Hemorrhagic shock patients

Generally, the major adverse effects associated with colloids are fluid overload, dilutional coagulopathy, and anaphy-lactoid/anaphylactic reactions.24,32 Although derived from pooled human plasma, there is no risk of disease transmission from commercially available albumin or PPF products since they are heated and sterilized by ultrafiltration prior to distribution.24 Because of direct effects on the coagulation system with the hydroxyethyl starch and dextran products, they should be used cautiously in hemorrhagic shock patients. This is another reason why crystalloids maybe preferred in hemorrhagic shock. Furthermore, hetastarch can result in an increase in amylase not associated with pancreatitis. As such, the adverse-effect profiles of the various fluid types should also be considered when selecting a resuscitation fluid. 

In two other trials, one in the United States and the other in Europe, DCLHb was tested in trauma and hemorrhagic shock patients as an adjunct to the current therapies for enhancing oxygen delivery fluids, blood, and operative intervention. In the multicenter, randomized, controlled, single-blinded efficacy trial conducted at 18 U.S. trauma centers from Feb 1997 to Jan 1998, patients with presumed or proven hemorrhage and persistent hypoperfusion were treated with DCLHb or normal saline (control) solution. Although there were no restrictions in the use of fluids, blood, or any other intervention prior to enrollment in this study, once enrolled, the patient received 500 ml of the treatment solution no later than 30 min after first... 

Blood products are indicated in adult hypovolemic shock patients who have sustained blood loss from hemorrhage exceeding 1500 mL. 

Morphine releases histamine and may cause peripheral vasodilation and orthostatic hypotension (Figure 47.7). The cutaneous blood vessels dilate around the blush areas such as the face, neck, and upper thorax. Morphine causes cerebral vasodilation (due to increased carbon dioxide retention secondary to respiratory depression), and hence, it increases the cerebrospinal fluid pressure. Therefore, morphine should be used cautiously in patients with either meningitis or a recent head injury. When given subcutaneously, morphine is absorbed poorly whenever there is either traumatic or hemorrhagic shock. 

There is some evidence that the responsiveness of the adrenal cortex to stress is related to blood flow through the gland. Patients in severe shock have been found to have very low plasma cortisol levels, which rise sharply after successful resuscitation (F2). Experimental studies show that cortisol production rose promptly with modest hemorrhage, but fell rapidly when shock was produced (Ml). There is also evidence that in severe hypovolemic states the blood flow is preferentially shunted from the adrenal cortex to the adrenal medulla (Ml). Interpretation of plasma cortisol levels in shocked patients is thus difiBcult without some idea of adrenal perfusion. 

A study in which a number of head injury patients were divided into groups depending on the severity of the injury showed a smaller rise in insulin levels in the first 3-5 days in the more severely injured. This fall in insulin levels as the severity of injury increases is probably related to catecholamine secretion. A decreased insulin response has also been observed following cardiogenic shock (D2) and hemorrhagic shock (B3). 

A major anticipated use of acellular Hb would be for the emergency treatment of patients with traumatic hemorrhagic shock. The probability of associated bacterial infections in this patient population is high. Thus, the potential for hemoglobin to potentiate or exacerbate bacterial infection has been discussed widely. 

Microbial translocation, particularly bacterial, is a possible cause of activation of SIRS. Surgical patients are at a high risk of bacterial translocation secondary to enteric overgrowth, intestinal ischemia, bowel status, or hemorrhagic shock. However, significance of bacterial translocation in the development of MODS is unclear. 

As you assess the patients, be aware that early causes of death in these patients are due to lung injuries, neurological injuries, and hemorrhagic shock. Ym may have to support respiration, but do so very carefully because positive-pressure ventilation may cause a pneumothorax in the lung-injured patient. 

Table 3.5. Estimated fluid and blood losses based on hemorrhagic shock severity class on patient s initial presentation. From [42], with permission...

Eastridge BJ, Starr A et al. (2002) The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 53(3) 446-50 discussion 450-1... 

Normal saline is an isotonic fluid composed of water, sodium, and chloride. It provides primarily ECF replacement and can be used for virtually any cause of TBW depletion. Common uses of normal saline include perioperative fluid administration volume resuscitation of shock, hemorrhage, or burn patients fluid challenges in hypotensive or oliguric patients and hyponatremia. 

CDC Case Definition A mosquito-borne viral illness characterized by acute onset and constitutional symptoms followed by a brief remission and a recurrence of fever, hepatitis, albuminuria, and symptoms and, in some instances, renal failure, shock, and generalized hemorrhages. Laboratory criteria for diagnosis is (1) fourfold or greater rise in yellow fever antibody titer in a patient who has no history of recent yellow fever vaccination and cross-reactions to other flaviviruses have been excluded or (2) demonstration of yellow fever virus, antigen, or genome in tissue, blood, or other body fluid. 

In the management of PE, thrombolytics restore pulmonary artery patency more rapidly when compared to UFH alone, but this early benefit does not improve long-term patient outcomes. Thrombolytic therapy has not been shown to improve morbidity or mortality and is associated with a substantial risk of hemorrhage. For these reasons, thrombolytics should be reserved for patients with PE who are most likely to benefit (e.g., those who present with shock, hypotension, right ventricular strain, or massive DVT with limb gangrene). 

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