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Second phase of resuscitation
During initial blood volume expansion, the patient is usually surveyed again by physical examination as well as point-of-care ultrasonography, if available. This gives the clinician an idea of where the major injuries are located, if there may be significant blood loss (such as intra-abdominal) and if other immediate interventions are required, such as thoracocentesis. If the patient continues to show signs of shock, despite initial blood volume expansion and analgesia, then there are several options to consider, including further fluid therapy, transfusion, antifibrinolytic therapy and, in rare cases, immediate surgical intervention.
Transfusion products, especially transfusion of stored red cells, are associated with increased free iron concentrations and a pro-inflammatory response. Red cell products that have been stored for a longer period have been associated with coagulation disturbances and thromboembolic disease in canine recipients.(10) There is also risk of acute reaction with transfusion of red cells and plasma.(11) Due to these known adverse effects of transfusion products, they should only be administered for the clinical indications of anaemia and coagulopathy.
If the patient requires further blood volume expansion,
has no evidence of coagulopathy or active bleeding, has no prior history of renal disease and there is physiologic justification for restricting interstitial fluid accumulation, then synthetic colloid solutions may be considered in this phase of resuscitation (preferably low molecular weight hydroxyethyl starch (HES)). If a patient requires blood volume expansion and there is a good reason to avoid isotonic crystalloids, then synthetic colloids currently
have the least amount of clinical evidence associated
with harm, compared to plasma and human albumin products. However, due to the possible adverse effects of coagulopathy in a trauma patient, doses should be limited to less than 20mL/kg in a 24-hour period. Prospective clinical trials are still needed to determine if synthetic colloids, particularly HES, are harmful to veterinary patients.
Administration of an antifibrinolytic may be beneficial in the initial phases of resuscitation, especially for patients with active bleeding or evidence of hyperfibrinolysis on viscoelastic coagulation tests. Although the benefits of antifibrinolytic therapy, such as tranexamic acid, have been well identified in human trauma patients, the evidence in veterinary medicine is limited. However, tranexamic acid is unlikely to cause harm when administered as a slow IV bolus followed by a constant rate infusion for several hours,(12) and may be beneficial in a bleeding patient.
Decision-making trees will be presented in this talk, reflecting the author’s approach to traumatic shock. Attendees are welcome to request a copy of the flow diagrams by email.
Your Singapore, the Tropical Garden City
References
1. Abelson AL, O’Toole TE, Johnston A, Respess M, de Laforcade AM. Hypoperfusion and acute traumatic coagulopathy in severely traumatized canine patients. Journal of Veterinary Emergency and Critical Care 2013;23(4):395-401.
2. Fletcher DJ, Rozanski EA, Brainard BM, de Laforcade AM, Brooks MB. Assessment of the relationships among coagulopathy, hyperfibrinolysis, plasma lactate, and protein C in dogs with spontaneous hemoperitoneum. Journal of Veterinary Emergency and Critical Care 2016;26(1):41-51.
3. Holowaychuk MK, Hanel RM, Darren Wood R, Rogers L, O’Keefe K, Monteith G. Prospective multicenter evaluation of coagulation abnormalities in dogs following severe acute trauma. Journal of Veterinary Emergency and Critical Care 2014;24(1):93-104.
4. Lynch AM, deLaforcade AM, Meola D, Shih A, Bandt C, Guerrero NH, Ricco C. Assessment of hemostatic changes in a model of acute hemorrhage in dogs. Journal of Veterinary Emergency and Critical Care 2016;26(3):333-43.
5. McBride D, Hosgood G, Raisis A, Smart L. Platelet closure time in anesthetized Greyhounds with hemorrhagic shock treated with hydroxyethyl starch 130/0.4 or 0.9% sodium chloride infusions. Journal of Veterinary Emergency and Critical Care 2016;26(4):509-515.
6. Sharma D, Holowaychuk MK. Retrospective evaluation of prognostic indicators in dogs with head trauma: 72 cases (January-March 2011). Journal of Veterinary Emergency and Critical Care 2015;25(5):631-9.
7. Silverstein DC, Aldrich J, KHaskins SC, Drobatz KJ, Cowgill LD. Assessment of changes in blood volume in response to resuscitative fluid administartion in dogs. Journal of Veterinary Emergency and Critical Care 2005;15(3):185-92.
8. Pinto FC, Oliveira MF, Prist R, Silva MR, Silva LF, Capone Neto A. Effect of volume replacement during combined experimental hemorrhagic shock and traumatic brain injury in prostanoids, brain pathology and pupil status. Arquivos de neuro-psiquiatria. 2015;73(6):499-505.
9. Adamik KN, Yozova ID, Regenscheit N. Controversies in the use of hydroxyethyl starch solutions in small animal emergency and critical care. Journal of Veterinary Emergency and Critical Care 2015;25(1):20-47.
10. Hann L, Brown DC, King LG, Callan MB. Effect of duration of packed red blood cell storage on morbidity and mortality in dogs after transfusion: 3,095 cases (2001-2010). Journal of Veterinary Internal Medicine 2014;28(6):1830-7.
11. Bruce JA, Kriese-Anderson L, Bruce AM, Pittman JR. Effect of premedication and other factors on the occurrence of acute transfusion reactions in dogs. Journal of Veterinary Emergency and Critical Care 2015;25(5):620-30.
12. Kelmer E, Segev G, Papashvilli V, Rahimi-Levene N, Bruchim Y, Aroch
I, Klainbart S. Effects of intravenous administration of tranexamic acid on hematological, hemostatic, and thromboelastographic analytes in healthy adult dogs. Journal of Veterinary Emergency and Critical Care 2015;25(4):495-501.
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