eMedicine Specialties > Trauma > Blood Loss and Trauma Management

Shock, Hemorrhagic: Follow-up

Author: John Udeani, MD, FAAEM, Assistant Professor, Department of Emergency Medicine, Charles Drew University/UCLA School of Medicine
Contributor Information and Disclosures

Updated: Sep 22, 2008

Follow-up

Further Inpatient Care

  • The remainder of care is determined by the proximate course of the hemorrhagic shock.
  • Patients with hemorrhagic shock are at risk for acute tubular necrosis, acute lung injury, transfusion-related acute lung injury, infections (principally nosocomial and related to operative sites or indwelling catheters), and multiple organ dysfunction syndrome, with its attendant risk of death. Discussion of each of these entities is beyond the scope of this article.

Inpatient & Outpatient Medications

  • Patients with hemorrhagic shock are often unable to mount an appropriate bone marrow response in the acute setting with regard to red blood cell production. Using erythropoietin (40,000 U/wk) in combination with supplemental iron and vitamin C to boost production is useful. This strategy has been used successfully to decrease red blood cell transfusions in a large multicenter trial in Canada.

Transfer

  • In general, few indications exist to transfer a patient who is in shock to a specialized facility. Ideally, all hospitals and physicians should be prepared to initially treat and stabilize the patient with exsanguinating hemorrhage. After control of the bleeding and reversal of acute shock, patients may be transferred to facilities that can treat additional injuries.
  • The patient should be transferred by an advanced life support unit with the capability of blood transfusion en route.
  • The decision for air ambulance transport instead of ground transportation is one that involves consideration of proximity, difficulty with the ground route, time en route, weather conditions, and availability.
  • Patients may be transferred for ongoing management of the initial injury when the injury complex demands care that exceeds the resources or capabilities of the initially receiving facility. This transfer should be made from the transferring physician to the receiving physician without intermediaries.

Complications

  • The primary complication is death.
  • The entire spectrum of organ failures may be the sequelae of resuscitated hemorrhagic shock.
  • The cascade of systemic inflammatory response syndrome (SIRS) progressing to multiple organ failure syndrome (as described by the late Roger Bone, MD) complicates the cases of approximately 30-70% of patients who present with hemorrhagic shock and survive their initial resuscitation.

Prognosis

  • Prognosis is related to the ability to be resuscitated from shock, as well as the underlying illness or injury, not the presentation of hemorrhagic shock.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • The primary pitfall is transfusing massive amounts of blood products into a Jehovah's Witness. This error occurs on occasion. Despite acting in the patient's best interest (prior to knowing that the patient would not want a blood transfusion), this error is a major incident for the patient. In this situation, honesty with the patient and the family member(s) is the rule. Involve the hospital's risk manager early. Family conferencing with a clergy member sometimes is helpful as well.

Special Concerns

  • Blood substitute: There are recognized risks associated with the transfusion of large quantities of packed red blood cells. As a result, other modalities are being investigated. One such modality is hemoglobin-based oxygen carriers (HBOC). Clinical application has been limited by its toxic effect profile. However, research is ongoing on the use of these products.
  • Hypertonic saline: In patients with hemorrhagic shock, hypertonic saline has the theoretical benefit of increasing intravascular volume with only small amounts of fluid. The combination of dextran and hypertonic saline may be beneficial in situations where infusion of large volumes of fluid may be harmful, such as in the elderly with impaired cardiac activity. Additional trials will be required before this combination is accepted as standard of care.
  • See related CME at Blood Substitutes Linked to Deaths, MI.
 


More on Shock, Hemorrhagic

Overview: Shock, Hemorrhagic
Differential Diagnoses & Workup: Shock, Hemorrhagic
Treatment & Medication: Shock, Hemorrhagic
Follow-up: Shock, Hemorrhagic
Multimedia: Shock, Hemorrhagic
References
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References

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Further Reading

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Keywords

hemorrhagic shock, shock, hypovolemia, hypovolemic shock, exsanguination, bleeding, blood loss, hemorrhage

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Contributor Information and Disclosures

Author

John Udeani, MD, FAAEM, Assistant Professor, Department of Emergency Medicine, Charles Drew University/UCLA School of Medicine
John Udeani, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Lewis J Kaplan, MD, FACS, FCCM, FCCP, Director, SICU and Surgical Critical Care Fellowship, Associate Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale University School of Medicine
Lewis J Kaplan, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association for Surgical Education, Connecticut State Medical Society, Eastern Association for the Surgery of Trauma, International Trauma Anesthesia and Critical Care Society, Society for the Advancement of Blood Management, Society of Critical Care Medicine, and Surgical Infection Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School
Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other; AstraZeneca Grant/research funds Other

 
 
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