Management of Hemorrhagic Shock According to the Revised “Physiological Classification” - Update 2024

Hemorrhagic shock management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage progressing from any named and visible vessel is the main stem fundamental praxis of therapeutic efficacy, ultimately an essential, obligatory, life-saving step. Blood loss replacement serves mainly the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The “revised physiological classification” is the only classification that suits timely intervention, tactics like titrated hypotensive resuscitation and iatrogenic vasoconstriction, and strategies like titrated-to-response anesthesia and damage control surgery. Timing and approach to management should follow the classification, from onset of the hemorrhage to cardiac arrest by exsanguination. In hypotensive shock, the body’s response to a fluid load test is the diriment cut-off information to have for distinguishing between compensation and progression, between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is to be given stat to refill the unstressed venous return volume. Progressing hypotensive shock is a danger scenario warranting rapid source control. In critical level of shock with signs indicating critical physiology of imminent/impending cardiac arrest the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) stays in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable; minimal interference with this actual physiological equilibrium and a rapid safe general anesthesia and surgery remain crucial for survival. Source control of any named and visible vessel must be fast and effective.

This is accomplishable rapidly and efficaciously only by a direct ingress for source control, which is a direct limb ingress, a crush laparotomy if the bleeding is coming from an abdominal +/- proximal lower limb, a rapid sternotomy if coming from mediastinum and an anterolateral thoracotomy if the bleeding is coming from chest +/- proximal upper limbs. Neck and limb bleedings require direct source access but bleeding from injury to the groin folds and thoracic outlet/neck base necessitates often of double compartment incision for proximal and distal control. In cardiac arrest by exsanguination, source control and heart refilling must be effected synchronously to a direct heart access and control via sternotomy. The priority and the core of the physiological rescue remains the rapid restoration of a sufficient venous return and left diastolic filling volume to make enough pressure to allow the heart pumping it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy, or spontaneously after aortic clamping in the chest or in the abdomen. Without first stopping the bleeding and refilling the heart, any resuscitation of advanced progressive HS or cardiac arrest by exsanguination is an exercise doomed to failure. Extracorporeal life support and induced hypothermia under sternotomy and direct vision is the last ditch.