Hemorrhagic shock and the nervous system

Hemorrhagic shock

A great deal has been learned about the pathophysiologic condition of hemorrhagic shock. The response of the hormonal and inflammatory mediator systems in patients in hemorrhagic shock appears to represent a distinct set of responses different from those of other forms of shock. The classic neuroendocrine response to hemorrhage attempts to maintain perfusion to the heart and brain, often at the expense of other organ systems. This intense vasoconstriction occurs via central mechanisms. The response of the peripheral microcirculation is driven by local tissue hypoperfusion that results in vasodilation in the ischemic tissue bed. Activation of the systemic inflammatory response by hemorrhage and tissue injury is an important component of the pathophysiologic condition of hemorrhagic shock. Activators of this systemic inflammatory response include ischemia/reperfusion injury and neutrophil activation. Capillary "no-flow" with prolonged ischemia and "no-reflow" with reperfusion may initiate neutrophil activation in patients in hemorrhagic shock. The mechanisms that lead to decompensated and irreversible hemorrhagic shock include (1) "arteriolar hyposensitivity" as manifested by progressive arteriolar vasodilation and decreased responsiveness of the microcirculation to alpha-agonists, and (2) cellular injury and activation of both proinflammatory and counterinflammatory mechanisms. These changes represent a failure of the microcirculation. Redistribution of cardiac output and persistent gut ischemia after adequate resuscitation may also contribute to the development of irreversible hemorrhagic shock. Treatment of hemorrhagic shock includes rapid operative resuscitation to limit activation of the mediator systems and abort the microcirculatory changes that result from hemorrhagic shock. Volume resuscitation and control of hemorrhage, should occur simultaneously. The end point in volume resuscitation of hemorrhagic shock must be maintenance of organ system and cellular function. Whether we use adequate urine output, correction of lactic acidemia, optimization of oxygen delivery, or oxygen consumption as our specific goal, the general objective is to provide adequate crystalloid solution and packed red blood cells to achieve and maintain normal organ and cellular perfusion and function.

Regional cerebral blood flow and oxygen consumption of the canine brain during hemorrhagic hypotension

The sequential changes in systemic and cerebral hemodynamics, systemic and cerebral oxygen transport and consumption rates, and the regional blood flows (measured with 15 micron microspheres) to the cortical and subcortical brain tissues were determined in nine dogs subjected to graded hemorrhage (10 ml/kg X 4 at 15 min intervals). As hemorrhage progressed, both mean arterial pressure and cardiac output decreased progressively. In contrast to the systemic circulation, the mean cerebral blood flow (mCBF) was well maintained by cerebral vasodilation and the cerebral O2 consumption rate (CMRO2) increased during the first three stages of hemorrhage. At 40 ml/kg of hemorrhage, there were significant reduction in mCBF and CMRO2 despite the increase in O2 extraction, suggesting the occurrence of cerebral hypoxia and decompensation of the cerebral circulation. There were remarkable regional variations in the responses of regional cerebral blood flows (rCBF) to hypovolemia, resulting in a significant redistribution of cerebral blood flow. The fractions of cardiac output supplying the diencephalon (thalamus and hypothalamus), the brain stem (pons and medulla oblongata) and the cervical spinal cord increased after hemorrhage up to 40 ml/kg. The redistribution of rCBF favors those areas where neurons related to cardiovascular control are located. These findings have significant implications relating to hemodynamic regulation during hemorrhagic hypotension.

Effects of hemorrhagic hypotension on the cerebral circulation. II. Electrocortical function

The effects of graded hemorrhagic hypotension on electrocortical function was investigated in 12 cats anesthetized with alpha-chloralose. Cerebral function was assessed both in terms of spontaneous activity (EEG) and the somatosensory evoked response. No significant changes in the EEG trace or in the amplitude of the positive/negative waves of the primary evoked response were observed at mean arterial pressures of between 120 mm Hg and 40 mm Hg. At levels of systemic arterial pressure of less than 40 mm Hg cortical rhythms became slower as pressure was decreased and an isoelectric EEG was recorded in the pressure range 10--30 mm Hg. The earliest sign of any change in the amplitude of the primary evoked responses was observed at arterial pressures of approximately 35--40 mm Hg. Below this value the amplitude decreased with decreasing systemic pressure and became zero in the pressure range 15--25 mm Hg.

Cerebral function during profound oligemic hypotension in the dog

✓ Electrocortigraphic activity and common carotid blood flow were studied in 12 dogs during and following profound oligemic hypotension. Five animals survived but seven died within 75 min of hypotension. Although an 80% to 90% reduction in both mean arterial pressure and common carotid blood flow was observed, only a 20% diminution of intracranial pressure occurred and there was little change in electrocorticographic function. The preservation of cerebral function in the presence of profound systemic hypotension was demonstrated. When death occurred during shock, no prior change in central nervous system function was noted. With reinfusion, no change in parameters was noted, but common carotid blood flow was depressed to 35% to 50% of control levels for up to 2½ hrs of observation.