Prehospital Care
Standard care consists of rapid assessment and expeditious transport to an appropriate center for evaluation and definitive care.
Intravenous access and fluid resuscitation are standard. However, this practice has become controversial. For many years, aggressive fluid administration has been advocated to normalize hypotension associated with severe hemorrhagic shock. Studies of urban patients with penetrating trauma have shown that mortality increases with these interventions; study findings call these practices into question. [11, 12, 13]
Resuscitation with crystalloid solutions has been shown to put patients with hemorrhagic shock at risk for marked acidosis and to iatrogenically worsen the lethal triad of coagulopathy, hypothermia, and acidosis. Lactated Ringer’s resuscitation, elevated lactate levels, and normal saline negatively affect the base deficit. [12, 13, 14, 15, 16, 17]
Reversal of hypotension prior to achievement of hemostasis may increase hemorrhage, dislodge partially formed clots, and dilute existing clotting factors. Findings from animal studies of uncontrolled hemorrhage support these postulates. These provocative results raise the possibility that moderate hypotension may be physiologically protective and should be permitted, if present, until hemorrhage is controlled. These findings should not yet be clinically extrapolated to other settings or etiologies of hemorrhage. The ramifications of permissive hypotension in humans remain speculative, and safety limits have not yet been established.
In a study of patients who received 7.5% NaCl (HS), 7.5% NaCl/6% Dextran 70 (HSD), or 0.9% NaCl (normal saline [NS]) in the prehospital setting, treatment with HS/HSD led to higher systolic blood pressure, sodium, chloride, and osmolarity at admission, whereas lactate, base deficit, fluid requirement, and hemoglobin levels were similar in all groups. HSD-resuscitated patients had higher international normalized ratio values at admission and greater hypocoagulability. Prothrombotic tissue factor was elevated in those with shock treated with NS but was depressed in both HS and HSD groups. HSD patients had the worst imbalance between procoagulation/anticoagulation and profibrinolysis/antifibrinolysis, resulting in increased hypocoagulability and hyperfibrinolysis. [13]
Emergency Department Care
Bleeding associated with hemorrhagic shock is often seen in emergency medical services or in the intensive care unit. Identifying the origin of the bleeding and additional disorders helps to reveal the degree of hemorrhagic shock. [4]
Initial therapy until blood products are available needs to be differentiated to be effective in terms of hemodynamic stabilization and coagulation. Crystalloidal and colloidal solutions should be used carefully because these solutions bear risk within themselves. Treatment of acidosis and hypothermia can further reduce bleeding complications. Early and repeated monitoring of clotting should be performed simultaneously with shock therapy to permit specific treatment and substitution of coagulation factors if needed. Hemorrhagic shock therapy should be continued until bleeding is stopped. [4]
Direct the management of hemorrhagic shock toward optimizing perfusion and delivery of oxygen to vital organs.
Diagnose and treat the underlying hemorrhage rapidly and concurrently with shock management.
Initiate supportive therapy, including oxygen administration, monitoring, and establishment of intravenous access (eg, 2 large-bore catheters in peripheral lines, central venous access). Optimize intravascular volume and oxygen-carrying capacity. In addition to crystalloids, some colloid solutions, hypertonic solutions, and oxygen-carrying solutions (eg, hemoglobin-based emulsions, perfluorocarbon emulsions) are used or are being investigated for use in hemorrhagic shock.
Blood products are often required in severe hemorrhagic shock. Replacement of lost components using red blood cells (RBCs), fresh frozen plasma (FFP), and platelets may be essential. The ideal ratio of RBCs to FFP remains undetermined. Combat experience has suggested that aggressive use of FFP may reduce coagulopathies and improve outcomes. [15, 22]
Determination of the site and etiology of hemorrhage is critical for guiding further interventions and definitive care.
Control of hemorrhage may be achieved in the ED, or control may require consultations and special interventions.
In an Australian study of long-term outcomes of patients with major trauma who received massive transfusions, massive transfusion was independently associated with unfavorable outcomes. Among massively transfused patients, the authors found no significant change in measured outcomes over the study period, with a persistent 23% mortality in hospital, a 52% unfavorable GOSE (Glasgow Outcome Score—extended) at 6 months, and a 44% unfavorable GOSE at 12 months. [14]
Medical Care
Optimal management of trauma-related hemorrhagic shock begins at the point of injury and continues throughout all hospital settings. [5]
Resuscitation of the critically ill patient with fluid and blood products is one of the most widespread interventions in medicine. This is especially relevant for trauma patients, as hemorrhagic shock remains the most common cause of preventable death after injury. Consequently, the study of the ideal resuscitative product for patients in shock has become an area of great scientific interest and investigation. The pendulum has swung toward increased utilization of blood products for resuscitation. However, pathogens, immune reactions, and the limited availability of this resource remain a challenge for clinicians. Technological advances in pathogen reduction and innovations in blood product processing will allow us to increase the safety profile and efficacy of blood products, ultimately for the benefit of patients. [2]
Consult a general or specialized surgeon, a gastroenterologist, an obstetrician-gynecologist, an interventional radiologist, and others as required.
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CT scan of a 26-year-old man after a motor vehicle crash shows a significant amount of intra-abdominal bleeding.
