Initial Resuscitation of Hemorrhagic Shock and Massive Transfusion Protocol

Abstract

Hemorrhage is considered the most preventable cause of in-hospital deaths worldwide, especially in the acute exsanguinating trauma setting. All the substantial bleeding patients in acute scenarios such as trauma, major surgery, gastrointestinal (GI) tract hemorrhage, aortic aneurysmal rupture, and postpartum hemorrhage (PPH) represent a major challenge of the daily practical activity of anesthesiologists and intensivists, both with surgeons and/or interventional radiologists, facing possible life-threatening blood loss, coagulation derangements, metabolic disorders, and finally, complex profound microcirculation and tissue disorders. The management of bleeding in these patients involves outstanding clinical aspects, requiring a pathophysiological and, possibly, a clinicopathological approach. Acidemia, hypothermia, and low calcium levels all play a pivotal role in persistent coagulopathy in massively bleeding patients. Less than prior fluid administration seeks to minimize overloads resulting in tissue edema and organ failure, dilutional coagulopathy, and coagulation interferences including the “popping the clot” effect, endothelial damage with resulting glycocalyx shedding with effects on increased permeability and interstitial edema, and activation of both inflammatory and coagulation systems with very similar consequences like those observed in sepsis state. Rapid identification of patients who are actively bleeding and need early activation and treatment adopting a massive transfusion protocol in the first hours represents the main objectives of the entire working team. To restore physiology and homeostasis, in parallel with hemostatic control as soon as possible, represents the primary care project of all the involved specialists managing a critical bleeding patient within a first-line position and partnership like blood bankers, beyond trauma surgeons and the other specialists always at work in the emergency department, in order to ameliorate the trauma team as well and to manage such a precious resource as blood and blood components.