What is the initial management of hemorrhagic shock?

Initial Management of Hemorrhagic Shock

The immediate priorities in hemorrhagic shock are simultaneous bleeding control and volume resuscitation with crystalloids, targeting a systolic blood pressure of 80-100 mmHg (permissive hypotension) until definitive hemorrhage control is achieved, followed by early surgical or interventional bleeding control procedures. 1

Immediate Assessment and Airway Management

• Minimize time to definitive intervention - the elapsed time between injury and operation should be minimized to reduce mortality 1
• Assess extent of hemorrhage using an established clinical grading system immediately upon patient arrival 1
• Evaluate respiratory status and consider intubation in cases of active hematemesis or inability to protect the airway 2
• Avoid hyperventilation - severely hypovolemic trauma patients should not be hyperventilated or subjected to excessive positive end-expiratory pressure, as this compromises venous return and cardiac output 1

Fluid Resuscitation Strategy

Initial Crystalloid Administration

• Begin with balanced crystalloids (Ringer's lactate preferred) or normal saline as the initial resuscitation fluid 1, 3
• Target systolic blood pressure of 80-100 mmHg in patients without traumatic brain injury until major bleeding is controlled (permissive hypotension strategy) 1, 2
• Use fluid challenge technique - continue crystalloid administration as long as hemodynamic improvement occurs (increased blood pressure, decreased heart rate, improved perfusion) 3
• Avoid excessive crystalloid volumes - more than 2000 mL increases coagulopathy incidence above 40%, and more than 3000 mL increases it above 50% 3

Blood Product Administration

• Transfuse packed red blood cells when hemoglobin falls below 7 g/dL, maintaining a target of 7-9 g/dL in most patients 2, 4
• Consider higher hemoglobin target of 10 g/dL in actively bleeding patients, elderly patients, or those at risk for myocardial infarction 4
• Do not delay blood products while giving excessive crystalloid volumes, as this worsens coagulopathy and outcomes 3

Fluids to Avoid

• Do not use colloids (hydroxyethyl starch, gelatins) - they impair coagulation and platelet function without survival benefit 3, 5
• Avoid albumin - no evidence of benefit and may be harmful in bleeding scenarios 3

Identification and Control of Bleeding Source

Diagnostic Approach

• Perform early FAST ultrasound for detection of free fluid in patients with suspected torso trauma 1
• Proceed to urgent surgery if significant free intraabdominal fluid with hemodynamic instability is identified 1
• Use CT scanning in hemodynamically stable patients with suspected head, chest, or abdominal bleeding following high-energy injuries 1
• Monitor serum lactate and base deficit to estimate and monitor the extent of bleeding and shock - do not rely on single hematocrit measurements alone 1

Immediate Bleeding Control

• Proceed to immediate bleeding control procedure if an identified source of bleeding exists and initial resuscitation measures are unsuccessful 1
• Perform immediate further assessment if hemorrhagic shock is present but the bleeding source is unidentified 1
• Apply pelvic ring closure and stabilization immediately in patients with pelvic ring disruption and hemorrhagic shock 1
• Use angiographic embolization or surgical packing for ongoing hemodynamic instability despite adequate pelvic ring stabilization 1

Surgical Interventions

• Employ damage control surgery in severely injured patients presenting with deep hemorrhagic shock, ongoing bleeding, coagulopathy, hypothermia, acidosis, or inaccessible major anatomic injury 1
• Achieve early bleeding control using packing, direct surgical control, and local hemostatic procedures 1
• Consider aortic cross clamping as an adjunct in the exsanguinating patient 1

Vasopressor Use (Cautious and Limited)

• Vasopressors may be used transiently to sustain arterial pressure and maintain tissue perfusion in life-threatening hypotension when fluid resuscitation alone is insufficient 1, 2
• Norepinephrine is the preferred agent if vasopressors are required 1, 2
• Use vasopressors cautiously - early aggressive use may be deleterious compared to volume resuscitation and should only be employed when blood pressure cannot be maintained by fluids alone 1, 6
• Target mean arterial pressure ≥65 mmHg while controlling bleeding 3

Adjunctive Pharmacologic Therapy

• Consider antifibrinolytic agents in bleeding trauma patients: tranexamic acid 10-15 mg/kg followed by infusion of 1-5 mg/kg/h 1
• Administer prophylactic antibiotics (ceftriaxone 1 g IV every 24 hours) in gastrointestinal bleeding to reduce infections, rebleeding, and mortality 2

Temperature Management

• Apply early measures to reduce heat loss and warm hypothermic patients to achieve normothermia 1
• Prevent hypothermia aggressively - remove wet clothing, cover the patient, increase ambient temperature, use forced air warming, and warm all fluids 1
• Recognize that hypothermia below 34°C compromises coagulation through altered platelet function and impaired coagulation factor function 1

Common Pitfalls to Avoid

• Do not delay definitive bleeding control while pursuing aggressive fluid resuscitation - these must occur simultaneously 1
• Do not rely solely on crystalloids when hemoglobin is critically low (≤7 g/dL) - oxygen-carrying capacity must be restored with packed red blood cells 3, 4
• Do not use vasopressors as first-line therapy - fluid resuscitation remains the mainstay of initial management 6, 7
• Do not target normal blood pressure prematurely - permissive hypotension (SBP 80-100 mmHg) until bleeding control reduces additional blood loss 1, 8