Reseña sobre las guías europeas para el manejo de la hemorragia postrauma (1)
Este es el primero de 3 posts sobre el manejo del shock hemorrágico en el politraumatizado, luego de la revisión de las guías europeas correspondientes.
La hemorragia no controlada es la principal causa de muerte evitable en pacientes politraumatizados. La coagulopatía por consumo de factores es un fenómeno frecuente y hay una franca asociación de la hemorragia no controlada con la falla de múltiples órganos y la mortalidad.
Evidentemente la cascada de eventos deletéreos asociados a la hemorragia no controlada tiene su origen y consecuencia en los mecanismos de acidosis, hipotermia, hemodilución, hipoperfusión y consumo de factores. estos mecanismos siguen una progresión autoalimentada con determinantes negativos de la evolución.
El abordaje del paciente politraumatizado con hemorragia debe tener como meta principal la resucitación inicial y la detención de la hemorragia. Es necesario basar este abordaje en la reducción del tiempo entre la lesión y la intervención para controlar la hemorragia. Incluso el control de la hemorragia debe iniciarse en la etapa pre-hospitalaria, lo que comprende hasta el uso de torniquetes o dispositivos de compresión externa.
Los otros vértices del abordaje es el diagnóstico y la monitorización, así como la cuantificación de la gravedad. Es fundamental establecer el mecanismo de la lesión, vigilar las variables fisiológicas y actuar preventivamente ante las posibles desviaciones con potencial riesgo, el patrón anatómico y determinar la respuesta a la resucitación.
De manera particular la herniación cerebral inminente es una condición que obliga a la acción inmediata e impide perder el tiempo en otras consideraciones.
| Pérdida sanguínea (mL) | > 750 | 750 – 1500 | 1500 – 2000 | > 2000 |
| Pérdida relativa (%) | > 15% | 15 – 30% | 30 – 40% | > 40% |
| Pulso | < 100 | > 100 | > 120 | > 140 |
| Tensión arterial | Normal | Normal | ↓ | ↓ |
| Presión de pulso | Normal o ↑ | ↓ | ↓ | ↓ |
| Ortostasis | Ausente | Mínima | Marcada | Marcada |
| Llenado capilar | Normal | Tardío | Tardío | Tardío |
| Frec. respiratoria | 14 – 20 | 20 – 30 | 30 – 40 | > 34 |
| diuresis (mL/hr) | > 30 | 20 – 30 | 5 – 15 | < 5 |
| CNS estado mental | Ansiedad leve | Ansiedad leve | Ansioso/confuso | Confuso/letargia |
| CI (L/min) | ↓ 0-10% | ↓ 20-50% | ↓ 50-75% | ↓ >75% |
Manejo de la hemorragia en el politraumatizado
La aproximación que implica la adecuada garantía de la vía aérea, la recuperación o resucitación de la volemia y la ventilación apropiada, las Guías Europeas sobre el manejo de la hemorragia en politraumatizado sugieren la normoventilación inicial.
Los volúmenes corrientes altos durante la asistencia ventilatoria constituyen un factor de riesgo para complicaciones posteriores inmediatas y a mediano plazo. En la lesión pulmonar aguda (ALI) es necesario el uso de volúmenes corrientes bajos.
La detección de un shock hemorrágico obliga a la intervención quirúrgica inmediata, cuando la fuente de la hemorragia está demostrada, con especial énfasis en trauma penetrante y fractura pélvica inestable.
En el shock hemorrágico, es prioritaria la investigación inmediata de la fuente de la hemorragia, cuando no está definido el origen. Esto implica evaluar el tórax, la cavidad abdominal y la pelvis mediante la exploración física, las pruebas de imagen y el lavado peritoneal.
La ecografía mediante protocolo FAST (Focus Assessment Sonography in Trauma) se ha convertido en una técnica standard a la cabecera. Los equipos de ultrasonido deberían estar disponibles en cada servicio de urgencias. El protocolo contempla la exploración ultrasonográfica limitada (con entrenamiento previo) en un paciente con trauma, en busca de líquido libre en pericardio y cavidad peritoneal, cuyo hallazgo implicaría hemorragia.
El Eco – FAST o la tomografía computada de tórax y abdomen precoces están establecidos como estudios (evidencia 1B) en trauma de tronco.
La inestabilidad hemodinámica o la presencia de líquido libre conllevan la intervención quirúrgica urgente.
El TAC de tórax y abdomen tiene indicación urgente en caso de estabilidad hemodinámica pero con sospecha de hemorragia en tronco o lesión de alta energía.
En el próximo post habrá detalles acerca del manejo específico de la hemorragia en politraumatizado, y los objetivos terapéuticos a alcanzar.
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