... (n.d.). Retrieved from http://www.iscb2013.dk/presentations2009/Session%207_Carrick_.pdf_br

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