What is the initial management of shock in trauma?

Initial Management of Shock in Trauma

Begin immediate fluid resuscitation with crystalloid solutions while simultaneously pursuing hemorrhage control, targeting a systolic blood pressure of 80-90 mmHg (permissive hypotension) in patients without traumatic brain injury. 1

Immediate Priorities

Hemorrhage Control

• Patients with hemorrhagic shock and an identified bleeding source require immediate bleeding control procedures unless initial resuscitation measures rapidly succeed. 1
• Damage control surgery should be employed in severely injured patients presenting with deep hemorrhagic shock, signs of ongoing bleeding, and coagulopathy. 1
• For pelvic ring disruption with hemorrhagic shock, perform immediate pelvic ring closure and stabilization. 1

Blood Pressure Targets

The target blood pressure differs critically based on the presence or absence of traumatic brain injury:

• Without TBI: Target systolic blood pressure of 80-90 mmHg until major bleeding is controlled. 1
• With severe TBI (GCS ≤8): Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion. 1

The rationale for permissive hypotension in non-TBI patients is that aggressive fluid resuscitation increases hydrostatic pressure on wounds, dislodges blood clots, dilutes coagulation factors, and causes hypothermia. 1 However, this approach is absolutely contraindicated in traumatic brain injury and spinal injuries where adequate perfusion pressure is essential for tissue oxygenation of the injured central nervous system. 1

Important caveats: Permissive hypotension should be carefully considered in elderly patients and may be contraindicated in patients with chronic arterial hypertension. 1

Fluid Resuscitation Strategy

Initial Fluid Choice

Initiate crystalloid solutions as the first-line fluid therapy. 1

• Balanced electrolyte solutions are preferred over 0.9% saline. 1
• If using 0.9% saline, limit to maximum 1-1.5 L to avoid hyperchloremic acidosis. 1
• Avoid hypotonic solutions (such as Ringer's lactate) in patients with severe head trauma to minimize fluid shift into damaged cerebral tissue. 1

Volume Strategy

Use a restrictive volume approach rather than aggressive high-volume resuscitation. 1

Evidence from the German Trauma Registry (17,200 patients) demonstrated that coagulopathy increased dramatically with fluid volume: >40% with >2,000 mL, >50% with >3,000 mL, and >70% with >4,000 mL administered pre-clinically. 1 Patients receiving pre-hospital low-volume resuscitation (0-1,500 mL) had higher survival rates than those receiving high-volume strategies (≥1,501 mL). 1

Colloid Considerations

• Colloids may be added if crystalloids alone with vasopressors cannot maintain basic tissue perfusion. 1
• Use colloids within prescribed limits for each solution if administered. 1
• No clear mortality benefit has been demonstrated for colloids over crystalloids in trauma. 1
• All hydroxyethyl starch and gelatin solutions impair coagulation and platelet function. 1

Blood Product Transfusion

Hemoglobin Target

If erythrocyte transfusion is necessary, target hemoglobin of 70-90 g/L (7-9 g/dL). 1

Early signs indicating need for RBC transfusion include: 1

• Relative tachycardia
• Relative hypotension
• Oxygen extraction >50%
• Mixed venous oxygen pressure (PvO₂) <32 mmHg

Critical consideration: Hemorrhagic shock is a rapidly evolving situation requiring anticipation of transfusion needs; decisions should not be based solely on hemoglobin levels. 1

Transfusion Strategy

• If high FFP:RBC ratios cannot be achieved, administer at least 1 L crystalloid per unit RBC to reduce overall mortality. 1
• Integrate depth of shock, hemodynamic response to resuscitation, and rate of actual blood loss into transfusion decisions. 1

Common Pitfalls to Avoid

1. Aggressive pre-hospital fluid administration increases mortality, particularly in penetrating trauma, hypotension, severe head injury, and patients requiring immediate surgery. 1

2. Using permissive hypotension in TBI patients will worsen outcomes due to inadequate cerebral perfusion. 1

3. Administering hypotonic solutions to head-injured patients exacerbates cerebral edema. 1

4. Excessive crystalloid volume is the greatest predictor of secondary abdominal compartment syndrome and increases coagulopathy risk. 1

5. Delaying hemorrhage control while pursuing aggressive resuscitation worsens outcomes. 1