Page 99 - JSOM Fall 2020

Risk of Harm Associated With Using
Rapid Sequence Induction Intubation and

Positive Pressure Ventilation in Patients With Hemorrhagic Shock

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Patrick Thompson, MCPara *; Anthony Hudson, FRCPEd, FRCEM ; Victor A. Convertino, PhD ;
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Christopher Bjerkvig, MD ; Håkon S. Eliassen, MD ; Brian J. Eastridge, MD ;
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Timm Irvine-Smith, CCP ; Maxwell A. Braverman, DO ; Stefan Hellander, MD ;
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Donald H. Jenkins, MD, FACS ; Joseph F. Rappold, MD, FACS ; Jennifer M. Gurney, MD, FACS ;
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Elon Glassberg, MD, MHA ; Andrew P. Cap, MS, MD, PhD, FACP ; Sylvain Ausset, MD ;
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Torunn O. Apelseth, MD, PhD ; Steve Williams, RN ; Kevin R. Ward, MD ;
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Stacy A. Shackelford, MD ; Pierre Stroberg, CRNA ; Bjarne H. Vikenes, MD ;
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Paul E. Pepe, MD, MPH ; Christopher J. Winckler, MD, LP ; Tom Woolley, MD, FRCA ;
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Stefan Enbuske, MD ; Marc De Pasquale, 18D ; Ken D. Boffard, MB, BCH, FRCS, FRCS(Edin),
FRCPS(Glas), FCSSA, FACS(Hon) ; Ivar Austlid, MD ; Theodore K. Fosse, MD ;
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Helge Asbjørnsen, MD ; Philip C. Spinella, MD, FCCM ; Geir Strandenes, MD 32
ABSTRACT
Based on limited published evidence, physiological principles, shock state. It is not recommended that RSI and PPV are
clinical experience, and expertise, the author group has de- seen as a first-line standard of care for these patients.
veloped a consensus statement on the potential for iatrogenic 2. The primary management focus in the hemorrhagic shocked
harm with rapid sequence induction (RSI) intubation and posi- patient should be hemorrhage control and resuscitation
tive-pressure ventilation (PPV) on patients in hemorrhagic shock. with blood products of which whole blood (WB) proba-
bly represents the best combination of effectiveness and
“In hemorrhagic shock, or any low flow (central hypovolemic) 3
state, it should be noted that RSI and PPV are likely to cause convenience.
iatrogenic harm by decreasing cardiac output.” 3. If RSI and PPV are required, every attempt should be made
to ensure that resuscitation has been effective enough to en-
The use of RSI and PPV leads to an increased burden of shock able the patient to withstand the impact of the intervention.
due to a decreased cardiac output (CO), which is one of the As a surrogate for this approach a systolic blood pressure
primary determinants of oxygen delivery (DO ). The dimin- (SBP) of > 100mmHg is recommended. 4
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ishing DO creates a state of systemic hypoxia, the severity of 4. Aggressive ventilation by “breath stacking,” high ventila-
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which will determine the magnitude of the shock (shock dose) tory pressures, positive end-expiratory pressure (PEEP),
and a growing deficit of oxygen, referred to as oxygen debt. and high ventilatory rates is likely to further reduce the car-
Rapid accumulation of critical levels of oxygen debt results in diac output. 5,6
coagulopathy and organ dysfunction and failure. Spontaneous
respiration induced negative intrathoracic pressure (ITP) pro- Takeaway Points:
vides the pressure differential driving venous return. PPV sub- • This recommendation reflects the position of the author
sequently increases ITP and thus right atrial pressure. The loss group and is based on the interpretation of existing evi-
in pressure differential directly decreases CO and DO with a dence applied to physiologic principles, in addition to
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resultant increase in systemic hypoxia. 1, 2 If RSI and PPV are clinical experience and expertise. It is not intended to be
deemed necessary, prior or parallel resuscitation with blood a replacement for clinical judgement in the management
products is required to mitigate post intervention reduction of of individual patients.
DO and the potential for inducing cardiac arrest in the criti- • This opinion relates specifically to the resuscitation of pa-
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cally shocked patient. tients with hemorrhagic shock and applies to clinical judg-
ment and the balance of risk and benefit to the patient.
Situational Guidance: • In hemorrhage, blood products are recommended for
1. An important part of the clinical decision-making in a pa- the resuscitation of hemorrhagic shock with WB being
tient with hemorrhagic shock is awareness of the fact that considered optimal in the remote damage control resus-
RSI and PPV are likely to decrease CO and worsen the citation (RDCR) environment. 7
*Correspondence email and affiliations are given on page 102.
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