Journal of Emergencies, Trauma, and Shock

EDITORIAL
Year
: 2011  |  Volume : 4  |  Issue : 4  |  Page : 441--442

What's new in Emergencies, Trauma and Shock ? Optimizing initial resuscitation strategies in a patient with shock


Jeffry L Kashuk 
 St. Mary's of Michigan/Midwestern Surgical Associates, 800 S. Washington Ave, Saginaw, MI 48602, USA

Correspondence Address:
Jeffry L Kashuk
St. Mary«SQ»s of Michigan/Midwestern Surgical Associates, 800 S. Washington Ave, Saginaw, MI 48602
USA




How to cite this article:
Kashuk JL. What's new in Emergencies, Trauma and Shock ? Optimizing initial resuscitation strategies in a patient with shock.J Emerg Trauma Shock 2011;4:441-442


How to cite this URL:
Kashuk JL. What's new in Emergencies, Trauma and Shock ? Optimizing initial resuscitation strategies in a patient with shock. J Emerg Trauma Shock [serial online] 2011 [cited 2019 Nov 13 ];4:441-442
Available from: http://www.onlinejets.org/text.asp?2011/4/4/441/86624


Full Text

Growing evidence suggests that efforts directed toward achieving an optimal resuscitation strategy in the shocked patient during the early, acute postinjury phase, while there is on-going hemorrhage, may profoundly impact ultimate survival. [1],[2],[3] Furthermore, while improvements in management of patients with uncontrolled hemorrhage, (such as the early application of damage control techniques) have improved outcomes, the mortality in this cohort has remained significant while the optimal approach to initial resuscitation is unclear.

Other recent data from the US military experience in Iraq, [4] with subsequent initial reports from the civilian population, [5] also support the concept that early, aggressive resuscitation using packed red blood cells and plasma in high ratios, in lieu of "standard" high dose crystalloid infusions, appears to improve survival as well. Despite this, a mechanistic link to the acute coagulopathy of trauma remains to be established. [6] What is becoming increasingly apparent, however, is that the untoward effects of excessive crystalloid administration clearly underlie many of these issues. This can be manifest clinically in several areas, including abdominal compartment syndrome, dilutional coagulopathy, and associated swings in blood pressure resulting from cyclic crystalloid infusion associated with hyper-resuscitation. Lastly, the role of a variety of adjunctive hemostatic agents, applied as dressings, remains to be elucidated, and their efficacy in the face of an established strategy of hypotensive resuscitation is unknown.

The current resuscitation model, [7] performed in the swine, attempts to address some of these questions. While clinical evidence suggests that 90 mmHg systolic may be an optimal target range, this study attempts to address this question with a well designed experimental porcine model. The researchers created a lethal femoral artery injury, controlling hemorrhage with the ExcelArrest product. After achieving the shock state, their study used an intravenous phenylephrine infusion to raise the blood pressure so as to determine the threshold for recurrent lethal hemorrhage, also commonly referred to as "popping the clot." The results showed that ExcelArrest was significantly more effective than standard dressings for prevention of re-bleeding in the presence of elevated blood pressures.

The results of this study confirm the clinical evidence supporting the 90 mmHg target range for resuscitation. More importantly, however, these findings suggest that an added benefit of hypotensive resuscitation strategies is the ability to apply novel methods of temporary hemorrhage control, such as ExcelArrest, which can effectively buy time until optimal surgical control can be obtained.

The potential benefits of such a strategy are significant. Clearly, these methods have strong potential benefits in the austere military environment, in cases where tourniquet use is not possible, and where surgical control may be delayed for significant time periods of time. In the civilian sector, such use may have strong potential benefits in the patient with multiple injuries, as another damage control adjunct.

In sum, the authors have shown that adjunctive hemostatic agents may be beneficial when applied to patients receiving hypotensive resuscitation.

The authors are to be congratulated for a well designed study, which begins to look at one aspect of the complex interactions between local as well as systemic hemostasis in the face of the growing evidence supporting hypotensive resuscitation strategies. Future work will be required, however, with larger experimental as well as clinical studies, to better elucidate the optimal timeframes for application, the ideal material for use, and optimal methods for monitoring the patient who arrives in shock with active hemorrhage and associated coagulopathy. Since life threatening hemorrhage remains a major cause of death in the trauma patient, studies that address our ability to improve the initial status of the critically injured patient are particularly important, because such advances will allow for definitive repair of wounds under optimal circumstances. Another important factor is the timeframe during which patients may be maintained with hypotensive resuscitation and the use of such adjunctive hemostatic agents. Although the current study addressed some of these factors in the face of acute hemorrhage, prolonged patient transfers in the civilian sector, as well as complicated field issues in the military clearly present unique challenges for this approach, and will need to be addressed. Other considerations include the need for normotensive resuscitation in patients with associated head injury in order to maintain cerebral perfusion pressure, as well as the need for increased fluid resuscitation in the patient with associated crush injury when efforts must be made to avoid myonecrosis and renal injury.

All of these issues serve to underscore the complexity of these processes and the need for continued experimental studies leading to extensive clinical trials. Such efforts may well usher in a new era in our approach to resuscitation in the shocked patient.

References

1Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, et al. Epidemiology of trauma deaths: Areassessment. J Trauma 1995;38:185-93.
2Kashuk JL, Moore EE, Johnson JL, Haenel J, Wilson M, Moore JB, et al. Postinjury life threatening coagulopathy: Is 1:1 fresh frozen plasma: Packed red blood cells the answer? J Trauma 2008;65:261-70.
3Gonzalez EA, Moore FA, Holcomb JB, Miller CC, Kozar RA, Todd SR, et al. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma 2007;62:112-9.
4Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at acombat support hospital. J Trauma 2007;63:805-13.
5Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civiliantrauma patients. Ann Surg 2008;248:447-58.
6Kashuk JL, Moore EE, Sawyer M, Wohlauer M, Pezold M, Barnett C, et al. Primary Fibrinolysis is integral in the pathogenesis of Postinjury Coagulopathy. Ann Surg 2010;252:434-42.
7Burgert JM, Gegel BT, Austin R 3 rd , Davila A, Deeds J, Hodges L, et al. Effects of arterial blood pressure on rebleeding using Celox and TraumaDEX in a porcine model of lethal femoral injury. AANA J 2010;78:230-6.