Hemorrhagic Shock in Emergency Medicine Clinical Presentation

  • Author: William P Bozeman, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Mar 18, 2011
 

History

History taking should address the following:

  • Specific details of the mechanism of trauma or other cause of hemorrhage are essential.
  • Inquire about a history of bleeding disorders and surgery.
  • Prehospital interventions, especially the administration of fluids, and changes in vital signs should be determined. Emergency medical technicians or paramedics should share this information.
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Physical

Findings at physical examination may include the following:

  • Head, ears, eyes, nose, and throat
    • Sources of hemorrhage usually are apparent.
    • The blood supply of the scalp is rich and can produce significant hemorrhage.
    • Intracranial hemorrhage usually is insufficient to produce shock, except possibly in very young individuals.
  • Chest
    • Hemorrhage into the thoracic cavities (pleural, mediastinal, pericardial) may be discerned at physical examination. Ancillary studies often are required for confirmation.
    • Signs of hemothorax may include respiratory distress, decreased breath sounds, and dullness to percussion.
    • Tension hemothorax, or hemothorax with cardiac and contralateral lung compression, produces jugular venous distention and hemodynamic and respiratory decompensation.
    • With pericardial tamponade, the classic triad of muffled heart sounds, jugular venous distention, and hypotension often is present, but these signs may be difficult to appreciate in the setting of an acute resuscitation.
  • Abdomen
    • Injuries to the liver or spleen are common causes of hemorrhagic shock. Spontaneous rupture of abdominal aortic aneurysm (AAA) may also cause severe intra-abdominal hemorrhage and shock.
    • Blood irritates the peritoneal cavity; diffuse tenderness and peritonitis are common when blood is present. However, the patient with altered mental status or multiple concomitant injuries may not have the classic signs and symptoms at physical examination.
    • Progressive abdominal distention in hemorrhagic shock is highly suggestive of intra-abdominal hemorrhage.
  • Pelvis
    • Fractures can produce massive bleeding. Retroperitoneal bleeding must be suspected.
    • Flank ecchymosis may indicate retroperitoneal hemorrhage.
  • Extremities
    • Hemorrhage from extremity injuries may be apparent, or tissues may obscure significant bleeding.
    • Femoral fractures may produce significant blood loss.
  • Nervous system
    • Agitation and combativeness may be seen in the initial stages of hemorrhagic shock.
    • These signs are followed by a progressive decline in level of consciousness due to cerebral hypoperfusion or concomitant head injury.
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Contributor Information and Disclosures
Author

William P Bozeman, MD  Associate Professor, Associate Director of Research, Department of Emergency Medicine, Wake Forest University School of Medicine

William P Bozeman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and National Association of EMS Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Daniel J Dire, MD, FACEP, FAAP, FAAEM  Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas School of Medicine at San Antonio

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US

Disclosure: Talecris Biotherapeutics Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Tom Scaletta, MD  Chairperson, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. National Center for Injury Control and Prevention. Ten Leading Causes of Death by age group. 2004. Center for Disease Control and Prevention; [Full Text].

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  3. Tsang BD, Panacek EA, Brant WE, Wisner DH. Effect of oral contrast administration for abdominal computed tomography in the evaluation of acute blunt trauma. Ann Emerg Med. Jul 1997;30(1):7-13. [Medline].

  4. Ward KR, Ivatury RR, Barbee RW, Terner J, Pittman R, Filho IP. Near infrared spectroscopy for evaluation of the trauma patient: a technology review. Resuscitation. Jan 2006;68(1):27-44. [Medline].

  5. Bickell WH, Wall MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. Oct 27 1994;331(17):1105-9. [Medline].

  6. Gonzalez EA, Moore FA, Holcomb JB, Miller CC, Kozar RA, Todd SR. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma. Jan 2007;62(1):112-9. [Medline].

  7. Roberts I, Shakur H, Ker K, Coats T. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev. Jan 19 2011;1:CD004896. [Medline].

  8. Gutierrez G, Reines HD, Wulf-Gutierrez ME. Clinical review: hemorrhagic shock. Crit Care. Oct 2004;8(5):373-81. [Medline]. [Full Text].

  9. Wilson M, Davis DP, Coimbra R. Diagnosis and monitoring of hemorrhagic shock during the initial resuscitation of multiple trauma patients: a review. J Emerg Med. May 2003;24(4):413-22. [Medline].

 
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