Practices Associated with Decreased Mortality from Traumatic Hemorrhagic Shock
Minimize the time between injury and definitive hemorrhage control—this is the single most critical factor for survival in traumatic hemorrhagic shock. 1
Time-Critical Interventions
Immediate Transport and System-Level Care
Transport severely injured patients directly to appropriate trauma facilities (Level I trauma centers when possible), as this significantly reduces mortality compared to lower-level facilities. 1 Level I trauma centers show significantly lower standardized mortality rates among bleeding trauma patients compared with level III and IV facilities. 1
Every additional minute of pre-hospital scene time correlates with a 1% increase in mortality, and every additional minute of pre-hospital response time correlates with a 2% increase in mortality in penetrating trauma. 1 This means rapid extraction and transport are paramount—do not delay on scene for interventions that can be performed en route.
More than 50% of trauma patients with fatal outcomes die within 24 hours of injury, with 34.5% of early hemorrhagic deaths classified as potentially preventable by stopping bleeding early. 1
Immediate Hemorrhage Control
Apply direct manual pressure to all bleeding wounds immediately—this remains the most effective initial intervention for external hemorrhage control. 1, 2, 3, 4
For life-threatening extremity bleeding that cannot be controlled by direct pressure, apply tourniquets immediately in the pre-surgical setting. 1 Tourniquet application has become standard of care for severe extremity hemorrhage, particularly from mangled extremity injuries, penetrating or blast injuries, or traumatic amputations. 1
Tourniquets should remain in place until surgical control is achieved but keep this timespan as short as possible (ideally under 2 hours, though military data shows extremity survival up to 6 hours). 1, 5 Prolonged placement can cause nerve paralysis and limb ischemia, though these complications are rare. 1, 5
Hemostatic dressings result in shorter time to hemostasis than standard dressings when used with direct manual pressure. 2, 4
Surgical and Interventional Control
Patients presenting with hemorrhagic shock and an identified bleeding source must undergo immediate bleeding control procedures (surgery or interventional radiology) unless initial resuscitation measures are successful. 1 This is particularly critical for:
- Penetrating vascular injuries requiring rapid surgical control 1
- Abdominal gunshot wounds with signs of severe hypovolemic shock 1
- Pelvic fractures with persistent hemodynamic instability 1
Delayed transfer to the operating room is a preventable cause of death—shorten the time required for diagnosis and resuscitation prior to surgery. 1 Establishing a 60-minute emergency department time limit for patients in hemorrhagic shock has been shown to significantly decrease mortality. 1
Ventilation Management
Avoid hyperventilation in severely hypovolemic trauma patients, as hyperventilated trauma patients have increased mortality compared to non-hyperventilated patients. 1, 6 Maintain initial normoventilation if there are no signs of imminent cerebral herniation. 6
- Do not use excessive positive end-expiratory pressure (PEEP) in severely hypovolemic patients, as this decreases cardiac output in hemorrhagic shock. 1 Use protective ventilation with low tidal volume and moderate PEEP only after stabilization. 6
Assessment and Monitoring
Clinically assess the extent of traumatic hemorrhage using the American College of Surgeons ATLS classification system (Classes I-IV based on blood loss, vital signs, and mental status). 1, 6 This grading system helps identify patients at risk of coagulopathy and guides resuscitation intensity.
Hemodynamic instability is defined as: systolic BP <90 mmHg, heart rate >120 bpm, cool/clammy skin, altered consciousness, and/or shortness of breath. 6
Do not rely solely on blood pressure as an indicator of hemodynamic stability—this is misleading. 6 Patients may maintain normal blood pressure until Class III hemorrhage (1,500-2,000 mL blood loss). 1
Recognize transient responders (patients who initially stabilize with fluid resuscitation but later decompensate) as unstable patients requiring immediate definitive intervention. 6
Common Pitfalls to Avoid
Never delay definitive hemorrhage control for prolonged resuscitation in the emergency department—this is a preventable cause of death. 1, 6
Do not use pressure point control for extremity bleeding—collateral circulation renders this ineffective within seconds. 1, 2
Avoid hyperventilation during resuscitation—rescue personnel have a tendency to hyperventilate patients, which worsens outcomes. 1
Do not remove initial gauze if bleeding continues—add more gauze on top while maintaining pressure. 2