What is the classification and management of a trauma patient with tachycardia (pulse 110), hypotension (blood pressure 90/60), delayed capillary refill (4 seconds), and tachypnea (respiratory rate 25)?

Class III Hemorrhagic Shock

This patient presents with Class III hemorrhagic shock based on the American College of Surgeons Advanced Trauma Life Support (ATLS) classification, requiring immediate aggressive resuscitation and urgent bleeding control. 1, 2

Classification Rationale

The patient's vital signs align precisely with Class III hemorrhagic shock criteria:

• Pulse 110 bpm: Exceeds the Class III threshold of >100 bpm but remains below the Class IV threshold of >140 bpm 1, 2
• Blood pressure 90/60 mmHg: Demonstrates hypotension (systolic <90 mmHg is the threshold), though not as severely decreased as Class IV 1, 3
• Capillary refill 4 seconds: Markedly prolonged (normal <2 seconds), indicating significant peripheral vasoconstriction and tissue hypoperfusion 1, 4
• Respiratory rate 25/min: Falls within the Class III range of 20-30/min 1

Class III hemorrhagic shock represents 30-40% blood volume loss (1,500-2,000 mL in a 70 kg adult), with expected findings of decreased blood pressure, decreased pulse pressure, anxious/confused mental status, and urine output of 5-15 mL/hour. 1, 2

Immediate Management Algorithm

Phase 1: Airway, Breathing, and Oxygen (First Priority)

• Administer high-flow oxygen at 10 L/min immediately 1
• Assess for need for airway protection given altered mental status expected in Class III shock 1

Phase 2: Vascular Access and Initial Resuscitation

• Insert two large-bore intravenous cannulae immediately 1
• Initiate crystalloid resuscitation with 20 mL/kg bolus of 0.9% saline or balanced crystalloid 1
• Obtain blood for type and cross-match, complete blood count, coagulation studies, and lactate/base deficit 1, 2

Phase 3: Permissive Hypotension Strategy

Target systolic blood pressure of 80-90 mmHg until bleeding is controlled, unless contraindications exist (traumatic brain injury, spinal cord injury, elderly with chronic hypertension). 1

• Avoid excessive crystalloid administration that may worsen coagulopathy and hemodilution 1, 2
• If target blood pressure cannot be achieved with restricted fluid strategy, add norepinephrine to maintain systolic BP ≥80 mmHg 1

Phase 4: Blood Product Transfusion

• Initiate massive transfusion protocol if patient shows minimal or no response to initial 20 mL/kg crystalloid bolus 2
• Class III shock patients typically require immediate blood product transfusion 2

Phase 5: Urgent Bleeding Control

Patients with Class III hemorrhagic shock require immediate bleeding control procedures (surgery or angioembolization) within 60 minutes of presentation. 1, 3

• Do not delay definitive intervention for prolonged resuscitation attempts 1
• Transient responders (those who initially improve but then deteriorate) require immediate operative intervention 3

Critical Monitoring Parameters

• Capillary refill time: Prolonged CRT (>2 seconds) is a reasonable prognostic indicator and should be serially assessed 1, 4
• Mental status: Confusion/anxiety indicates inadequate cerebral perfusion 1
• Urine output: Target >1 mL/kg/hour as indicator of adequate renal perfusion 1
• Base deficit/lactate: Serial measurements guide resuscitation adequacy 2, 3
• Response to resuscitation: Classify as rapid responder, transient responder, or minimal/no responder to guide urgency of operative intervention 2, 3

Common Pitfalls to Avoid

• Do not rely solely on blood pressure: Compensatory mechanisms may maintain near-normal BP despite 30-40% blood loss 3, 5
• Do not assume absence of tachycardia excludes significant hemorrhage: 35% of hypotensive trauma patients are not tachycardic 5
• Avoid hyperventilation: Increases mortality in trauma patients and decreases cardiac output in hemorrhagic shock 1
• Do not use excessive PEEP: Decreases cardiac output in severely hypovolemic patients 1
• Avoid excessive crystalloid resuscitation: More than 40 mL/kg without blood products worsens outcomes 1
• Do not delay surgical intervention: Establishing a 60-minute time limit from presentation to operating room significantly decreases mortality 1

Special Considerations

If traumatic brain injury or spinal cord injury is present, permissive hypotension is contraindicated—maintain mean arterial pressure adequate for cerebral perfusion (typically MAP ≥80 mmHg). 1

In elderly patients or those with chronic hypertension, permissive hypotension should be carefully reconsidered, as they may require higher perfusion pressures to maintain organ function. 1