The document discusses guidelines for resuscitation of hemorrhagic shock. It summarizes some key recommendations from European guidelines from 2016, which recommend initiation of isotonic crystalloid fluids for hypotensive bleeding trauma patients and a target hemoglobin level of 7-9 g/dL. It also notes that military guidelines recommend use of whole blood, plasma, red blood cells, and platelets in a 1:1:1 ratio as the preferred resuscitation strategy over crystalloids alone. The document questions whether the European guideline recommendations are well-aligned with the pathophysiology of hemorrhagic shock.

1. 1
Challenging hemorrhagic shock
resuscitation guidelines
WHOLE BLOOD . «THE RELIGION OF PEACE»
GeirStrandenes
Blood banker

2. 2

3. 3

4. 4
The guideline now recommends that patients be transferred directly to an
appropriate trauma treatment centre and encourages use of a restricted volume
replacement strategy during initial resuscitation.

5. GRADING THE EVIDENCE. EUROPEAN
GUIDLINES 2016
• 1A Strong recommendation, high-quality evidence.
Benefits clearly outweigh risk and burdens, or vice
versa
• 1B Strong recommendation, moderate-quality
evidence. Benefits clearly outweigh risk and burdens,
or vice versa
• 1C Strong recommendation, low-quality or very low-
quality evidence. Benefits clearly outweigh risk and
burdens, or vice versa
5

6. SUMMARY OF EUROPEAN GUIDELINES
LAST UPDATED 2016
• Recommendation: 16:We recommend that fluid
therapy using isotonic crystalloid solutions be
initiated in the hypotensive bleeding trauma
patient. (Grade 1A)
• Recommendation 17: We recommend a target
Hb of 7 to 9 g/dl. (Grade 1C)
6
ARE THEY ALIGNED WITH THE PATHOPHYSIOLOGY OF SHOCK??

7. SUMMARY OF EUROPEAN GUIDELINES
LAST UPDATED 2016
• Recommendation 3:We recommend
normoventilation of trauma patients. (Grade 1B)
• Recommendation 13: We recommend a target
systolic blood pressure of 80–90 mmHg
until major bleeding has been stopped in the
initial phase following trauma without brain
injury. (Grade 1C)
7

8. Guidelines
Civilian guidelines
• Use of isotonic crystalloid
solutions should be initiated in
the hypotensive bleeding
trauma patient.
• RBC treatment should aim to
achieve a target Hb of 7-9 g/dl
• Platelets should be
administered to maintain a
platelet count >50 109/l. A
platelet count >100 109/l in
patients with ongoing bleeding
and/or TBI may be maintained.
Military guidelines (TCCC)
1) Whole Blood
2) Plasma RBC’s Platelets (1 : 1 : 1)
3) Plasma RBC’s (1 : 1)
4) Plasma or RBC’s alone
5) Colloids and crystalloids only if
above is not available

9. GRADING OF ANEMIA
(NATIONAL CANCER INSTITUTE)
9

10. TO PUT IN IN A SIMPLE WAY
• EUROPEAN GUIDELINE RECOMMEND SEVERE ANEMIA
FOR SEVERE BLEEDING
• EUROPEAN GUIDELINES ACCEPT UP TO 50%
HEMODILUTUION IN SEVERE BLEEDING PATIENTS
• EUROPEAN GUIDELINE RECOMMEND HYPOTENSIVE
RESUSCITATION PRIOR TO SURGICAL CONTROLL
• EUROPEAN GUIDELINE RECOMMEND
NORMOVENTILATION FOR ALL TRAUMAPATIENTS
10

11. Bleeding
• Stop the bleeding
• Reverse Shock
• Maintain hemostasis

12. PROBLEM 2 FOLD
• Maintain best possible Oxygen Deliver (DO) during
ongoing central hypovolemia until bleeding is
controlled.(Avoid delivery dependent Oxygen
consumption(V02) )
• Maintain hemostatic potential
• HYPOTENSIVE RESUSCITATION?? OXYMORON OR A
GOOD IDEA??
12

13. Anestesia
Prehospital spontaneous breathing versus OR in general anesthesia
2 different physilogies

14. 14
POI
FIRST
RESPONDER
START
RESUSCITATION
ER
DIAGNOSTIICSAND
STABILISATION
OR
HEMORRHAGE
CONTROL
NORMOVOLEMIA
CENTRAL HYPOVOLEMIA

15. POINT OF INJURY
Arrival ER
OR
SBP(I) 58+/- 35
(D) 59+/-34
SBP(I) 79+/-46
(D) 72+/43
SBP(I) 112+/-33
(D) 113+/-30
Pointofinjury
Substantial
mortality
70% in I
62% in D

16. FICK`S EQUATION
16
D02 = 1.34 x Hgb x CO x Sa02
YOU MIGHT HAVE A DIFFERENT OPINION
BUT YOU CAN`T CHOOSE YOUR OWN
PHYSIOLOGY
KEVIN WARD MD

17. FICK`S EQUATION
• D02 is oxygen delivered to all the cells in the body
• VO2 is oxygen consumption and the maximum
amount of oxygen possible to extract from D02 is
70%
• So 85 kg male will have resting V02 of 300ml pr
min. (140-150ml/m2/min)
• Critical D02 will be 430ml pr min – below this
“GLOBAL CELLULAR HYPOXIA” = SHOCK
• 70% of 430 is 300
• Start playing with the numbers
17

18. BLEEDING FAST REDUCES BP AND CO
ACCORDINGLY
18

19. CARDIAC OUTPUT AT SYST 80-90
• ACCORDING TO GUYTONS PHYSIOLOGY
50% REDUCTION IN CARDIAC OUTPUT
• ACCORDING TO VIC CONVERTINOS
RESEARCH GROUP 50% REDUCTION AT
SYST 80-90 IN HEALTHY INDIVIDUALS IN
LBNP CHAMBER ( GOOD COMPENSATORS)
19

20. EMERSON FIGURED THIS OUT IN 1945
20
systolic pressures were below
85 mm. of mercury; the
average blood volume deficit in
these cases was 40 per cent.
All cases with a systolic
arterial pressure
exceeding 1oo mm. of
mercury showed a deficit
in blood volume of less
than 25 per cent.
ANNALS OF SURGERY VOL 122 NOVEBER, 1945 No.L5

21. FIGURING OUT CRITICAL D02 LOWEST SURVIVABLE
HEMOGLOBINE WITH CO OF 3,0 L PR MIN
• CRITICAL D02 is 430 and RESTING V02 IS 300
• D02 = 1,34 x CO x Hb X Sa02
• 430 = 1,34 x 30 x X x 0.98
• X = 430/39,39 = 10,91 gr/dl
• If saturation is 90 the cutoff is
11,88
• EUROPEAN GUIDLEINES
RECOMMEND 7-9 gr/dl
21

22. FIGURING OUT CRITICAL D02 AND LOWEST
SURVIVABLECO WITH Hb OF 7,0 GR/DL
• CRITICAL D02 = 430
• 430 = 1,34 x 70 x X x 0,98
• X = 430/91,92 = 4,67L/MIN
• So conclusion is that guideline allowing for Hb
as low as 7,0gr/dl requires close to
normovolemia
• Thats the problem!! Normovolemia can not be
aquired until hemorrhage control.
22

23. NO GO
ZONE
DANGER
ZONE
COMFORT
ZONE

24. DO2
Time
D02 = 1.34 x Hgb x Sa02 x CO
Critical D02=430ml/min (extraction rate max 70% = 300ml/min)
Critical DO2
Aerobic metabolism
Dose of shock
POI Active bleeding
DO2 falling
Compensation
Shock
Resuscitation
Anaerobic metabolism
Male 85 kg, baseline
V02=300ml/min
430ml/min
GOOD
COMPENSATORS:
50% REDUCTION IN
CO WITH SYST 80-
90
DOSE OF SHOCK
CORRELATES WITH
DEGREE OF
COAGULOPATHY AND
INFLAMMATION

25. DO2
Time
D02 = 1.34 x Hgb x Sa02 x CO
Critical DO2
Anaerobic metabolism
WB
1:1:1
Saline
D02 = 1.34 x Hgb x Sa02 x CO
Critical D02=430ml/min
D02 =1,34 x 90 x 0,98 x 3,0 =
354ml/min

26. DO2
Time
D02 = 1.34 x Hgb x Sa02 x CO
Critical DO2
Anaerobic metabolism
WB
D02 = 1.34 x Hgb x Sa02 x CO
Critical D02=430ml/min
D02 =1,34 x 130 x 0,98 x 3,0 =
512 ml/min

27. DO2
Time
D02 = 1.34 x Hgb x Sa02 x CO
Critical DO2
Anaerobic metabolism
1:1:1
D02 = 1.34 x Hgb x Sa02 x CO
Critical D02=430ml/min
D02 =1,34 x 90 x 0,98 x 3,0 =
354ml/min

28. DO2
Time
D02 = 1.34 x Hgb x Sa02 x CO
Critical DO2
Anaerobic metabolism
Saline
D02 = 1.34 x Hgb x Sa02 x CO
Critical D02=430ml/min
D02 =1,34 x 70 x 0,98 x 3,0 =
276 ml/min

29. What targets?
Hypotension is 100 mm Hg on the battlefield
Brian J. Eastridge, M.D.*, Jose Salinas, Ph.D., Charles E. Wade, Ph.D.,
Lorne H. Blackbourne, M.D.
Aim at
mortality of
20% ????

30. 30
WHAT TARGET???
AIM AT THIS MORTALITY??

31. Outcomes following trauma laparotomy for
hypotensive trauma patients: A UK military
and civilian perspective.
• Despite improvements in survival after trauma for
patients overall, the mortality for patients undergoing
laparotomy who arrive at the ED with hypotension has
not changed and appears stubbornly resistant to all
efforts
31
Mortality was higher in hypotensive patients (47.6% vs. 12.4% in normotensive patients; p < 0.001).
In both cohorts of hypotensive patients, neither the average injury severity, the prehospital time,
the ED arrival systolic blood pressure, nor mortality rate changed significantly during the study
period.

32. MOLLISON AGE OF RED BLOOD
CELLS
• 1:1:1 GIVES YOU AVERAGE
Hb of around 9-10 (
depending on plasma batch
volume 2-300)
• Hb of 10gr/dl and remove
25% than the patient ends
up with Hb of 7,5 by the end
of the day if there has been
an exchange transfusion!!!
• REF SUBANALYSIS OF
PROPER
32

33. Ann Emerg Med. 2018 Nov 14. pii: S0196-0644(18)31326-X. doi:
10.1016/j.annemergmed.2018.09.033. [Epub ahead of print]
Older Blood Is Associated With Increased Mortality and Adverse Events in Massively
Transfused Trauma Patients: Secondary Analysis of the PROPPR Trial
• CONCLUSION:
• Increasing quantities of older packed RBCs are
associated with increased likelihood of 24-hour
mortality in trauma patients receiving massive packed
RBC transfusion (≥10 units), but not in those who
receive fewer than 10 units.
33

34. 34
PLASMA NORMAL = 55%
PLASMA IN 1:1:1 = 38%
PLASMA IN WHOLE BLOOD= 48%
Hb 1:1:1 = 9-10gr/dl
Hb WB = 12-13GR/dl

35. Volume and additive solutions
components versus whole blood
6 erytrocyttkonsentrat
• 6 x 100 ml = 600 ml
6 plasma
• 6 x 50 ml = 300 ml
2 trombocyttkonsentrat
• 2 x 200 ml = 400 ml
Totalt 1300 ml
6 fullblod
• 6 x 63 ml = 378
Totalt 378 ml
35
TOTAL VOLUME TRANSFUSED = 3000 ML
REAL BLOOD = 2622 ML
TOTAL VOLUME TRANSFUSED = 3600 ML
REAL BLOOD = 2300 ML
NEED 4150 ML TO EQUAL WB

36. Advantages of Whole Blood
• Natural
• Organic
• Non-GMO
• Free range
• Gluten Free
• High in protein
• Low in carbs

37. EMERSON 1945
• It was the experience of many surgeons operating at
the front in the African and Sicilian campaigns, that a
considerable proportion of patients in severe shock
failed to respond adequately to plasma transfusions,
death occurring preoperatively or in the course of
operation.
• DILLUTION : INADEQUATE D02 = DEATH BY
HEMODILLUTION.
37

38. EMERSON 1945
• The data obtained indicated that the magnitude of the
blood loss sustained by patients exhibiting signs of
severe shock was substantially greater than had been
generally appreciated.
• The average total volume of plasma and blood
required to produce an elevation of arterial pressure
from below 85 to above IOO mm. of mercury was I,250
cc.
38

39. PREPARING CASUALTIES FOR SURGERY
• those patients admitted with a low arterial pressure
attributable, as far as could be detected, to blood loss
alone, received 2,000 CC. of blood preoperatively, or, if
an adequate response was not attained, 1ooo cc.
beyond that amount required to restore the systolic
arterial pressure to approximately 1oo mm. of
mercury.
39

40. PREPARING CAUSUALTIES FOR SURGERY
• The use of more than 1000 cc. of plasma in the
treatment of severe oligemic shock results in a very
profound anemia,
• The presence of severe anemia, with marked
diminution of the oxygen-carrying power of the blood,
renders these patients especially prone to develop
irreversible shock, in consequence of prolonged tissue
anoxia.
40

42. «The transfusion of whole blood – A suggestion for
its more frequent employment in war surgery»
«But the addition of salt solution to the circulation is
at best only a temporary measure, and merely
makes up for the loss of fluid, which is only one
factor in the condition»
«The broad indications for blood transfusion are
based on the fact that transfused blood is the best
substitute for blood lost (…) In certain haemorrhages
it has definitive haemostatic properties (…)

43. PERFUSE IT OR LOSE IT
43
THE SOLUTION TO
TRANSFUSION IS
AVOIDANCE OF DILUTION

44. 44
Questions???

45. 45
All truth passes through
three stages. First, it is
ridiculed. Second, it is
violently opposed. Third,
it is accepted as being
self-evident.
Arthur Schopenhauer

46. 46

47. DONTDISCONNECT THE HEART LUNGMACHINE
WARNING