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Hemorrhagic shock is caused by the loss of a significant amount of blood that results in inadequate cellular oxygen delivery and can eventually be a cause of sudden death. Hemorrhage can be caused by a number of factors, including trauma, gastrointestinal hemorrhage, post-operative hemorrhage, rupture of an aneurysm, and maternal hemorrhage (Mannucci PM, N Engl J Med 2007;356:2301) and represents a worldwide issue. Moreover, people who survive the initial hemorrhagic shock risk having poor functional outcomes and long-term mortality.

Hemorrhage causes an inadequate cellular oxygen delivery that results in a shift from aerobic to anaerobic metabolism (Barbee RW, Shock 2010;33:113–122), with an accumulation of lactic acid and oxygen radicals that lead to an inflammatory state, also maintained by damaged-associated molecular patterns. For these reasons cellular homeostasis fails and cell death by membrane rupture, apoptosis, or necroptosis soon follows. At the tissue level, hypovolemia and vasoconstriction cause hypoperfusion resulting in multiple organ failure (MOF), malignant arrhythmias, and brain anoxia. At the site of hemorrhage, a plug gets formed by the clotting cascade and the activation of platelets, at distance, instead, fibrinolytic activity increases to prevent microvascular thrombosis and an excess plasmin activity and autoheparinization can result in pathologic hyperfibrinolysis and diffuse coagulopathy.

Three additional iatrogenic factors can be responsible for a worsening of coagulopathy, and these are:

  • an exaggerated amount of crystalloid used for resuscitation dilutes the clotting factor concentrations.

  • infusion of cold fluids that decreases the body heat ending in a decreased enzymal function for the formation of platelets plug.

  • The use of a great deal of acidic crystalloid solutions increases the acidosis caused by hypoperfusion and decreases the function of clotting factors, thus resulting in an increase of coagulopathy, that together with hypothermia and acidosis contributes to cause the triad of death especially in trauma patients (Biswadev M, Emerg Med J. 2012;29(8):622–5).

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Colombo, S., Bissacco, D. (2022). Hemorrhagic Patient. In: Bissacco, D., Settembrini, A.M., Mazzari, A. (eds) Primary Management in General, Vascular and Thoracic Surgery. Springer, Cham.

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