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Initial Resuscitation and Management of the Hemodynamically Unstable Patient

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Common Problems in Acute Care Surgery

Abstract

Resuscitation during ongoing hemorrhagic shock restores physiologic balance by achieving control of hemorrhage and providing fluid and blood products, titrated to laboratory and clinical parameters. Phases of resuscitation occur in the pre-hospital environment, emergency room, operating room, interventional radiology suite, and intensive care unit (ICU) where multiple health care providers and physicians influence patient outcome by their attentiveness and diligence to this careful art.

The patient’s clinical picture is dynamic, in constant flux, requiring continuous attention to the details of the resuscitation. While profound hemorrhagic shock is easily recognized and its source targeted with haste, it is difficult to gain control of bleeding with meaningful outcome once cardiopulmonary collapse has occurred. Subtle signs of impending hemorrhagic shock often go unnoticed or unrecognized, but shock can be reversible when identified early in relation to the timing of the traumatic event. Coagulopathy must be prevented or corrected and temperature optimized in conjunction with source control. It is often not until entering the emergency department that patients receive the first unit of blood or blood product, and it generally is not until reaching the operating room or interventional radiology suite that effective control of bleeding is achieved. Many centers are pushing blood products to the pre-hospital area, and adjuncts for earlier truncal hemorrhage control will occur within the next several years.

Hemorrhagic shock correlates to a source of bleeding. Coagulopathy, acidosis, and hypothermia wreak havoc on metabolic processes and physiologic responses during the perioperative period. In the operating theater, surgeons frequently focus on operative management, while decisions regarding transfusion, colloid, and crystalloid administration are made by the anesthesiologist. Improved communication between these two specialties is essential to optimize patient outcomes. During damage control operations, bleeding is quickly controlled in preparation for further resuscitation in the ICU. Once in the ICU, serial laboratory values, continued resuscitation, and correction of the acidosis, hypothermia, and coagulopathy continue until the patient shows signs of stabilization, returns emergently to the operating room or interventional suite, or succumbs to death. This chapter outlines the general principles of resuscitation and future perspectives.

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Authors and Affiliations

  1. Department of Surgery, The Johns Hopkins Bayview Medical Center, Baltimore, MD, USA

    Diane A. Schwartz

  2. Division of Acute Care Surgery, Department of Surgery, The University of Texas Medical School at Houston, 6410 Fannin St., Houston, TX, 77030, USA

    John Holcomb

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Editors and Affiliations

  1. Department of Surgery, The University of Texas McGovern Medical School - Houston, Houston, Texas, USA

    Laura J. Moore

  2. General Surgery and Trauma Ben Taub Hospital, Houston, Texas, USA

    S. Rob Todd

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Schwartz, D.A., Holcomb, J. (2017). Initial Resuscitation and Management of the Hemodynamically Unstable Patient. In: Moore, L., Todd, S. (eds) Common Problems in Acute Care Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-42792-8_1

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