Hemorrhagic Shock Clinical Presentation

Author: John Udeani, MD, FAAEM; Chief Editor: John Geibel, MD, DSc, MA more...
Updated: Dec 6, 2012
History
No single historical feature is diagnostic of shock. Some patients may report fatigue, generalized lethargy, or lower
back pain (ruptured abdominal aortic aneurysm). Others may arrive by ambulance or in the custody of law
enforcement for the evaluation of bizarre behavior.
Obtaining a clear history of the type, amount, and duration of bleeding is very important. Many decisions in regard to
diagnostic tests and treatments are based on knowing the amount of blood loss that has occurred over a specific
time period.
If the bleeding occurred at home or in the field, an estimate of how much blood was lost is helpful.
For GI bleeding, knowing if the blood was per rectum or per os is important. Because it is hard to quantitate lower GI
bleeding, all episodes of bright red blood per rectum should be considered major bleeding until proven otherwise.
Bleeding because of trauma is not always identified easily. The pleural space, abdominal cavity, mediastinum, and
retroperitoneum are all spaces that can hold enough blood to cause death from exsanguination.
External bleeding from trauma can be significant and can be underestimated by emergency medical personnel.
Scalp lacerations are notorious for causing large underestimated blood loss.
Multiple open fractures can lead to the loss of several units of blood.
Physical
The physical examination in patients with hemorrhagic shock is a directed process. Often, the examination will be
paramount in locating the source of bleeding and will provide a sense of the severity of blood loss. Differences exist
between medical patients and trauma patients in these regards. Both types of patients usually will require concurrent
diagnosis and treatment.
The hallmark clinical indicators of shock have generally been the presence of abnormal vital signs, such as
hypotension, tachycardia, decreased urine output, and altered mental status. These findings represent secondary
effects of circulatory failure, not the primary etiologic event. Because of compensatory mechanisms, the effects of
age, and use of certain medications, some patients in shock will present with a normal blood pressure and pulse.
However, a complete physical examination must be performed with the patient undressed.
The general appearance of a patient in shock can be very dramatic. The skin may have a pale, ashen color, usually
with diaphoresis. The patient may appear confused or agitated and may become obtunded.
The pulse first becomes rapid and then becomes dampened as the pulse pressure diminishes. Systolic blood
pressure may be in the normal range during compensated shock.
The conjunctivae are inspected for paleness, a sign of chronic anemia. The nose and pharynx are inspected for
blood.
The chest is auscultated and percussed to evaluate for hemothorax. This would lead to loss of breath sounds and
dullness to percussion on the side of bleeding.
News & Perspective
Drugs & Diseases
CME & Education
Log In
Register
The abdominal examination searches for signs of intra-abdominal bleeding, such as distention, pain with palpation,
and dullness to percussion. The flanks are inspected for ecchymosis, a sign of retroperitoneal bleeding. Ruptured
aortic aneurysms are one of the most common conditions that cause patients to present in unheralded shock. Signs
that can be associated with a rupture are a palpable pulsatile mass in the abdomen, scrotal enlargement from
retroperitoneal blood tracking, lower extremity mottling, and diminished femoral pulses.
The rectum is inspected. If blood is noted, take care to identify internal or external hemorrhoids. On rare occasion,
these are a source of significant bleeding, most notably in patients with portal hypertension.
Patients with a history of vaginal bleeding undergo a full pelvic examination. A pregnancy test is warranted to rule out
ectopic pregnancy.
Trauma patients are approached systematically, using the principles of the primary and secondary examination.
Trauma patients may have multiple injuries that need attention concurrently, and hemorrhage may accompany other
types of insults, such as neurogenic shock.
The primary survey is a quick maneuver that attempts to identify life-threatening problems, as follows:
To assess the airway, ask the patient's name. If the answer is articulated clearly, the airway is patent.
The oral pharynx is inspected for blood or foreign materials.
The neck is inspected for hematomas or tracheal deviation.
The lungs are auscultated and percussed for signs of pneumothorax or hemothorax.
The radial and femoral pulses are palpated for strength and rate.
A quick inspection is made to rule out any external sources of bleeding.
A gross neurological examination is performed by asking the patient to squeeze each hand and dorsiflex both
feet against pressure. Advanced trauma life support (ATLS) suggests that a "miniature" neurologic
examination categorizes the patient's level of consciousness by whether the patient is alert, responds to
voice, responds to pain, or is unresponsive (ie, AVPU).
The patient then is exposed completely, taking care to maintain thermoregulation with blankets and external
warming devices.
The secondary examination is a head-to-toe, careful examination that attempts to identify all injuries, as follows:
The scalp is inspected for bleeding. Any active bleeding from the scalp should be controlled before
proceeding with the examination.
The mouth and pharynx are examined for blood.
The abdomen is inspected and palpated. Distention, pain on palpation, and external ecchymosis are
indications of intra-abdominal bleeding.
The pelvis is palpated for stability. Crepitus or instability may be an indication of a pelvis fracture, which can
cause life-threatening hemorrhage into the retroperitoneum.
Long bone fractures are noted by localized pain to palpation and boney crepitus at the site of fracture. All long
bone fractures should be straightened and splinted to prevent ongoing bleeding at the sites. Femur fractures
are especially prone to large blood losses and should be immobilized immediately in a traction splint.
Further diagnostic tests are warranted to diagnose intrathoracic, intra-abdominal, or retroperitoneal bleeding.
Causes
Hemorrhagic shock is caused by the loss of both circulating blood volume and oxygen-carrying capacity. The most
common clinical etiologies are penetrating and blunt trauma, gastrointestinal bleeding, and obstetrical bleeding.
Contributor Information and Disclosures
Author
John Udeani, MD, FAAEM Assistant Professor, Department of Emergency Medicine, Charles Drew University of
Medicine and Science, University of California, Los Angeles, David Geffen School of Medicine
John Udeani, MD, FAAEM is a member of the following medical societies: American Academy of Emergency
Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.
Specialty Editor Board
Lewis J Kaplan, MD, FACS, FCCM, FCCP Director, SICU and Surgical Critical Care Fellowship, Associate
Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale
University School of Medicine
Hemorrhagic Shock Differential Diagnoses
Author: John Udeani, MD, FAAEM; Chief Editor: John Geibel, MD, DSc, MA more...
Updated: Dec 6, 2012
Differential Diagnoses
Abdominal Trauma, Blunt
Abdominal Trauma, Penetrating
Abruptio Placentae
Ampullary Carcinoma
Angiodysplasia of the Colon
Angiofibroma
Angiosarcoma
Aortic Dissection
Benign Gastric Tumors
Benign Neoplasm of the Small Intestine
Bile Duct Tumors
Biliary Trauma
Bladder Trauma
Blunt Chest Trauma
Carcinoma of the Ampulla of Vater
Cardiac Tamponade
Colon Cancer, Adenocarcinoma
Colonic Polyps
Corpus Luteum Rupture
Disseminated Intravascular Coagulation
Diverticulosis, Small Intestinal
Duodenal Ulcers
Dysfibrinogenemia
Dysfunctional Uterine Bleeding
Ectopic Pregnancy
Esophageal Varices
Esophagitis
Gastric Ulcers
Gastritis, Acute
Hemangioblastoma
Hemangiomas, Hepatic
Hemolytic Anemia
Hemolytic-Uremic Syndrome
Hemophilia, Overview
Hemorrhoids
Hemostatic Disorders, Nonplatelet
Hemothorax
Hypersensitivity Reactions, Immediate
Immune Thrombocytopenic Purpura
Inflammatory Bowel Disease
Initial Evaluation of the Trauma Patient
Intestinal Leiomyosarcoma
Intestinal Perforation
Intra-abdominal Sepsis
Mallory-Weiss Tear
News & Perspective
Drugs & Diseases
CME & Education
Log In
Register
Menorrhagia
Myocardial Rupture
Pancreatic Trauma
Pancreatitis, Acute
Penetrating Chest Trauma
Penetrating Head Trauma
Penetrating Neck Trauma
Perioperative Anticoagulation Management
Portal Hypertension
Renal Artery Aneurysm
Renal Trauma
Septic Shock
Shock, Distributive
Splenic Rupture
Toxic Shock Syndrome
Trauma and Pregnancy
Upper Gastrointestinal Bleeding
Contributor Information and Disclosures
Author
John Udeani, MD, FAAEM Assistant Professor, Department of Emergency Medicine, Charles Drew University of
Medicine and Science, University of California, Los Angeles, David Geffen School of Medicine
John Udeani, MD, FAAEM is a member of the following medical societies: American Academy of Emergency
Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.
Specialty Editor Board
Lewis J Kaplan, MD, FACS, FCCM, FCCP Director, SICU and Surgical Critical Care Fellowship, Associate
Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale
University School of Medicine
Lewis J Kaplan, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association
for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association for
Surgical Education, Connecticut State Medical Society, Eastern Association for the Surgery of Trauma,
International Trauma Anesthesia and Critical Care Society, Society for the Advancement of Blood Management,
Society of Critical Care Medicine, and Surgical Infection Society
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College
of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate
Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and
Harvard Medical School
Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics,
American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons
Disclosure: Nothing to disclose.
Timothy D Rice, MD Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent
Medicine, St Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and
American College of Physicians
Disclosure: Nothing to disclose.
Chief Editor
John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal
Hemorrhagic Shock Workup
Author: John Udeani, MD, FAAEM; Chief Editor: John Geibel, MD, DSc, MA more...
Updated: Dec 6, 2012
Laboratory Studies
Generally, laboratory values are not helpful in acute hemorrhage because values do not change from normal until
redistribution of interstitial fluid into the blood plasma occurs after 8-12 hours. Many of the derangements that
eventually occur are a result of replacing a large amount of autologous blood with resuscitation fluids.
Hemoglobin and hematocrit values remain unchanged from baseline immediately after acute blood loss. During the
course of resuscitation, the hematocrit may fall secondary to crystalloid infusion and re-equilibration of extracellular
fluid into the intravascular space.
No absolute threshold hematocrit or hemoglobin level that should prompt transfusion exists. A hemoglobin
concentration of less than 7 g/dL in the acute setting in a patient that was otherwise healthy is concerning only
because the value most likely will drop considerably after re-equilibration.
In the absence of preexisting disease, transfusions can be withheld until significant clinical symptoms are present or
the rate of hemorrhage is enough to indicate ongoing need for transfusion.
Patients with significant heart disease are at higher risk of myocardial ischemia with anemia, and transfusion should
be considered when values drop below 7 mg/dL.
Arterial blood gas may the most important laboratory value in the patient in severe shock.
Acidosis is the best indicator in early shock of ongoing oxygen imbalance at the tissue level. A blood gas with a pH of
7.30-7.35 is abnormal but tolerable in the acute setting. The mild acidosis helps unload oxygen at the peripheral
tissues and does not interfere with hemodynamics.
A pH below 7.25 may begin to interfere with catecholamine action and cause hypotension unresponsive to
inotropics. Although this is a time-honored concept, recent data do not find evidence of this phenomenon.
Metabolic acidosis is a sign of underlying lack of adequate oxygen delivery or consumption and should be treated
with more aggressive resuscitation, not exogenous bicarbonate. Life-threatening acidemia (pH < 7.2) initially may be
buffered by the administration of sodium bicarbonate to improve the pH. However, be aware that no survival benefit
to this practice has been documented.
Coagulation studies generally produce normal results in the majority of patients with severe hemorrhage early in the
course. The notable exceptions are patients who are on warfarin, low molecular weight heparin, or antiplatelet
medications or those patients with severe preexisting hepatic insufficiency.
If patients are unable to provide adequate medication histories, tests for primary and secondary hemostasis should
be ordered. The prothrombin time (PT) and the activated partial thromboplastin time (aPTT) will identify major
problems with secondary hemostasis.
The best test for platelet function is the bleeding time. This test is difficult to perform in the patient with acute
hemorrhage.
An alternative is thromboelastography, which is at least equivalent, and possibly superior, to the bleeding time. This
test is an ex vivo analysis of all of the components of clotting and has been used extensively in orthotopic hepatic
transplantation, cardiac surgery, and trauma.
Qualitative platelet dysfunction can be inferred in those patients with a clinical coagulopathy and normal PT and
News & Perspective
Drugs & Diseases
CME & Education
Log In
Register
aPTT values. Obviously, abnormal PT or aPTT values should be corrected emergently in the context of severe
hemorrhage.
Electrolyte studies usually are not helpful in the acute setting. After massive resuscitation, certain abnormalities can
occur.
Sodium and chloride may increase significantly with administration of large amounts of isotonic sodium chloride.
Hyperchloremia may cause a nonion gap acidosis and significantly worsen an existing acidosis.
Calcium levels may fall with large-volume, rapid blood transfusions. This is secondary to chelation of the calcium by
the ethylenediaminetetraacetic acid (EDTA) preservative in stored blood. Newer methods of blood banking avoid
using EDTA, and the problem of hypocalcemia should be minimized.
Likewise, potassium levels may rise with large-volume blood transfusions.
Creatinine and blood urea nitrogen usually are within normal limits unless preexisting renal disease is present.
Caution should be used when administering iodinated contrast in patients with elevated creatinine because the dye
load could initiate a contrast-induced nephropathy in addition to chronic renal impairment.
A blood specimen for type and crossmatch should be obtained as soon as the patient arrives.
For patients who are actively bleeding, 4 U of packed red blood cells (PRBCs) should be prepared, along with 4 U of
fresh frozen plasma (FFP). Platelets may be obtained as well, depending on the physician's estimation of the
likelihood of the need for platelet transfusion (less commonly needed compared to FFP).
Imaging Studies
Imaging studies are aimed at identifying the source of bleeding. In many types of severe hemorrhage, therapeutic
interventions, such as exploratory laparotomy, will preclude comprehensive diagnostic studies.
Chest radiographs
Chest radiographs indicate a diagnosis of hemothorax by showing a large opacity in one or both lung fields.
Hemothoraces large enough to cause shock usually are obvious as a complete whiteout of one pleural space.
Abdominal radiographs
Abdominal radiographs are rarely helpful. Hemoperitoneum usually will not be visible on plain film.
Occasionally, a radiograph will have a diffuse ground glass appearance, suggesting a large amount of intraperitoneal
fluid, but this sign is not reliable.
Rarely, a ruptured abdominal aortic aneurysm can be diagnosed by noting an incomplete shell (calcified wall) of a
dilated aorta.
Loss of the psoas shadow unilaterally also can suggest retroperitoneal blood.
CT scan
Computed tomography (CT) scan, as seen in the image below, is sensitive and specific for diagnosing intrathoracic,
intra-abdominal, and retroperitoneal bleeding. It is the test of choice for diagnosing bleeding in these cavities.
CT scan of a 26-year-old man after a motor vehicle crash shows a significant amount of intra-abdominal bleeding.
CT scan only has an adjunctive role in the diagnosis of GI bleeding when other tests have suggested a mass lesion
as part of the disease process.
Ultrasound is rapidly replacing CT scan as the diagnostic test of choice for the identification of hemorrhage in major
body cavities. It is, of course, limited in its ability to evaluate the retroperitoneum. Retroperitoneal evaluation remains
the purview of the CT scan.
Esophagogastroduodenoscopy
Esophagogastroduodenoscopy (EGD) is the test of choice for acute upper GI bleeding because it can provide a
specific diagnosis and has therapeutic potential.
Lavage the stomach with a large gastric tube before the procedure to remove as much clot as possible.
Capabilities for epinephrine injection and bipolar circumactive probe (BICAP) cautery should be available.
Aortoenteric fistulas are very rare and usually are caused by erosion of an aortic aneurysm into the duodenum. EGD
may be able to diagnose this problem, but the false-negative rate in these cases is very high.
Colonoscopy
Colonoscopy is used to diagnose acute lower GI bleeding.
It is considered by most to be difficult to perform in the acute setting and may fail to show the exact source of
bleeding in cases of rapid hemorrhage.
Although some experience exists with therapeutic interventions, such as cauterization for acute arteriovenous
malformation bleeding, these techniques are not used widely.
Ultrasound
Ultrasound is a useful technique to diagnose intraperitoneal bleeding in the trauma patient.
The focused abdominal sonographic technique (FAST) examination realistically has replaced diagnostic peritoneal
lavage as the test of choice for identifying intraperitoneal fluid in the trauma patient.
The FAST examination includes 4 anatomical views of the pericardium, abdomen, and pelvis that attempt to identify
free intra-abdominal fluid.
Bedside ultrasound can be performed by radiologists, surgeons, and emergency medicine physicians who have
specialized training and certification.
Angiography
Angiography is extremely useful in the diagnosis of acute hemorrhage from many different sources. Its utility is
limited by the availability of an angiographer on a timely basis.
In cases of lower GI bleeding, angiography is one of the best tests to localize a bleeding source. Angiography usually
can detect bleeding that is at least 1-2 mL/min. Selective angiograms of the celiac, superior mesenteric, and inferior
mesenteric arteries are performed to locate the areas of bleeding. The best time to perform the examination is when
the patient is actively bleeding. Once the source is identified, embolotherapy may be used as an acute means of
arresting hemorrhage. This will allow resuscitation to proceed prior to operation. If embolotherapy is not used, then
identifying the site of bleeding will allow a more limited bowel resection to be performed if surgery becomes indicated
during the admission.
Angiography can be used for diagnosis and management of severe bleeding from pelvic fractures. Although most
bleeding from severe pelvic fractures is venous in origin, occasional significant arterial bleeding can be diagnosed
and treated effectively with embolization.
Severe liver injuries pose a challenge to the trauma surgeon because of the large amounts of blood loss and the
difficulty in gaining surgical control quickly. Many severe liver injuries now are being diagnosed and treated with
angiographic embolization. Angiography is increasingly considered first-line intervention (before laparotomy) for
severe liver injuries in centers that are equipped to perform rapid angiography and angiographic intervention. Similar
methods may be used for other solid organ injuries, such as the spleen and kidney.
Angiography may be used in the diagnosis of massive hemoptysis of unclear etiology. Selective angiography of the
bronchial arteries, combined with a selective pulmonary angiogram through a separate venous catheterization can
localize bleeding.
The role of angiography in upper GI bleeding is more limited. Hemobilia is a rare cause of upper GI bleeding. If blood
definitely is observed emanating from the ampulla of Vater, angiography should be performed to localize and control
the source of bleeding.
Nuclear medicine scanning
Nuclear medicine scanning can be used to localize GI bleeding.
A tagged red blood cell scan may help differentiate upper from lower GI bleeding and may provide anatomic
information, such as identifying bleeding from the right versus left colon. Overlap of structures will confound the utility
and accuracy of this test.
The test requires a significant amount of time to complete, but it is very sensitive, detecting bleeding as slow as 0.5
mL/min.
Procedures
Diagnostic peritoneal lavage is a bedside procedure that utilizes a small midline laparotomy and insertion of a
catheter directly into the peritoneal cavity. Percutaneous insertion techniques are available but carry an increased
risk of injury to underlying structures.
The intent of diagnostic peritoneal lavage is to determine if significant intra-abdominal bleeding or injuries to hollow
organs are present.
If more than 5 mL of blood is aspirated, the test result is said to be grossly positive and laparotomy usually is
indicated.
If blood is not aspirated, 1000 mL of warm lactated Ringers solution is infused into the abdomen and then allowed to
drain out into the IV bag. The contents of the bag are examined in the lab. A red blood cell count of greater than
10,000 per L is considered a microscopically positive test result.
Other conditions that make the test results positive include the following: white blood cell count greater than 500/L;
high levels of amylase, lipase, or bilirubin; and particulate matter that may be from an intraluminal source.
Central venous access
Central venous access is considered an adjunct to large-bore (16- or 14-gauge) peripheral IV lines.
Flow through a catheter is inversely proportional to the length and directly proportional to the diameter. Thus, long
small-caliber lines, such as a standard triple lumen catheter, will deliver significantly less volume than a short large-
caliber line, such as a peripheral IV.
Large-bore (12F) central resuscitation lines
This large-bore sheath introducer is used for volume resuscitation. Smaller sizes are less effective but are more
effective than a standard multi-lumen central venous catheter.
If significant intra-abdominal bleeding from a venous injury is suspected, volume lines should be avoided in the
femoral veins.
In general, access above and below the site of an injury is a good practice. This allows the operator to switch the
primary resuscitation lines should one or more be ineffective or be positioned directly below an injury in the vessel in
which the catheter resides.
Chest tube
The initial management of a hemothorax involves the insertion of a large-caliber chest tube for drainage, or open
thoracotomy. In most patients with a hemothorax, tube thoracostomy alone is sufficient.
Surgical exploration with open thoracotomy is mandated in the presence of persistent bleeding; the presence of
more than 1500 mL of blood in the initial chest tube drainage; or drainage of more than 200 mL/h for 2-4 hours.

Protocolo Assistencial do Hospital Universitrio de Santa Maria


12
completo diminuem o dbito cardaco, enquanto que a fibrilao ventricular cessa o
dbito
3
.

Anormalidades mecnicas: incluem defeitos valvares, como ruptura de

msculo papilar ou cordoalha tendnea, estenose artica crtica, defeitos de septos
ventriculares, mixomas atriais e ruptura de aneurisma de parede ventricular
3
.

Anormalidades extracardacas (obstrutivas) incluem embolismo pulmonar

macio, pneumotrax hipertensivo, pericardite constritiva severa, tamponamento
pericrdico e hipertenso pulmonar severa.
Choque distributivo: h muitas causas, entre elas choque sptico, sndrome da
resposta inflamatria sistmica, sndrome do choque txico, anafilaxia e reaes anafilactides,
entre outras.

4. CRITRIOS DE INCLUSO
Pacientes maiores de 18 anos, com hipotenso arterial que no responde a
ressussitao volmica com 500 ml de soluo cristalide.

5. CRITRIO DE EXCLUSO
NA

6. TRATAMENTO
A sistematizao do atendimento inicial fundamental. D-se prioridade sempre ao
CAB: C (circulation) corresponde manuteno da circulao e deve-se sempre dar ateno
para as causas responsveis pela instabilidade hemodinmica, de modo a procurar o tratamento
definitivo do problema
2
. A (airway) corresponde ao acesso s vias areas de modo a mant-las
prvias e proteger contra obstruo; e B (breathing) corresponde adequada ventilao e
oxigenao.

Acesso venoso calibroso deve ser providenciado. Se no for possvel acesso

perifrico, deve ser providenciado um acesso venoso central. A escolha da soluo ainda tema
de controvrsia. Nem colide, nem cristalide parecem ser superiores um ao outro, porm o custo
das solues cristalides bem menor. Durante a reposio volmica, comum o aparecimento
de hipotermia, a qual deve ser prevenida pelo uso de solues cristalides aquecidas
1
. As
caractersticas das solues esto listadas na tabela 8.

Reposio volmica agressiva: a pr-carga deve ser aumentada, visto que quase
sempre h hipovolemia absoluta ou relativa. A quantidade inicial de fluidos deve ser sempre pelo
menos 20ml/Kg e deve ser monitorizada pela diminuio da taquicardia, melhora do volume
urinrio e do nvel neurolgico
1
.

Parmetros para monitorizar a reposio volmica: valores absolutos de presses

de enchimento, como PVC e presso de ocluso de artria pulmonar, no so bons parmetros,

Protocolo Assistencial do Hospital Universitrio de Santa Maria


13
pois os pacientes crticos tm alterao da complacncia cardaca. Apesar de a tendncia desses
valores ser importante, nenhum estudo correlacionou um determinado valor-alvo com melhor
prognstico
1
.

Falncia respiratria: deve ser tratada, no mnimo, com suplementao de

oxignio, e todos os pacientes com choque grave devem ser intubados e colocados em ventilao
mecnica para diminuir seu consumo de energia
1
.

Ps-carga: pacientes adequadamente ressuscitados do ponto de vista volmico,

que se apresentem normotensos ou hipertensos, so candidatos s terapias que interfiram na ps-
carga. Esse princpio mais utilizado em pacientes com choque cardiognico, para facilitar o
trabalho do ventrculo esquerdo. Geralmente, o agente de escolha nesse caso o nitroprussiato,
que um vasodilatador tanto venoso, quanto arterial. Em pacientes coronariopatas, a escolha
nitroglicerina, que produz vasodilatao das artrias coronrias. Durante a sepse, ocorre
preservao do fluxo sanguneo em reas de demanda metablica normal, e baixo fluxo em outras
com demandas mais altas (efeito shunt). Os nitratos e outros vasodilatodores, como prostaciclina,
N-acetilcistena e pentoxifilina, agiriam nesses tecidos. Pesa contra seu uso teraputico o nmero
ainda restrito de estudos clnicos neste sentido
1
.

Tabela 8 - Comparao entre as solues de expanso intravascular colide x cristalide
1

Albumina
5% 20%
Poliamidas
6% 10%
Dextran
40-10%
Cristalide
NaCl 0,9% NaCl 7,5%
Osmolaridade (mOsm/L) 300 300 325 280-325 250-310 900-2400
Peso molecular (KDa) 69 450 280 30 0 0
Presso coloidosmtica em
que unidade (mmHg)
20 100 30 60 30 0 0
Expanso volmica (%) 100 500 100 150 150 25 40-100
Durao da expanso (h) 12-24 8-36 1-2 0,5-4

6.1 Agentes inotrpicos, vasopressores e vasodilatadores
Agentes inotrpicos somente deveriam ser utilizados aps ressuscitao volmica ser
realizada, ou como ponte, enquanto essa feita e a presso arterial est muito baixa
1
.

Dobutamina - apresenta efeito predominante betaadrenrgico, responsvel por

sua ao inotrpica positiva e vasodilatadora perifrica discreta, que ocasiona aumento do dbito
cardaco e diminuio da resistncia vascular perifrica. No libera norepinefrina endgena e
induz menos taquicardia, arritmias e isquemia miocrdica do que a dopamina e noradrenalina
1,2
.
No tem efeito vasodilatador renal, mas o volume urinrio e o fluxo renal parecem aumentar
igualmente em comparao com a dopamina. Isso sugere que o aumento da perfuso renal,
secundrio ao aumento do dbito cardaco, o mais importante determinante da manuteno da
funo renal
2
. A dose usual 2,5 a 20 g/Kg/min, dose inicial de 2,5 g/Kg/min, com aumentos de
2,5 g/Kg/min
1,2
. No deve ser usada com presso sistlica abaixo de 90 mmHg, j que pode
promover diminuio da resistncia vascular perifrica e presso sistmica por sua interao com

Protocolo Assistencial do Hospital Universitrio de Santa Maria


14
receptores betaadrenrgicos vasculares
2
. Pode aumentar a demanda de oxignio miocrdico,
efeito que pode ser contraprodutivo no miocrdio isqumico e em falncia.

Inibidores da Fosfodiesterase a amrinona e o milrinona so drogas de uso

parenteral; apresentam inotropismo positivo, efeito lusitrpico e causam vasodilatao sistmica,
com conseqente aumento do dbito cardaco e reduo das presses de enchimento ventricular.
No tm nenhum efeito relatado sobre o consumo de oxignio miocrdico. A milrinona, mais
comumente usada, mais potente e possui menos efeito pr-arrtmico que amrinona
2
. Pode ser
usada isolada ou associada com a dobutamina, na insuficincia cardaca severa, na dose de
ataque de 50 g/Kg (10min) e manuteno de 0,375 a 0,75 g/Kg/min.

Noradrenalina mediador adrenrgico natural, com potente efeito constritor

venoso e arterial (alfa dependente) e modesto efeito inotrpico positivo (beta1 dependente)
1,2
. A
noradrenalina aumenta, predominantemente, a presso arterial pela elevao da resistncia
vascular sistmica e pode no melhorar, ou at diminuir, o dbito cardaco
2
. utilizada,
principalmente, no choque sptico e em condies de choque refratrio. Pode ser til no choque
cardiognico por infarto agudo do miocrdio, porque aumenta a presso na raiz da aorta,
melhorando a perfuso coronria. Necrose tecidual pode ser observada se ocorrer
extravasamento para o subcutneo
2
. A dose eficaz no choque sptico geralmente est entre 0,2 e
1,3 g/Kg/min, mas doses de at 5 g/Kg/min podem ser necessrias. O uso dessa droga deve
ser visto como uma medida temporria e a dose deve ser reduzida ou a administrao
descontinuada assim que possvel
2
.

Dopamina percussor imediato da noradrenalina na via biossinttica das

catecolaminas. Estimula diretamente receptores alfa e betaadrenrgicos, ao mesmo tempo em
que promove liberao de norepinefrina endgena
2
. Doses baixas (1 a 3 g/Kg/min) tm efeito
basicamente dopaminrgico (em pacientes sadios observa-se aumento do fluxo renal, porm esse
mesmo efeito no foi encontrado em doentes crticos e seu uso no recomendado)
1
. Doses
intermedirias (3 a 10 g/Kg/min ) tm efeito, principalmente, beta-estimulante (inotrpico positivo)
e doses > 10 g/Kg/min tm efeito alfa-estimulante com aumento da resistncia vascular perifrica
e da presso arterial
1,2
.

Nitroprussiato de sdio vasodilatador arterial e venoso, no indutor de

taquifilaxia, com rpido incio de ao, usado em situaes emergenciais, em que se observa
aumento da presso de enchimento do ventrculo esquerdo como insuficincia mitral aguda
(disfuno ou ruptura do msculo papilar) ou ruptura de septo intraventricular ps-IAM. S deve
ser usado em pacientes com presso arterial sistlica > 90 mmHg. Alm da hipotenso, pode
desencadear taquicardia reflexa, piora da isquemia miocrdica e intoxicao por tiocianato (uso
prolongado ou insuficincia renal). A dose deve variar entre 0,25 a 10 g/Kg/min.

Nitroglicerina - vasodilatador predominantemente venoso, alm de vasodilatador

coronrio. Extremamente til em pacientes com insuficincia cardaca congestiva, que cursam
com sinais de congesto pulmonar e principalmente, em pacientes cardiopatas com etiologia
isqumica. Inicia-se com 10 g/min, aumenta-se 10 g/min a cada 5 minutos at a dose mxima
de 100 g/Kg/min.

Protocolo Assistencial do Hospital Universitrio de Santa Maria


18
6.3 Choque hemorrgico
O objetivo do tratamento do choque hemorrgico cessar o sangramento, restaurar o
volume intravascular
33
, alm de normalizar o metabolismo oxidativo e a perfuso tissular.
Sangramento gastrintestinal e trauma so as causas mais comuns de hemorragia.
Outras causas de choque hemorrgico incluem ruptura de aneurisma artico, sangramento
espontneo da anticoagulao e sangramento relacionado ao ps-parto. Gestao ectpica rota
ou ruptura de cisto ovariano podem ser causa de choque quando no h evidncia de perda
sangunea
33
. Perdas sanguneas devido a laceraes externas so difceis de ser estimadas, mas
geralmente respondem a compresso direta e ressuscitao com volume. Leses intratorcicas,
especialmente pulmo, corao e grandes casos podem resultar em perda severa de litros de
sangue no trax sem evidncia externa de hemorragia, assim como as leses de rgos slidos
intrabdominais.
Preferencialmente, a terapia deve ser guiada pela taxa de sangramento ou
modificaes dos parmetros hemodinmicos, tais como presso arterial, frequncia cardaca,
dbito cardaco e presso venosa central. Tambm pode ser guiada por medida da presso na
artria pulmonar e saturao venosa mista
33
.
Quatro aspectos devem ser considerados quando se trata de choque hemorrgico:
tipo de fluido a ser dado, quanto, tempo de infuso e os objetivos teraputicos. O fluido ideal para
a ressuscitao no est bem estabelecido. A regra 3 para 1- 3ml de cristalide para 1ml de
sangue perdido- tem sido aplicada para a classificao de hemorragia para estabelecer uma linha
de base para guiar a terapia
34
, e o uso de cristalide (ringer lactato ou soluo fisiolgica)
recomendado pelo Colgio Americano de Cirurgies
35
. Embora os pontos finais sejam similares
utilizando ringer lactato e soluo salina normal, acidose metablica hiperclormica tem sido
relatada quando h infuso de grandes volumes de soluo salina normal (> 10 L)
36
. Solues
coloidais podem ser administradas em casos de diminuio abrupta do volume circulatrio.
Pesquisas comparando colide e cristalide no comprovaram maior eficcia do uso de solues
de albumina nos estgios iniciais da ressuscitao
37-39
.
Quanto soluo salina hipertnica, h algumas evidncias de que seu uso em
pacientes com trauma cranioenceflico fechado pode ter eficcia, mas h controvrsia e a US
Food and Drug Administration no a aprova para esse uso durante a ressuscitao de pacientes
31
.
A transfuso de sangue e seus componentes necessria quando a estimativa de
perda sangunea excede 30% do volume sanguneo (hemorragia classe III)
31
. Atualmente, um
paciente hipotenso que no respondeu infuso de 2 litros de cristalide com provvel causa
hemorrgica deve ser tratado com sangue ou hemoderivados. Transfuses sanguneas tm
diversos efeitos secundrios negativos e tm sido associadas a um pior resultado em pacientes
com trauma
40
. Transfuses profilticas so desaprovadas, pois em pacientes com nveis de
hemoglobina maiores que 10g/dl no h benefcios comprovados com a transfuso. No h
indicaes precisas quanto transfuso em pacientes de alto risco, sendo geralmente realizadas
a critrio clnico, mas estudos mostram benefcios nas estratgias restritas quanto transfuso
(hemoglobina mantida entre 7 e 9 g/dL)
41
.