eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Shock, Hemorrhagic: Differential Diagnoses & Workup

Author: William P Bozeman, MD, Associate Professor, Associate Director of Research, Department of Emergency Medicine, Wake Forest University School of Medicine
Contributor Information and Disclosures

Updated: Sep 18, 2008

Differential Diagnoses

Abdominal Trauma, Blunt
Pregnancy, Postpartum Hemorrhage
Abdominal Trauma, Penetrating
Pregnancy, Trauma
Abortion, Complications
Shock, Cardiogenic
Anemia, Acute
Shock, Hypovolemic
Anemia, Chronic
Shock, Septic
Blast Injuries
Spinal Cord Injuries
Disseminated Intravascular Coagulation
Pneumothorax, Tension and Traumatic
Pregnancy, Ectopic

Other Problems to Be Considered

Cardiac tamponade
Knife wounds

Workup

Laboratory Studies

  • Laboratory studies are essential in management of many forms of hemorrhagic shock. Baseline levels are determined frequently, but these infrequently change the initial management after trauma. Serial evaluations of the following can help guide ongoing therapy.
    • CBC
    • Prothrombin time and/or activated partial thromboplastin time
    • Urine output rate can help guide adequacy of perfusion.
    • ABGs (Levels reflect acid-base and perfusion status.)
    • Lactate and base deficit are used in some centers to indicate the degree of metabolic debt. Clearance of these markers over time can reflect the adequacy of resuscitation.
  • Typed and crossmatched packed red blood cells should be ordered immediately based on clinical suspicion of hemorrhagic shock. Fresh frozen plasma and platelets also may be required to correct or prevent coagulopathies that develop in severe hemorrhagic shock.

Imaging Studies

  • Standard radiography
    • Cervical spine, chest, and pelvis radiographs are the standard screening images for severe trauma.
    • Other radiographs may be indicated for orthopedic injuries.
  • Computed tomography
    • Image the appropriate region of suspected injury.
    • CT scanning frequently is the method of choice for evaluating possible intra-abdominal and/or retroperitoneal sources of hemorrhage in stable patients.
    • Oral contrast material may not increase the diagnostic yield of abdominal CT scanning in blunt trauma. Scanning should not be delayed to administer oral contrast material.3
  • Ultrasonography
    • Bedside abdominal ultrasonography can be very useful for the rapid detection of AAA and free intra-abdominal fluid.
    • Thoracic ultrasonographic findings can immediately confirm hemothorax or pericardial tamponade.
  • Directed angiography may be diagnostic and therapeutic. Interventional radiologists have had good success achieving hemostasis in hemorrhage caused by a variety of vessels and organs.

Other Tests

  • An ECG can be useful for detecting dysrhythmias and cardiac sequelae of shock.
  • Tissue oximetry using Near Infrared Spectroscopy (NIRS) shows promise for continuous noninvasive measurement of perfusion in hemorrhagic shock and other conditions.4

Procedures

  • Tube thoracostomy is necessary in significant hemothorax with or without pneumothorax.
  • Central venous access facilitates fluid resuscitation and monitoring of central venous pressure and is necessary if peripheral intravenous access is inadequate or impossible to obtain.
  • Diagnostic peritoneal lavage is used to detect intra-abdominal blood, fluid, and intestinal contents. It is sensitive but not specific for abdominal injury. It is not used to evaluate the retroperitoneum, which can hold significant hemorrhage, and does not identify the source of hemorrhage.

More on Shock, Hemorrhagic

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

  2. Cocchi MN, Kimlin E, Walsh M, Donnino MW. Identification and resuscitation of the trauma patient in shock. Emerg Med Clin North Am. Aug 2007;25(3):623-42, vii. [Medline].

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

  8. 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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Further Reading

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Keywords

blood loss, hemorrhage, shock, shocklike state, hemorrhagic shock, spontaneous hemorrhage, trauma, clinical hemorrhagic shock, acute bleeding, severe hemorrhagic shock, sepsis, bleeding disorders, intracranial hemorrhage, abdominal aortic aneurysm, AAA, intra-abdominal hemorrhage, retroperitoneal hemorrhage, retroperitoneal bleeding, abdominal bleeding, organ failure

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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.

Medical Editor

Daniel J Dire, MD, FACEP, FAAP, FAAEM, Clinical Associate Professor, Department of Emergency Medicine, University of Texas-Houston
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: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Tom Scaletta, MD, Past-President, American Academy of Emergency Medicine; Chairperson, Department of Emergency Medicine, Edward Hospital; Assistant Professor of Emergency Medicine, Rush Medical College and Cook County Hospital
Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

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, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
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

 
 
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