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Hemorrhagic Shock

Hemorrhagic Shock

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Published by Rickky Kurniawan,MD
Hemorrhagic shock is a condition of reduced tissue perfusion, resulting in the inadequate delivery of oxygen and nutrients that are necessary for cellular function. Whenever cellular oxygen demand outweighs supply, both the cell and the organism are in a state of shock.
Hemorrhagic shock is a condition of reduced tissue perfusion, resulting in the inadequate delivery of oxygen and nutrients that are necessary for cellular function. Whenever cellular oxygen demand outweighs supply, both the cell and the organism are in a state of shock.

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Published by: Rickky Kurniawan,MD on Jul 14, 2011
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10/22/2013

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Advanced Trauma Life Support_Journal@2011
Hemorrhagic Shock 
 Published By : Rickky Kurniawan,MD(member of MedScape)
1
Hemorrhagic Shock 
Author :
John Udeani, MD, FAAEM
 
Assistant Professor, Department of Emergency Medicine, Charles DrewUniversity of Medicine and Science, University of California, Los Angeles, David Geffen School of Medicine
 
,
Chief Editor : John Geibel, MD, DSc, MA
Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital
Background
Hemorrhagic shock is a condition of reduced tissue perfusion, resulting in theinadequate delivery of oxygen and nutrients that are necessary for cellular function. Whenever cellular oxygen demand outweighs supply, both the cell andthe organism are in a state of shock.On a multicellular level, the definition of shock becomes more difficult becausenot all tissues and organs will experience the same amount of oxygen imbalancefor a given clinical disturbance. Clinicians struggle daily to adequately define andmonitor oxygen utilization on the cellular level and to correlate this physiology touseful clinical parameters and diagnostic tests.The 4 classes of shock, as proposed by Alfred Blalock, are as follows:
[1]
Hypovolemic
Vasogenic (septic)
Cardiogenic
NeurogenicHypovolemic shock, the most common type, results from a loss of circulatingblood volume from clinical etiologies, such as penetrating and blunt trauma,gastrointestinal bleeding, and obstetrical bleeding. Humans are able tocompensate for a significant hemorrhage through various neural and hormonalmechanisms. Modern advances in trauma careallow patients to survive whenthese adaptive compensatory mechanisms become overwhelmed.
Pathophysiology
Well-described responses to acute loss of circulating volume exist.Teleologically, these responses act to systematically divert circulating volumeaway from nonvital organ systems so that blood volume may be conserved for vital organ function. Acute hemorrhage causes a decreased cardiac output anddecreased pulse pressure. These changes are sensed by baroreceptors in theaortic arch and atrium. With a decrease in the circulating volume, neural reflexes
 
Advanced Trauma Life Support_Journal@2011
Hemorrhagic Shock 
 Published By : Rickky Kurniawan,MD(member of MedScape)
2
cause an increased sympathetic outflow to the heart and other organs. Theresponse is an increase in heart rate, vasoconstriction, and redistribution of bloodflow away from certain nonvital organs, such as the skin, gastrointestinal tract,and kidneys.Concurrently, a multisystem hormonal response to acute hemorrhage occurs.Corticotropin-releasing hormone is stimulated directly. This eventually leads toglucocorticoid and beta-endorphin release. Vasopressin from the posterior pituitary is released, causing water retention at the distal tubules. Renin isreleased by the juxtamedullary complex in response to decreased mean arterialpressure, leading to increased aldosterone levels and eventually to sodium andwater resorption. Hyperglycemia commonly is associated with acute hemorrhage.This is due to a glucagon and growth hormone–induced increase ingluconeogenesis and glycogenolysis. Circulating catecholamines relatively inhibitinsulin release and activity, leading to increased plasma glucose.In addition to these global changes, many organ-specific responses occur. Thebrain has remarkable autoregulation that keeps cerebral blood flow constant over awide range of systemic mean arterial blood pressures. The kidneys can toleratea90% decrease in total blood flow for short periods of time. With significantdecreases in circulatory volume, intestinal blood flow is dramatically reduced bysplanchnic vasoconstriction. Early and appropriate resuscitation may avertdamage to individual organs as adaptive mechanisms act to preserve theorganism.
Epidemiology
Age
Hemorrhagic shock is tolerated differently, depending on the preexistingphysiologic state and, to some extent, the age of the patient. Very young andvery old people are more prone to early decompensation after loss of circulatingvolume.
Pediatric patients have smaller total blood volumes and, therefore, are at risk tolose a proportionately greater percentage of blood on an equivalent-volumebasis during exsanguination compared to adults. The kidneys of childrenyounger than 2 years are not mature; they have a blunted ability to concentratesolute. Younger children cannot conserve circulating volume as effectively asolder children. Also, the body surface area is increased relative to the weight,allowing for rapid heat loss and early hypothermia, possibly leading tocoagulopathy.
Elderly people may have both altered physiology and preexisting medicalconditions that may severely impair their ability to compensate for acute blood
 
Advanced Trauma Life Support_Journal@2011
Hemorrhagic Shock 
 Published By : Rickky Kurniawan,MD(member of MedScape)
3
loss. Atherosclerosis and decreased elastin cause arterial vessels to be lesscompliant, leading to blunted vascular compensation, decreased cardiacarteriolar vasodilation, and angina or infarction when myocardial oxygendemand is increased. Older patients are less able to mount a tachycardia inresponse to decreased stoke volume because of decreased beta-adrenergicreceptors in the heart and a decreased effective volume of pacing myocyteswithin the sinoatrial node. Also, these patients frequently are treated with avariety of cardiotropic medications that may blunt the normal physiologicalresponse to shock. These include beta-adrenergic blockers, nitroglycerin,calcium channel blockers, and antiarrhythmics.
The kidneys also undergo age-related atrophy, and many older patients havesignificantly decreased creatinine clearance in the presence of near-normalserum creatinine. Concentrating ability may be impaired by a relativeinsensitivity to antidiuretic hormone. These changes in the heart, vessels, andkidneys can lead to early decompensation after blood loss. All of these factorsin concert with comorbid conditions make management of elderly patients withhemorrhage quite challenging.
History
No single historical feature is diagnostic of shock. Some patients may reportfatigue, generalized lethargy, or lower back pain (ruptured abdominal aorticaneurysm). Others may arrive by ambulance or in the custody of lawenforcement for the evaluation of bizarre behavior.
Obtaining a clear history of the type, amount, and duration of bleeding is veryimportant. Many decisions in regard to diagnostic tests and treatments arebased on knowing the amount of blood loss that has occurred over a specifictime period.
If the bleeding occurred at home or in the field, an estimate of how muchblood was lost is helpful.
For GI bleeding, knowing if the blood was per rectum or per os is important.Because it is hard to quantitate lower GI bleeding, all episodes of bright redblood per rectum should be considered major bleeding until proven otherwise.
Bleeding because of trauma is not always identified easily. The pleural space,abdominal cavity, mediastinum, and retroperitoneum are all spaces that canhold enough blood to cause death from exsanguination.
External bleeding from trauma can be significant and can be underestimatedby emergency medical personnel.
Scalp lacerations are notorious for causing large underestimated blood loss.
Multiple open fractures can lead to the loss of several units of blood.

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