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Choc hémorragique chez l’enfant

Hemorrhagic shock in children

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Médecine Intensive Réanimation

Résumé

Le choc hémorragique est une situation à haut risque de morbimortalité. Le pronostic du patient dépend de la rapidité de prise en charge du choc et de la vitesse de correction des troubles de l’hémostase. Il est donc important d’en faire rapidement le diagnostic; celui-ci est essentiellement clinique, facile en cas de saignement extériorisé. Sa reconnaissance peut cependant être difficile chez l’enfant du fait de ses particularités physiopathologiques, particulièrement en cas d’hémorragie interne. La prise en charge associe hémostase de la lésion hémorragique et réanimation hémodynamique pour maintenir une oxygénation cellulaire satisfaisante. L’efficacité du traitement s’apprécie d’abord sur les paramètres hémodynamiques classiques: fréquence cardiaque, pression artérielle moyenne, perfusion cutanée, conscience et diurèse horaire, notamment. Néanmoins, les signes cliniques peuvent être insuffisants pour évaluer le statut hémodynamique, et la mesure de la pression artérielle non invasive peut être imprécise; il est souvent nécessaire de monitorer la pression artérielle invasive dans les cas les plus sévères. Le concept du damage control resuscitation, initialement décrit chez l’adulte, peut être appliqué à l’enfant en tenant compte de ses particularités anatomophysiologiques. Le principe repose sur une réanimation ciblant la triade létale (coagulopathie–acidose–hypothermie) associée à un geste d’hémostase rapide permettant une stabilisation physiologique. Le traitement définitif de la lésion est réalisé une fois le patient stabilisé ou quand tous les patients ont été traités en cas d’afflux de victimes. Le principe du damage control s’applique dès la prise en charge initiale, sur les lieux mêmes d’un accident ou à domicile et se poursuit après l’admission à l’hôpital.

Abstract

Hemorrhagic shock is a situation with a high risk of morbidity and mortality. The recovery widely depends on early and effective treatment. Diagnosis mainly relies upon physical examination and is usually easy in the case of external bleeding. However, diagnosis may be difficult in children because of some pathophysiological particularities, especially in the case of internal hemorrhage. The management of treatment includes the combination of hemostasis of the hemorrhagic lesion and hemodynamic resuscitation to maintain adequate tissue oxygenation. The effectiveness of treatment is first assessed on conventional hemodynamic parameters, including mean arterial pressure, which is the driving perfusion pressure for organs, as well as hourly urine output. Nevertheless, clinical signs may be insufficient to assess precisely the hemodynamic status, while noninvasive blood pressure measurement may be inaccurate. Therefore, it is often necessary to monitor blood pressure invasively, especially in the most severe cases. The concept of damage control resuscitation was first described in adults but can also be applied to children with uncontrolled bleeding; however, some anatomo-physiological particularities of children need to be taken into account. The concept prioritizes short-term physiological recovery and is mainly based on resuscitative maneuvers targeting the lethal triad (coagulopathy, acidosis, and hypothermia), in association with damage control surgery. Definitive repair of all injuries is performed once the patient is stabilized or when all patients have received primary care in case of multiple casualties. The damage control concept starts at the scene of an accident or at home and continues during transport and on admission to the hospital.

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Authors and Affiliations

  1. Fédération des réanimations chirurgicales pédiatriques, hôpital universitaire Necker–Enfants-Malades, AP–HP, université Paris-Descartes, 149, rue de Sèvres, F-75743, Paris cedex 15, France

    G. Orliaguet, E. Vergnaud, C. Duracher & P. Meyer

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  1. G. Orliaguet
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  2. E. Vergnaud
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  3. C. Duracher
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  4. P. Meyer
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Correspondence to G. Orliaguet.

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Orliaguet, G., Vergnaud, E., Duracher, C. et al. Choc hémorragique chez l’enfant. Méd. Intensive Réa 25, 619–627 (2016). https://doi.org/10.1007/s13546-016-1230-3

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  • DOI: https://doi.org/10.1007/s13546-016-1230-3

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