Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and
positive-pressure ventilation (PPV) on patients in
hemorrhagic shock. "In
hemorrhagic shock, or any low flow (central
hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of
shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of
oxygen delivery (DO2). The diminishing DO2 creates a state of systemic
hypoxia, the severity of which will determine the magnitude of the
shock (
shock dose) and a growing deficit of
oxygen, referred to as
oxygen debt. Rapid accumulation of critical levels of
oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (
ITP) provides the pressure differential driving venous return. PPV subsequently increases
ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic
hypoxia. If RSI and PPV are deemed necessary, prior or parallel
resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing
cardiac arrest in the critically shocked patient.