Hemorrhagic Shock & Trauma Resuscitation

David Ray Velez, MD
The Operative Review of Surgery. 2023; 1:1-10.

Hemorrhagic Shock
Damage Control Resuscitation
Massive Transfusion Protocol (MTP)
Adjuncts

Mnemonics
References

Hemorrhagic Shock

Definition

Inadequate Oxygen Delivery & Tissue Perfusion Due to Blood Loss
*A Form of Hypovolemic Shock

Pathophysiology

Cellular Level
- Oxygen Delivery Unable to Meet Oxygen Demand
- Aerobic Metabolism Converted to Anaerobic Metabolism ¹
  - Produces: Oxygen Radicals, Lactic Acid & Inorganic Phosphates ¹
- Release of DAMPs Incite Systemic Inflammatory Response ²
- Predictable Hemostasis Fails & Cells Die
Organ Level
- Hypovolemia & Resultant Vasoconstriction Cause End-Organ Hypoperfusion & Damage
- Hypoperfusion of the Brain & Myocardium Lead to Cerebral Anoxia & Fatal Arrhythmia within Minutes ³

Acute Traumatic Coagulopathy (ATC)

Also Called Trauma-Induced Coagulopathy (TIC)
Present in 24.4% of Trauma Patients ⁴
Associated with High Mortality ⁵
Mechanisms:
- Activated Protein C (APC)
  - Anticoagulant – Inactivates Factors Va and VIIIa
  - Increased Activity in Trauma ^6,7
    - Possibly Due to Upregulation of Thrombomodulin Activity in the Setting of Hypoperfusion
- Endothelial Glycocalyx Layer (EGL)
  - “Shedding” of EGL After Injury Due to Yet Undetermined Mechanisms ⁸
  - Anticoagulant Components Such as Chondroitin Sulfate and Heparan Sulfate ⁸
- Increased Fibrinolysis
  - Clotting Cascade Activated Locally ^8,9
  - Distant Fibrinolytic Activity Increased ^8,9
    - Believed to Prevent Microvascular Thrombosis ^8,9
- Platelet Impairment
  - Numbers are Depleted ¹
  - Migration is Decreased ¹
  - Function is Impaired ¹
The Lethal Triad (Hypothermia, Acidosis, & Coagulopathy) Compound on Each Other and Result in Significant Morbidity and Mortality ¹⁰

Hemorrhagic Shock Diagnosis

First Step: Recognize its Presence ¹¹
- May Miss if Only Looking at Blood Pressure Due to Early Compensation
- Earliest Signs: Tachycardia & Cutaneous Vasoconstriction ¹¹
Second Step: Determine the Cause ¹¹
- Hemorrhagic Shock is Most Common in Trauma ¹¹
- Obstructive Shock Caused by Cardiac Tamponade or Tension PTX ¹¹
- Cardiogenic, Neurogenic or Septic Shock Can Also be Present
Diagnosis Should Not Delay Appropriate Resuscitation

Possible Source of Occult Hemorrhage Mn

Street/In the Field
Chest
Retroperitoneum
Abdomen
Pelvis
Thighs

Hemorrhagic Shock Class Mn

Class	Blood Loss	HR	BP	Pulse Pressure	RR	UOP	Mental Status
I	< 750 cc (< 15%)	Normal	Normal	Normal	Normal	Normal	Slightly Anxious
II	> 750 cc (15-30%)	> 100	Normal	Narrow	> 20	< 30	Mildly Anxious
*III*	> 1500 cc (30-40%)	> 120	Low	Narrow	> 30	< 15	Confused, Anxious
IV	> 2000 cc (> 40%)	> 140	Low	Narrow	> 40	0	Confused, Lethargic

Damage Control Resuscitation

Initial Fluid Resuscitation

Initial Step: 1-2 L Warmed Lactated Ringer Bolus ¹¹
- *If Class III/IV Shock May Consider Immediate Transfusion to Blood/Blood Products to Limit Crystalloid Transfusions
- Pediatrics (If < 40 kg): 20 cc/kg ¹¹
Response: ¹¹
- Rapid Responder
  - Quick Correction that is Maintained
  - Indicates Class I Shock
- Transient Responder
  - Initially Responds but Then Deteriorates
  - Indicates Class II-III Shock
- Non-Responder
  - No Correction
  - Indicates Class IV Shock
Next Step: ¹¹
- Rapid Responder: No Further Immediate Boluses Required
- Transient or Non-Responders: Transition to Blood or Blood Products
  - Strongly Consider Activation of Massive Transfusion Protocols (MTP) if Significant Volumes are Anticipated

Blood Transfusion

Initial Blood: Type O pRBC
- Until Type & Crossmatch Available
Approaches to Massive Transfusion Protocol (MTP)
- Hemostatic Resuscitation (1:1:1 Ratio)
- TEG-Guided Transfusion
- Whole Blood

Permissive Hypotension

Also Known as: Hypotensive Resuscitation or Controlled Resuscitation
Initial Goal SBP: ≥ 70 mmHg Until Definitive Hemostasis Achieved ^12,13
Rapid Resuscitation Exacerbates Bleeding By: ^12,13
- Dislodging Fragile Clots
- Decreasing Blood Viscosity
- Exacerbating Lethal Triad
Contraindicated in TBI – Maintenance of Cerebral Perfusion Pressure Essential to Prevent Secondary Brain Injury ¹⁴
- Age 15-49: ≥ 110 mmHg
- Age 50-69: ≥ 100 mmHg
- Age ≥ 70: ≥ 110 mmHg

Massive Transfusion Protocol (MTP)

Definitions

≥ 10 U pRBC in 24 Hours
≥ 4 U PRBC in 1 Hour
*Generally Indicates a Large Volume of Blood/Blood Product Transfusion

Benefits ¹⁵

Improves Survival
Decreases Use of Blood Products
Decreases Costs

Activation Indications

Over a Dozen Scoring Systems ¹⁶
- Differ in Criteria & Significance
- Most Common Criteria: FAST, Hypotension, Tachycardia, Unstable Pelvic Fracture, & Low Hgb
Scoring Systems:
- Trauma-Associated Severe Hemorrhage (TASH) Score – Most Well Validated if Using Exam, Labs, & FAST ¹⁶
- Assessment of Blood Consumptions (ABC) Score
- Vandromme Score
- Schreiber Score
- Shock Index

Hemostatic/Balanced Resuscitation

pRBC:FFP:Plt at Ratio 1:1:1
Closest Approximation to Whole Blood Available
PROPPR RCT Demonstrated Decreased Death Due to Exsanguination ¹⁷
Generally Consider the Standard Modern Approach
Concentration After Dilution & Storage: ^18,19
- Hematocrit: 29% (5-10% Are Lost After Transfusion)
- Platelet Count: 88,000 (Only 2/3 Are Viable After Transfusion)
- Coagulation Factors: 65% of Normal
Effective Concentration (After Dilution, Storage & Immediate Losses): ^18,19
- Hematocrit: 26%
- Platelet Count: 59,000
- Coagulation Factors: 65% of Normal
- *Adding More of One Component Dilutes the Other Two & Adding Fluids Dilutes All Three
- Barely Keeps Levels Above Traditional Transfusion Indications

Thrombelastography (TEG)

Measures the Viscoelastic Properties of Clot Formation in Real Time
Reading & Response:
- *See Thrombelastogram (TEG)
Allows More Rapid Goal-Directed Resuscitation than Conventional Coagulation Assays ^20,21
High-Grade Evidence of Improved Outcomes is Lacking

Whole Blood

Better Access in Military with “Fresh Blood” from a “Walking Blood Bank” of Prescreened Soldiers ^22,23
- Increasingly Becoming Available in Civilian Populations ²⁴
Concentration After Dilution & Storage: ¹⁹
- Hematocrit: 35-38%
- Platelet Count: 150,000-200,000
- Coagulation Factors: 85% of Normal
May Decrease Transfusion Requirements & Mortality Although Evidence Insufficient
*Many Still Advocate Whole Blood as the Best Available Resuscitation Product

Adjuncts

Tranexamic Acid (TXA)

MOA: Inhibits Plasminogen Conversion to Plasmin, Inhibiting Fibrinolysis & Clot Breakdown
Off-Label Use in the US
Dosing: 1 g Bolus & Second 1 g Infusion Over 8 Hours
Recommended for Significant Hemorrhage if Given Within 3 Hours of Injury ¹⁵
- *Based Largely on the CRASH-2 RCT ²⁵
- If Given Within 3 Hours: Reduces Mortality and Blood Transfusions (Debated)
- If Given After 3 Hours: Increased Mortality ²⁶
No Evidence of Increased VTE Risk ¹⁵

Recombinant Activated Factor VIIa (rVIIa)

MOA: Activates Factor X & Thrombin Formation
Off-Label Use in the US
Dosing: 200 μg/kg Bolus Followed By 100 μg/kg at One & Three Hours ^27,28
Generally Fallen Out of Favor
- *Initially There was Significant Hype but Subsequent Studies Fail to Demonstrate Any Improved Outcomes ¹⁵

Cryoprecipitate

MOA: Replaces Fibrinogen
- Fibrinogen is the First Factor to Reach Critically Low Concentrations in Major Blood Loss & Low Levels are Associated with Poor Outcomes ^29,30
Insufficient Evidence to Guide Use

Vasopressors

Historically Been Considered Heresy in Hemorrhagic Shock Due to Increased Mortality ³¹
- *Evidence is However Poor with High-Risk of Bias Through Observational Studies ³²
Arginine Vasopressin (AVP)
- Dosing: 4-U Bolus & 0.04-U/min Infusion
- AVERT Shock Trial: ³³
  - Decreased Transfusion Requirements
  - No Change in Mortality
  - No Increased Risk of Complications but May Decrease Risk of DVT
- Insufficient Evidence to Definitively Guide Use

Pneumatic Antishock Garment (PASG)/Military Antishock Trousers (MAST)

Historical Tool, No Longer Used Today
Inflatable Garment to Promote Hemostasis and Manually Increases Peripheral Vascular Resistance (PVR)
- 3 Inflatable Compartments: Abdomen/Pelvis and x2 Legs
- Each Inflated/Deflated Separately
Was Previously Used in Pre-Hospital Settings
Compartments Released One-At-A-Time Once in ED
Contraindicated by Thoracic Trauma
No Improvement in Mortality & May Even Worsen ³⁴
Can Cause Lower Extremity Ischemia/Compartment Syndrome ³⁵
Non-Pneumatic Anti-Shock Garment (NASG) – A Variation that Creates Compression by Tension without the Use of Inflation

MAST/PSAG ³⁶

NASG ³⁷

Mnemonics

Possible Source of Occult Hemorrhage

Bloodied Patients Have Been “SCRAPT”
S: Street/In the Field
C: Chest
R: Retroperitoneum
A: Abdomen
P: Pelvis
T: Thighs

Hemorrhagic Shock Class (Percent Blood Loss)

Tennis Scoring System – Similar to How the Game Tennis is Scored
0-15-30-40
- Class I: < 15%
- Class II: > 15%
- Class III: > 30%
- Class IV: > 40%

References

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Hemorrhagic Shock & Trauma Resuscitation

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