Managing Shock at the “Battlefront” of Surgery
- Dr. Alexander Truesdell of the INOVA Heart and Vascular Institute discusses how physicians can apply the same shock management principles found on the battlefront into everyday surgical practice.
- Early recognition of shock and early revascularization are two essential elements of successful treatment for shock on the battlefield as well as in conventional care centers.
For the past few decades, early revascularization has been considered the cornerstone of treatment for cardiogenic shock (CS). Despite widespread adoption and implementation of this management strategy, rates of mortality following interventional cardiology procedures for CS remain high.
Dr. Alexander Truesdell of the INOVA Heart and Vascular Institute mentions in his editorial War on Shock that the method for treating CS requires a more aggressive, combat-like approach, embracing strategies he learned while serving as an interventional cardiologist in Iraq and Afghanistan.1 “Only with strong leadership, teamwork, and a national commitment to a joint integrated countrywide network of cardiogenic shock care, research, and innovation,” said Truesdell, “can we hope to achieve our desired goal of zero preventable death from cardiogenic shock.”
In his editorial, Truesdell mentions the fact that, in war, early recognition of shock and restoration of normal physiology is an immediate priority for facilitating early intervention. The literature appears to reflect this practice; evidence suggests the reduction of myocardial oxygen demand and the maintenance of vital organ perfusion depends on early implementation of ventricular and circulatory support.2 Typically, this support is provided by percutaneous mechanical devices. Thus, this action places normal physiology (vs normal anatomy) as a greater priority.
Improved door-to-balloon time (DTB), as mentioned in this editorial, has resulted in better mortality outcomes following myocardial infarction (MI). Despite this, mortality benefits obtained from improved DTB have leveled off in recent years. Early revascularization via rapid administration of mechanical circulatory support devices may impart similar outcomes as observed by the civilian and military trauma system. The “shoot, move, and communicate” military adage applies well for the treatment of CS.
Similar to forming a military operation that consists of a concise collection and evaluation of pertinent information on the enemy and past battle successes, effective treatment for CS or MI relies on data collected on previous catheterization and revascularization interventions. The collection and retrieval of large-scale data in a national consolidated registry, such as the ongoing cVAD registry, can facilitate a more intelligent study and development of future treatment strategies, potentially improving the level of care provided for patients presenting with acute MI or CS.
1. Truesdell AG. War on Shock. J Invasive Cardiol. 2017;29(1):E14-E15.
2. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med. 1999;341(9):625-634.