**4. Resuscitation**

#### **4.1 Prehospital care**

Time is everything. Causa prima: optimization should be performed in cardiogenic shock, and treatment should be aimed at the underlying cause in hemorrhagic and septic shock. Survival of the patients with time-sensitive disorders like myocardial infarction or stroke can be made possible with prehospital arrangements, which should be performed in the patients with severe hemorrhage as well [70]. Minimizing the bleeding and limiting fluid resuscitation with large peripheral vascular access and immediate transfer to a center for ultimate treatment are limited options for prehospital care. Recent findings have demonstrated that when the patient can immediately be transported to the healthcare center for treatment, applying tourniquets to the proximal extremities to the origin of bleeding is lifesaving without leading to dysfunction or amputation of the extremities [71, 72]. Recent guidelines accept application of tourniquets in patients in whom direct compression cannot be performed during the first-aid procedures or during the prehospital interventions [73, 74]. In large injuries or injuries in joints such as groin and axilla, where tourniquets cannot be applied, a group of newly introduced homeostatic dressings have been demonstrated to be of benefit [75]. Canon demonstrated that, in a patient with a penetrating injury in the torso, delaying the intravenous fluid treatment starting from the urban treatment center until admission to the hospital for final treatment contributes to survival probably by preventing the development of dilutional coagulopathy [76].

Bickell et al. compared the outcomes of immediate and delayed fluid therapies in hypotensive patients with penetrating injuries and found out that survival rates at 62 and 70% were higher and serious complication rates from 30 to 23% were lower in delayed fluid treatment. In contrast to the predictions, the delayed fluid treatment was not disadvantageous but timesaving. The principal motivation of the treatment is to ensure a fast recovery in the patient with an acute injury favoring the transport of the patient compared to primary stabilization [77]. A number of experimental studies on animals' standard resuscitation associated with decreased oxygen delivery, increased rates of hemorrhage, reperfusion injuries, organ failures, and coagulopathies [16].

Duton et al. challenged the findings reported by Bickel et al. and suggested to limit the fluid therapy maintain systolic blood pressure around 70 mmHg using an intermediate approach rather than 100 mmHg as it is in the conventional standard methods. The results did not demonstrate any significant benefit in mortality [78].

In regard to damage control resuscitation (DCR), Holcomb suggested an exchange of plasma with limited amounts of volume and crystalloids and proposed an early use of plasma with limited support for systolic blood pressure [79]. Plasma helps prevent coagulopathy due to acidosis and hypothermia. In the daily clinical practice, the patients treated with conventional methods were compared with the patients to whom DCR was applied, resulting in findings favoring DCR. Increasing the blood volume may prevent the development of both acidosis and hypothermia. Plasma contains coagulation factors activated by temperature and brings the hydrogen ion concentrations to normal levels [80].

There is not any proof on that fluids are superior over each other in patients with trauma in the literature. Due to the fact that colloidal fluids quickly increase oncotic pressure, they are much faster than the plasma expansion colloidal fluids. Although crystalloids are cheap, benefits of colloid applications on survival could not be proved in the studies [81]. In a review of clinical studies dating back to 2002 with safety data documented in ICU patients who received hydroxyethyl starch (HES), gelatin, dextran, or albumin, Groeneveld et al. showed that impaired coagulation, clinical bleeding, and acute kidney injury were frequently reported after HES infusion [82].

Although blood to plasma ratios have not been definitely established yet, their increase from 1:8 to 1:1.4 provided a decrease in the mortality rates from 64 to 9% in injured patients with approximately the same severity [83]. Kashuk et al. reported that blood-plasma ratios of 1:2 improved the mortality rates and that fluid replacements with lactated ringer solution resulted in increased international normalized ratios [84]. A multi-center study reported that the daily clinical use of plasma-red blood cell ratios at 1:1 or more in civilians reduced the 24-hour mortality rates by half [85].

In the treatment of hemorrhagic shock, Velasco et al. brought resuscitation with hypertonic saline solution (HTS) to the forefront. Their studies were conducted both on animals and on the patients in hemorrhagic or septic shock using either HTS alone or HTS and 6% dextrane combination [86]. Vassar et al. reported the efficacy of the latter combination in injured patients in their country [87]. The purpose of this combination lied on the fact that HTS moved the intracellular fluid to the extracellular space, while dextrane kept a significant amount of that fluid in the vascular bed. The relative efficacy of 7.5% NaCl did not cause a significant change in the survival rates regardless of its use either alone or in combination with dextrane; however, it has been demonstrated that this mode of treatment increased the costs [88]. The Resuscitation Outcomes Consortium found out that neither HTS nor hypertonic dextrane solution provided benefits compared to the fluid resuscitation with normal saline solution during the prehospitalization period in a mixed population of patients with either penetrating or blunt injuries [89]. Similarly, albumin did not provide any benefits over crystalloid solutions [90]. A recent retrospective analysis of a cohort, where trauma patients in the war were compared, demonstrated that a prehospital transfusion of an erythrocyte suspension or plasma or a combination of both, all provided significant benefits on survival. However, a number of studies being conducted currently have reported that they do not provide benefits in the daily practice [91]. Current practice shows that the radial pulse should be maintained in the patients with serious hemorrhage in the prehospital interventions, and crystalloid solutions should be used in relatively smaller quantities to keep the patients conscious [92].

**51**

*Hemorrhagic Shock*

**4.2 Treatment**

*DOI: http://dx.doi.org/10.5772/intechopen.82358*

the use of cross-matched blood [100].

resuscitation with blood and blood products [93–95].

A successful resuscitation requires to stop the hemorrhage at all sources and to replace the intravascular volume immediately. These allow for preventing the mounting oxygen debt and replacing it [51]. In the trauma patients, a combination of damage-control surgery and damage-control resuscitation helps to achieve these objectives. In several hemorrhage cases except trauma, the patients similarly benefit from controlling the bleeding upon identifying the hemorrhage source and from

The arrival of a patient with hemorrhage at the hospital first requires restoration of the intravascular volume with fluid replacement and hemorrhage control. The strategies in replacing the intravascular volume include the conventional fluid resuscitation with plasma, platelet, red blood cells, or whole blood. Massive blood transfusion can be performed with universal blood products including packed red cells, plasma, platelets, and cryoprecipitate in predetermined volumes accompanied with the administration of several pharmaceutical agents like calcium and tranexamic acid at the patient bedside. These treatment protocols provide benefits for patients with acute hemorrhage in regard to survival [95]. Multiple scoring systems guide the therapeutic teams in identifying the need for massive blood transfusion. Any delays

A panel moderated by Sheldon et al. announced a warning stating that blood is the most dangerous drug we have ever used [97]. Potentially, the best alternative to replace the blood is the crystalloid solutions without colloid; its use should be followed by type-specific blood according to the specific need of a patient. The required multiple component therapy is provided by transfusing a single unit of whole blood. Increasing the hematocrit levels over 30% provides no benefits in injuries [98]. In a review evaluating the use of whole blood and blood expanders during the Vietnam war, Sheldon et al. suggested the use of type-specific fresh whole blood preferably [99]. Although the experts in the area agree that blood is the best fluid replacement therapy in hemorrhagic patients, blood transfusion is not free of risks. Therefore, the use of "blood substitutes" or administration of a blood component therapy or acellular oxygen carriers should be considered [98]. Gervin and Fischer have reported type-specific noncross-matched blood as a safer alternative option to

Red blood cell, plasma, and platelet ratios provide clinical values; however, the ratios have not been definitely established yet. A systemic review and two prospective studies reported that plasma, platelet, and red blood cell ratios around 1:1:1 were safe and decreased the mortality rates in trauma-associated hemorrhages. The general use is to administer six units of plasma and one unit of platelets processed by apheresis for each six units of red blood cells, which constitute an equivalent to six units of pooled thrombocytes [95, 101, 102]. A platelet to red blood cell ratio of over 1:2 has been demonstrated to reduce the mortality in the first 48 hours; however, plasma use at these ratios has not provided any benefits [103]. Barry et al. a total of 17 studies were included in this meta-analysis and including total of 10,610 patients. High fresh frozen plasma (FFP) to packed red blood cell ratios result low posthemorrhage mortality; however, the need for further optimization is highlighted as evidenced by reported increase in post-damage control resuscitation

(DCR) sepsis, MOF, and hospital lengths of stay among survivors [104].

All of these blood products contain citrate as an anticoagulant, which is metabolized rapidly by a healthy human liver. However, the use of high volumes of blood products may reach toxic doses in the patients in hemorrhagic shock and may lead to the development of life-threatening hypoglycemia and progressive coagulopathy

in actualizing the treatment protocols increase the mortality rates [96].
