What are the next steps in managing a patient with hemorrhagic shock who has received initial treatment with cardiopulmonary resuscitation (CPR), intravenous (IV) fluids, blood, and epinephrine (Epi) at a critical access facility?

Critical Next Steps in Hemorrhagic Shock at a Critical Access Facility

Your immediate priority is to identify and surgically control the bleeding source while simultaneously arranging urgent transfer to a trauma center, as definitive hemorrhage control is the only life-saving intervention at this stage. 1, 2, 3

Immediate Source Control Assessment

Without gunshot wounds to head, chest, or abdomen/pelvis, you must rapidly identify the bleeding source through:

• Focused physical examination for extremity injuries, pelvic instability, retroperitoneal bleeding, or occult torso trauma 1, 2
• FAST ultrasound to detect free intraabdominal fluid if available 2
• Direct visualization of all wounds, drains, and potential bleeding sites (clothing, floor, external surfaces) 1
• Pelvic examination and assessment for pelvic ring disruption - if present with ongoing shock, perform immediate pelvic binder application or sheet wrapping for temporary stabilization 2

Optimize Resuscitation Strategy

Switch from aggressive fluid resuscitation to permissive hypotension:

• Target systolic blood pressure of 80-100 mmHg (not normotension) until bleeding is controlled 2
• Stop or minimize further crystalloid administration - you've already given fluids, now focus on blood products 1, 2
• Continue warmed blood products in massive transfusion protocol ratios if available 1, 2
• Administer O-negative blood immediately if cross-matched products unavailable 1, 2

Address Coagulopathy Aggressively

Hemorrhagic shock rapidly causes coagulopathy that perpetuates bleeding:

• Give tranexamic acid (TXA) immediately if not already administered - this is a critical antifibrinolytic intervention 2
• Check coagulation parameters: PT, aPTT, Clauss fibrinogen (not derived fibrinogen) 1, 2
• Consider empiric fresh frozen plasma and platelets if massive transfusion protocol not yet initiated 1
• Use TEG/ROTEM if available for real-time coagulation assessment 1, 2

Prevent the Lethal Triad

Active warming is non-negotiable:

• Aggressively warm the patient using forced-air warming devices, warmed blankets, increased room temperature 1, 2
• Warm all IV fluids and blood products before administration 1, 2
• Monitor core temperature continuously - hypothermia worsens coagulopathy and mortality 1

Optimize Vascular Access

If not already done:

• Place large-bore central access (8-Fr) for rapid volume administration 1
• Consider intraosseous access if central access fails 1
• Avoid lower extremity access in hemorrhagic shock patients 4

Vasopressor Management

Reassess your epinephrine use:

• Epinephrine should be used cautiously in hemorrhagic shock - it's indicated for septic shock, not as primary therapy for hypovolemic shock 1, 4
• Vasopressors should be avoided until bleeding is controlled and volume adequately replaced 1
• If using epinephrine for cardiac arrest/peri-arrest, continue per ACLS protocols 1, but recognize this suggests the patient may be in extremis

Arrange Immediate Transfer

At a critical access facility, definitive care requires transfer:

• Activate emergency transfer protocols immediately - contact nearest trauma center 3, 5
• Communicate directly with accepting surgeon about need for immediate operative intervention 1
• Consider air medical transport if ground transport time exceeds 30 minutes 5
• Continue resuscitation during transport with blood products if possible 5

Monitor Critical Parameters

Track these specific markers:

• Lactate and base deficit - best indicators of tissue perfusion and shock severity 2
• Urine output - target >0.5 mL/kg/hr as marker of end-organ perfusion 6, 7
• Mental status - consciousness indicates adequate cerebral perfusion 1
• Avoid relying solely on blood pressure - patients can compensate despite significant blood loss 1, 2

Common Pitfalls to Avoid

Critical errors that worsen outcomes:

• Do not pursue normotensive resuscitation before bleeding control - this increases blood loss and mortality 2, 5
• Do not delay transfer for additional imaging or procedures you cannot definitively manage 2, 3
• Do not use excessive crystalloids - this dilutes clotting factors and worsens coagulopathy 1, 2, 7
• Do not hyperventilate if intubated - this decreases cardiac output in hypovolemia 2
• Do not use vasopressors as primary therapy - they mask hypovolemia and worsen tissue perfusion 1

If Patient Arrests

Cardiac arrest from exsanguination requires:

• Immediate consideration of resuscitative thoracotomy if within your facility's capabilities and patient arrested within last 10 minutes 3
• Aortic cross-clamping to redirect blood flow to heart and brain 3
• Massive transfusion with direct cardiac refilling 3
• Recognition that standard ACLS has limited efficacy without simultaneous hemorrhage control and volume replacement 3, 5

The fundamental reality: without identifying and controlling the bleeding source, this patient will die regardless of other interventions. 1, 3, 5 Your critical access facility's limitations mean transfer for definitive surgical control is likely the only path to survival.