Therapeutic Decisions Based on Response to Initial Fluid
The patients response to initial fluid resuscitation is the key to determine subsequent therapy. (See Table, Responses to Initial Fluid Resuscitation.) Having established a preliminary diagnosis and plan based on the initial evaluation of the patient, the physician can now modify management based on the patient’s response to the initial fluid resuscitation. Observing the response to the initial resuscitation identifies those patients whose blood loss was greater than estimated and those with ongoing bleeding. In addition, it limits the probability of over transfusion or unneeded transfusion of blood in those whose initial status was disproportionate to the amount of blood loss. It is particularly important to distinguish the patient who is “hemodynamically stable” from one who is “hemodynamically normal”.
A hemodyna-mically stable patient may be persistently tachycardic, tachypneic, and oliguric, clearly remaining underperfused and under-resuscitated. In contrast, the hemodynamically normal patient is one who exhibits no signs of inadequate tissue perfusion. The potential response patterns can be discussed in three groups.
A. Rapid Response to Initial Fluid Administration
A small group of patients respond rapidly to the initial fluid bolus and remain stable and hemodynamically normal when the initial fluid bolus has been completed and the fluids are slowed to maintenance rates. Such patients usually have lost minimal (less than 20%) blood volume. No further fluid bolus or immediate blood administration is indicated for this small group of patients. Type and crossmatched blood should be kept available. Surgical consultation and evaluation are necessary during initial assessment and treatment.
B.Transient Response to Initial Fluid Administration
The largest group of patients responds to the initial fluid bolus. However, in some patients, as the initial fluids are slowed, the circulatory perfusion indices may begin to show deterioration, indicating either an ongoing blood loss or inadequate resuscitation. Most of these patients initially have lost an estimated 20% to 40% of their blood volume. Continued fluid administration and initiation of blood administration are indicated. The response to blood administration should identify patients who are still bleeding and require rapid surgical intervention.
C.Minimal or No Response to Initial Fluid Administration
This response is seen in a small but significant percentage of injured patients. For most of these patients, failure to respond to adequate crystalloid and blood administration in the emergency department dictates the need for immediate surgical intervention to control exsanguinating hemorrhage. On very rare occasions, failure to respond may be due to pump failure as a result of myocardial contusion or cardiac tamponade. The possible diagnosis of nonhemorrhagic shock always should be entertained in this group of patients. Central venous pressure monitoring helps differentiate between the various shock etiologies.
Hemorrhagic Shock is a major killer and undiagnosed and untreated shock causes death for many young, active productive people. This is a diagnosis which cannot be missed and early attempts at resuscitation and appropriate management would yield significant results interms of saving lives and preventing disabilities.
The family practitioner would do well if he is able to suspect an impending or an ongoing hemorrhagic shock and initiate the management with oxygen therapy and appropriate I.V. lines give the bolus dose of I.V. fluids, obtain blood tests and keep blood available for transfusion and also promptly notify the specialists (OBGYN/Surgeon/ Ortho-pedician) to join his efforts.
The family practitioners have to look out for this dreadful disease in every age group with the presenting circumstantial history and findings. Shock is a clinical diagnosis.