Page 103 - JSOM Fall 2020

trauma, swelling, and airway burns. In the case of RSI and with blood products to achieve an SBP above 100mmHg. Pain
PPV for the hypovolemic, shocked trauma patient, the author and/or combative patients can be treated with ketamine.
36
group has concerns that in some systems the procedures have RSI and PPV may be delayed until the patient is resuscitated
become a standard of care, prior to resuscitation, which wors- or damage control surgery is imminent. If advanced airway
ens the shock causing iatrogenic harm. procedures are necessary, every effort should be made to re-
suscitate the patient first. In hemorrhagic shock with central
Contraindications hypovolemia the impact of RSI and PPV must be recognized as
It may be reasonable to argue that central hypovolemia from a contributing factor to the pathophysiological burden, which
hemorrhagic shock could be seen as a relative contraindication is harming the patient, potentially catastrophically. This proce-
to RSI and PPV. dure should not be attempted as part of a standard of care. In
the risk benefit anaylsis of patients in hemorrhagic shock, the
Complications golden principle of “first do no harm” shuold be appropriately
Because the prevention of complications is an important part weighted due to the potential for iatrogenesis.
of the knowledge of the provider, the main complication is
the effect of RSI and PPV on CO as discussed; it is the critical Author Contributions
clinical decision of the care provider to decide if the patient’s PT wrote the first draft. GS, AH, VC, MD, CB, EG, AC, and PS
condition is such that these procedures can be tolerated. The contributed edits and references to the final draft, and all au-
drugs associated with RSI may also exacerbate the patient’s thors reviewed the final manuscript and suggested references.
condition.
Disclosures
Mitigation The authors have nothing to disclose.
Resuscitation with blood products to an SBP of 100mmHg
is the primary mitigation strategy; this restores circulating References
blood volume and the patient’s ability to withstand the drop 1. Cournand A, Motley HL. Physiological studies of the effects
in CO due to the interventions, while simultaneously treat- of intermittent positive pressure breathing on cardiac output in
ing the shock state and repaying critical oxygen debt. It may man. Am J Physiol. 1948;152(1):162–174.
also be possible to maintain spontaneous respiration while 2. Herff H, Paal P, von Goedecke A, et al. Influence of ventilation
providing the protection by surgical cricothyroidotomy. Novel strategies on survival in severe controlled hemorrhagic shock.
Crit Care Med. 2008;36(9):2613–2620.
approaches to intubation while maintaining spontaneous 3. Butler FK, Holcomb JB, Schreiber MA, et al. Fluid resuscita-
res piration are ketamine-only breathing intubation or using tion for hemorrhagic shock in Tactical Combat Casualty Care:
short-acting NMBAs to facilitate tube placement allowing TCCC guidelines change 14-01--2 June 2014. J Spec Oper Med.
spontaneous respiration to return while maintaining sedation. 2014;14(3):13–38.
The relatively recent concept of delayed sequence induction 4. Woolley T, Thompson P, Kirkman E, et al. Trauma Hemostasis
35
is using procedural se dation, to ensure preoxygenation, and re- and Oxygenation Research Network position paper on the role of
suscitation with blood products, after which the patient can be hypotensive resuscitation as part of remote damage control resus-
citation. J Trauma Acute Care Surg. 2018;84(6S suppl 1):S3–S13.
paralyzed and intubated. If PPV is finally required, then PPV 5. Pepe PE, Lurie KG, Wigginton JG, et al. Detrimental hemody-
limit excessive ventilatory pressures and high tidal volumes. namic effects of assisted ventilation in hemorrhagic states. Crit
Care Med. 2004;32(9 Suppl):S414–S420.
6. Pepe PE, Roppolo LP, Fowler RL. The detrimental effects of
Synthesis ventilation during low-blood-flow states. Curr Opin Crit Care.
In critical illness, clinical decision-making may be difficult and 2005;11(3):212–218.
time short. This may be compounded by environmental diffi- 7. Jenkins DH, Rappold JF, Badloe JF, et al. Trauma hemostasis and
oxygenation research position paper on remote damage control
culties. In these situations, clinicians often follow highly proto- resuscitation: definitions, current practice, and knowledge gaps.
colized guidelines. Many guidelines provide a list of procedures Shock. 2014;41(suppl 1):3–12.
but not the clinical judgment required to accurately weigh the 8. Alarhayem AQ, Myers JG, Dent D, et al. Time is the enemy:
risks and benefits, which is recognized by the frequent inscrip- Mortality in trauma patients with hemorrhage from torso injury
tion of “This document is a guideline only and not a substitute occurs long before the “golden hour.” Am J Surg. 2016;212(6):
1101–1105.
for clinical judgment.” The path to experienced clinical judg- 9. Shackelford SA, Del Junco DJ, Powell-Dunford N, et al. Asso-
ment is not a short one. Simplicity and speed to definitive care ciation of prehospital blood product transfusion during medical
with greater resources are often seen as key steps to patient sur- evacuation of combat casualties in Afghanistan with acute and
vival. The discussion here may be synthesized into guidelines, 30-day survival. JAMA. 2017;318(16):1581–15891.
facilitating a reduction in time at the scene, limiting difficult de- 10. Spahn DR, Bouillon B, Cerny V, et al. The European guideline
cision-making, focusing on the greatest pathophysiological risk on management of major bleeding and coagulopathy following
trauma: fifth edition. Crit Care. 2019;23(1):98.
to the patient, treating the problem, and avoiding iatrogenic 11. Schwartz DE, Matthay MA, Cohen NH. Death and other compli-
harm. Reassessment remains key; if airway positioning is fail- cations of emergency airway management in critically ill adults. A
ing, then advanced airway management is required. However, prospective investigation of 297 tracheal intubations. Anesthesi-
even here there are options to maintain spontaneous breathing. ology. 1995;82(2):3673–3676.
12. Convertino VA. Mechanisms of inspiration that modulate car-
diovascular control: the other side of breathing. J Appl Physiol
Conclusion (1985). 2019;127(5):1187–1196.
13. Vincent JL, De Backer D. Oxygen transport: the oxygen delivery
In hemorrhagic shock, the primary aim is to control the bleed- controversy. Intensive Care Med. 2004;30(11):1990–1996.
ing and limit time to definitive (surgical) care. The patient 14. Moreno AH, Burchell AR, Van der Woude R, et al. Respira-
should be positioned to maintain airway patency. Once IV/IO tory regulation of splanchnic and systemic venous return. Am J
access has been obtained, the patients should be resuscitated Physiol. 1967;213(2):455–465.

RSI/PPV in Patients With Hemorrhagic Shock | 101