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Actualités sur le choc hémorragique

Update on hemorrhagic shock

  • Mise au Point / Update
  • Published:
Réanimation

Résumé

Le choc hémorragique est caractérisé par une diminution du volume sanguin circulant avec une baisse du retour veineux. La réponse adaptative initiale consiste en une stimulation sympathique qui a pour but de redistribuer le volume sanguin résiduel vers les organes « protégés » (cerveau et cœur) aux dépens des circulations splanchniques, musculocutanées et rénales. Le remplissage vasculaire est la première thérapeutique à entreprendre avec un objectif de pression artérielle systolique (PAS) compris entre 80 et 100 mmHg et pression de perfusion cérébrale moyenne compris entre 65 et 70 mmHg en cas de lésion cérébrale. Le remplissage vasculaire peut être réalisé par des cristalloïdes ou par des colloïdes. Le remplissage vasculaire massif présente des effets délétères. Dans le cadre de la réanimation à « petit volume », l’emploi de sérum salé hypertonique peut être discuté. L’hypotension profonde impose un recours précoce aux catécholamines (noradrénaline). La transfusion de concentrés globulaires (CG) doit être instaurée dès que possible, l’apport d’érythrocytes est obligatoire quand l’hémoglobine est inférieure à 7 g/dl. Des plasmas frais congelés (PFC) sont perfusés afin de maintenir un taux de prothrombine supérieur à 40 %. Le ratio d’emploi des CG et des PFC doit être proche d’un CG pour un PFC. La transfusion de plaquettes est nécessaire en dessous de 50 G/l en cas de choc hémorragique et de 100 G/l en cas de lésions intracrâniennes associées. L’emploi de fibrinogène est envisagé quand sa concentration sanguine est inférieure à 1,5 g/l. Une insuffisance surrénalienne est régulièrement mise en évidence au cours du choc traumatique. L’hydrocortisone (à la dose de stress de 200 mg/j) semble diminuer la morbidité de cette insuffisance surrénalienne.

Abstract

Hemorrhagic shock is characterized by a decreased circulating blood volume that leads to an alteration of the venous return. The initial adaptative response relies on a central sympathetic activation in an attempt to distribute the residual blood volume to the protected organs (brain and heart). At the opposite, splanchnic as well as muscular and kidney vasculature beds are sacrificed during the ischemic period. Volume resuscitation is the first therapeutic measure to undertake, with a systolic arterial pressure target of 80–100 mmHg and a mean cerebral perfusion pressure of 65–70 mmHg in the case of an associated brain injury. Massive fluid resuscitation is associated with a significant morbidity. Some authors advocated the early use of vasopressors (norepinephrine) along with a controlled volume resuscitation. In the setting of moderate-volume resuscitation, the use of hypertonic saline solution is encouraged. Red blood cells should be transfused as soon as possible, especially when hemoglobinemia is < 7 g/dl. Fresh frozen plasma (FFP) should be used to maintain a prothrombin ratio > 40%. A transfusion strategy using FFP and red blood cells at a 1:1 ratio is recommended. Platelet concentrates are used to maintain a platelet count > 50 G/l and > 100 G/l when traumatic brain injuries are associated. Fibrinogen treatment should be considered and systematically administered when fibrinogen concentration is < 1.5 g/l. An adrenal insufficiency is frequent, and a stress dose of 200 mg/day of hydrocortisone decreases morbidity after a traumatic shock.

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Authors and Affiliations

  1. Service d’anesthésie-réanimation, CHU de Nantes, 1, place Alexis-Ricordeau, F-44093, Nantes cedex 01, France

    K. Asehnoune & A. Roquilly

  2. Service d’anesthésie-réanimation chirurgicale, centre hospitalier de Bicêtre, F-94275, Le-Kremlin-Bicêtre cedex, France

    A. Harrois & J. Duranteau

Authors
  1. K. Asehnoune
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  2. A. Roquilly
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  3. A. Harrois
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  4. J. Duranteau
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Correspondence to K. Asehnoune.

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Asehnoune, K., Roquilly, A., Harrois, A. et al. Actualités sur le choc hémorragique. Réanimation 21, 165–170 (2012). https://doi.org/10.1007/s13546-012-0452-2

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