What is the appropriate management for a patient in hemorrhagic shock?

Management of Hemorrhagic Shock

Immediate hemorrhage control and rapid fluid resuscitation with crystalloids while simultaneously identifying and controlling the source of bleeding are the cornerstones of hemorrhagic shock management. 1

Initial Assessment and Actions

• Rapid clinical assessment:

  • Look for obvious blood loss (on clothes, floor, drains)
  • Check for signs of internal bleeding
  • Assess physiology (skin color, heart rate, blood pressure, capillary refill, conscious level) 2
  • Use established grading system to assess extent of hemorrhage 2

• Immediate interventions:

  • Control obvious bleeding points (direct pressure, tourniquets, hemostatic dressings) 1
  • Administer high FiO2 2
  • Establish large-bore IV access (8-Fr central access ideal in adults) 2
  • Avoid hyperventilation or excessive PEEP in hypovolemic patients 2

Hemorrhage Control

• Identified bleeding source: Immediate bleeding control procedure unless initial resuscitation is successful 2
• Unidentified bleeding source: Immediate further assessment 2
• Diagnostic approach:
  • Early focused sonography (FAST) for detection of free fluid in suspected torso trauma 2
  • Urgent surgery for patients with significant free intraabdominal fluid and hemodynamic instability 2
  • CT scan for hemodynamically stable patients with suspected bleeding following high-energy injuries 2
  • Monitor serum lactate and base deficit to estimate extent of bleeding and shock 2

Fluid Resuscitation Strategy

• Initial fluid therapy:

  • Begin with crystalloid solutions (normal saline or balanced solutions) 1
  • Initial bolus of 20 mL/kg 1
  • Target systolic blood pressure of 80-100 mmHg until major bleeding is controlled (permissive hypotension) 2, 1
  • Higher targets needed for patients with traumatic brain injury or chronic hypertension 1

• Blood transfusion:

  • Consider if hemoglobin drops below 70-90 g/L 1
  • Maintain hemoglobin around 10 g/dL in actively bleeding patients, elderly, or those at risk for myocardial infarction 3
  • Prepare for massive transfusion protocol if needed

Specific Interventions Based on Injury Pattern

• Pelvic ring disruption: Immediate pelvic ring closure and stabilization 2
• Ongoing instability despite pelvic stabilization: Early angiographic embolization or surgical bleeding control, including packing 2
• Severe hemorrhagic shock with ongoing bleeding: Consider damage control surgery 2
• Exsanguinating patient: Aortic cross clamping may be employed as adjunct bleeding control 2

Coagulation Management

• Antifibrinolytic agents:

  • Consider tranexamic acid 10-15 mg/kg followed by infusion of 1-5 mg/kg/h 2
  • Alternative: ε-aminocaproic acid 100-150 mg/kg followed by 15 mg/kg/h 2

• Laboratory monitoring:

  • Baseline bloods: FBC, PT, aPTT, Clauss fibrinogen, cross-match 2
  • Near-patient testing if available (TEG or ROTEM) 2
  • Single hematocrit measurements should not be used as isolated marker for bleeding 2

Vasopressor Use

• Indications: Only if fluid resuscitation fails to achieve target blood pressure 1
• Administration:
  • Norepinephrine should be diluted in 5% dextrose solution 4
  • Start at 2-3 mL/minute (8-12 mcg/minute) and titrate to response 4
  • Average maintenance dose: 0.5-1 mL/minute (2-4 mcg/minute) 4
  • Administer through central venous catheter 4

Temperature Management and Ongoing Care

• Actively warm the patient and all transfused fluids 2, 1
• Once bleeding is controlled:
  • Normalize blood pressure, acid-base status, and temperature 2
  • Avoid vasopressors if possible 2
  • Commence standard venous thromboprophylaxis as soon as bleeding is controlled 2
  • Admit to critical care for monitoring 2

Common Pitfalls to Avoid

• Delaying hemorrhage control while focusing solely on fluid resuscitation
• Targeting normal blood pressure too early, which may increase bleeding
• Failing to recognize occult blood volume depletion
• Neglecting temperature management, which can worsen coagulopathy
• Overlooking the need for early surgical intervention or damage control surgery
• Relying on single hematocrit measurements to guide resuscitation