Hemorrhagic shock

Background

Goals of management

1. FIND and STOP the bleeding
2. Rapidly restore blood volume
3. Maintain functional blood composition (i.e. hemostasis, pH, oxygen carrying capacity, oncotic pressure and biochemistry)

Clinical Features

Classes of hemorrhagic shock

Class	I	II	III	IV
Blood Loss (mL)	<750	750-1000	1500-2000	>2000
Blood Loss (%)	<15	15-30	30-40	>40
Pulse rate (per min)	<100	100-120	120-140	>140
Blood Pressure	Normal	Normal	Decreased	Decreased
Pulse Pressure (mmHg)	Normal or Increased	Decreased	Decreased	Decreased
Respiratory Rate (per min)	14-20	20-30	30-40	>35
Urine Output (mL/hr)	>30	20-30		Negligible
Mental Status	Slightly Anxious	Mildly Anxious	Anxious, Confused	Confused, Lethargic
Fluids	Crystalloid	Crystalloid	Crystalloid and blood	Crystalloid and blood

Differential Diagnosis

Shock

• Cardiogenic
  • Acute valvular Regurgitation/VSD
  • CHF
  • Dysrhythmia
  • ACS
  • Myocardial Contusion
  • Myocarditis
  • Drug toxicity (e.g. beta blocker, CCB, or bupropion OD)
• Obstructive
  • Air embolism
  • Aortic Stenosis
  • Cardiac Tamponade
  • PE
  • Tension pneumothorax
• Distributive
  • Adrenal crisis
  • Anaphylaxis
  • Neurogenic shock
  • Sepsis
  • Toxicologic
• Hypovolemic
  • Severe dehydration
  • Hemorrhagic shock (traumatic and non-traumatic)

Evaluation

• Ultrasound in Shock and Hypotension

Locations of Possible Life-Threatening Bleeding

• External
• Internal
  • Thoracic cavity
  • Peritoneal cavity
  • Retroperitoneal space (i.e. pelvic fracture)
  • Femur fracture (into muscle/subcutaneous tissue)

Management

• Find and treat the cause
• Correct coagulopathy
• Get help early (e.g. surgeon, IR)

See Also

• Undifferentiated shock
• Massive Transfusion Protocol
• Trauma (main)

References

Authors

Ross Donaldson, Daniel Eggeman, Daniel Ostermayer, Neil Young