The treatment of traumatic shock: recent advances and unresolved questions

Abstract

Uncontrolled bleeding remains a leading cause of potentially preventable death after trauma. Timely, adequate resuscitation in traumatic shock is an essential, lifesaving aspect of polytrauma care. Whilst basic principles in the treatment of traumatic shock remain the same-achieving hemorrhage control and replacing lost volume, the way this is achieved has changed significantly in the last five years. The abandonment of blood pressure driven uncontrolled fluid resuscitation, the introduction of the concept of hemostatic resuscitation, and the increasing use of massive transfusion protocols have all contributed to an improvement in timely access to various blood products. The increase in knowledge regarding the pathophysiology of trauma, the availability of adjuncts, and the array of resuscitation monitoring options available have all contributed to a potentially improved approach to resuscitation. The purpose of this report is to review the most important advances in traumatic shock therapy in the last five years.

Postinjury multiple organ failure in polytrauma: more frequent and potentially less deadly with less crystalloid

“…4 Cumulative incidence of extubation days in the presence of competing risk of death for admission years-2005, 2010 and 2015 [28]. The concept of haemostatic resuscitation, recognising the therapeutic end points as important, no longer targeting blood pressure but making an accurate assessment and then supporting organ perfusion whilst assessing and correcting coagulopathy and gaining anatomical control of any bleeding [28][29][30][31]. There was a gradual alignment with the prehospital services providers as they moved towards limiting crystalloid resuscitation.…”

The challenges and advances of polytrauma care in 2012

“…The current issue of the European Journal of Trauma and Emergency Surgery summarises some of the recent key developments of our understanding of the complexity of the polytrauma patients' response to injury [1,2] and some recent paradigm shifts in treatment [3,4].…”

“…The timing of surgical intervention in polytrauma patients is not necessarily a very new topic [3] but, most likely with our current approach of haemostatic resuscitation [4], will allow more severely injured patients (especially those with borderline physiology) to be treated with early total care. Haemostatic resuscitation simply does make sense; although there is no high level of evidence behind it, there is a tendency that it has rapidly put the crystalloid/colloid-based resuscitation with delayed blood and blood product administration into history.…”

Efeitos do choque hemorrágico seguido de ressuscitação na homeostasia em suínos

“…A reação inflamatória decorrente da hipóxia/isquemia caracteriza-se pela expressão aumentada de citocinas pró e anti-inflamatórias, bem como pelo aumento da formação de espécies reativas de oxigênio (ROS) e de nitrogênio (RNS) (12)(13)(14). Danos causados por ROS e RNS afetam proteínas, DNA e a membrana lipídica, podendo induzir necrose ou apoptose celular e, assim contribuindo para disfunções orgânicas (14)(15)(16)(17).…”

“…Uma das mais importantes citocinas pró-inflamatórias no CH é a interleucina 6 (IL-6), que regula a reação pró-inflamatória e é usada clinicamente como um marcador importante de gravidade da reação inflamatória (17,18).…”