**5. Conclusion**

*Clinical Management of Shock - The Science and Art of Physiological Restoration*

monitored at frequent intervals.

have been demonstrated as discussed previously.

[68, 105]. Empirically, 1 gram of calcium chloride infusion can be administered following four units of blood product infusion, and the electrolyte levels should be

Resuscitation with isotonic crystalloids has been in use for decades since the historical treatments for hemorrhage. However, isotonic crystalloids provide no intrinsic benefits other than increasing the intravascular volume temporarily. Complication rates are increased after high-volume infusions of isotonic crystalloids. The potential complications may include respiratory failure, compartment syndromes in the abdomen or in the extremities, and coagulopathy. In acute

hemorrhagic trauma patients, it is recommended to administer crystalloid infusions in the first 6 hours of admission to the hospital, but the volume of infusion should not exceed 3 l [106]. Blood products are not included in this limit. No benefits of prehospital resuscitation with colloid, dextran, and hypertonic saline infusions

Pruit et al. found out that fluid resuscitation with normal saline was sufficient to replace both the blood loss and the sequestrated extravascular fluid in males with a moderate level of hemorrhage [107]. Lactated ringer's solution has found to be superior probably because it does not contain acetate or magnesium, and its chlorine content is low [108]. Recent studies stress that infusion of normal saline may lead to hyperchloremic acidosis. In addition, caution is advised against uncontrolled use of crystalloids [109, 110]. The experiences during the times of war showed that administration of blood in combination with protein-free fluids did not cause edema and did not lower the serum albumin levels in severely injured persons [111]. Procoagulant hemostatic such as activated recombinant factor VII, tranexamic acid, prothrombin complex concentrate, and fibrinogen concentrate can be included in the treatment in patients with hemorrhage [112]. The use of procoagulant hemostatic is off-label in patients receiving warfarin and in patients with hemophilia except for the use of prothrombin complex concentrate in the former group of patients and the use of activated recombinant factor VII and tranexamic acid in the latter, respectively. Vasopressin, included in the treatment of patients in hemorrhagic shock, reduces the need for administering blood products and fluids [113]. Prolonged hemostasis in pelvic fractures or in patients with a ruptured aneurysm of aorta or with gastrointestinal bleeding causes an increased need for blood transfusion, elevates the risk levels for mortality, or it may cause both of them simultaneously [114–116]. The duration of emergency department stay should be less than 10 minutes to make a diagnosis and start the initial treatment for trauma patients with hemorrhage in the body in order to keep the mortality risk at a relatively lower level [116]. Patients bleeding out of their extremities, who were applied tourniquets, should be immediately operated to perform a vascular exploration. In a patient bleeding into more than one space in the body, vascular exploration should be performed in the space where most of the bleeding occurs in order to reduce

Regardless of the origin of bleeding, the patients with abdominal or pelvic hemorrhage may benefit from the endovascular occlusion of the aorta as a temporary measure. This approach is called as resuscitative endovascular balloon occlusion of aorta (REBOA). In severe bleeding, this approach reduces the perfusion pressure distal to the origin of bleeding, increases the afterload, and the remaining blood volume is redirected especially to the brain and heart. REBOA reduces intraoperative mortality in patients with a ruptured aneurysm of the abdominal aorta [118]. The method can also be used in gastrointestinal bleeding or in peripartum

Aoki et al. reported that the use of vasopressor agents increases mortality in the

traumatic hemorrhagic shock in the retrospective cohort study [120].

**52**

mortality [117].

hemorrhages [119].

The definite treatment of hemorrhage is to stop the bleeding in its source as soon as possible. However, almost all of these hemorrhages occur at locations away from the hospitals. The time from the start of the bleeding until the time of intervention and the ultimate treatment is critical in the management of hemorrhages occurring due to an illness or due to trauma. Then, the primary approach should aim to shorten this period. Critical time is considerably exceeded when the time required for fluid resuscitation is added to the time elapsed at the scene where hemorrhage occurred. Crystalloid solutions are always at our disposal, and they are cheap and available fluids for intravenous use. Physiological saline administration in high volumes is a cause for increased mortality. No kinds of crystalloid fluids are superior to the other. What can be their alternatives? Type-specific blood and blood products have limitations in their supply, storage, and transport to the event scene. If the supply of these products and their storage can be achieved especially in the absence of cold chain facilities, they can provide solutions to the existing issues; however, the near future is not promising at all in this respect. There is continuing research on the use of 0-type whole blood and the use of freeze-dried plasma in the management of patients with trauma-associated hemorrhage [121, 122].

Systems, preventing the blood loss mechanically, such as REBOA can be developed. Generally, the first people to arrive at the scene are paramedics and young doctors. The required time and feasibility of applying these systems to a patient with weakened or no peripheral pulses in the adverse conditions of the scene during the induced sense of panic should be reviewed and estimated in detail.

We may suggest that hemorrhage and hemorrhagic shock has been an issue since the initial existence of humanity. Initiated by a toxin hypothesis, the understanding in physiopathology of shock has already been advanced; however, our achievements in terms of creating solutions to the existing problems are still limited. Technology progresses at a faster pace in terms of creating a trauma, causing injuries, and killing people compared to its advances in maintaining survival.
