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
Approximate blood loss	<15%	15-30%	30-40%	>40%
Heart rate	↔	↔/↑	↑	↑↑
Blood pressure	↔	↔	↔/↓	↓
Pulse Pressure (mmHg)	↔	↓	↓	↓
Respiratory Rate (per min)	↔	↔	↔/↑	↑
Urine Output (mL/hr)	↔	↔	↓	↓↓
Glasgow coma scale score	↔	↔	↓	↓
Base deficit^	0 to -2 mEq/L	-2 to -6 mEq/L	-6 to -10 mEq/L	-10 or less mEq/L
Need for blood products	Monitor	Possible	Yes	Massive transfusion protocol

^Base excess is the quantity of base (HCO3-, in mEq/L) that is above or below the normal range in the body. A negative number is called a base deficit and indicates metabolic acidosis.

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
• Avoid hypothermia
• Resuscitate; consider massive transfusion protocol
• Get help early (e.g. surgeon, IR)

Disposition

• Admit

See Also

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