The primary treatment of hemorrhagic shock is to control the source of bleeding as soon as possible and to replace fluid. In controlled hemorrhagic shock (CHS), where the source of bleeding has been occluded, fluid replacement is aimed toward normalization of hemodynamic parameters. In uncontrolled hemorrhagic shock (UCHS), in which the bleeding has temporarily stopped because of hypotension, vasoconstriction, and clot formation, fluid treatment is aimed at restoration of radial pulse or restoration of sensorium or obtaining a blood pressure of 80 mm Hg by aliquots of 250 mL of lactated Ringer's solution (hypotensive resuscitation). When evacuation time is shorter than 1 hour (usually urban trauma), immediate evacuation to a surgical facility is indicated after airway and breathing (A, B) have been secured ("scoop and run"). Precious time is not wasted by introducing an intravenous line. When expected evacuation time exceeds 1 hour, an intravenous line is introduced and fluid treatment is started before evacuation. The resuscitation should occur before, or concurrently with, any diagnostic studies. Crystalloid is the first fluid of choice for resuscitation. Immediately administer 2 L of isotonic sodium chloride solution or lactated Ringer’s solution in response to shock from blood loss. Fluid administration should continue until the patient's hemodynamics become stabilized. Because crystalloids quickly leak from the vascular space, each liter of fluid expands the blood volume by 20-30%; therefore, 3 L of fluid need to be administered to raise the intravascular volume by 1 L. Alternatively, colloids restore volume in a 1:1 ratio. Currently available colloids include human albumin, hydroxy-ethyl starch products (mixed in either 0.9% isotonic sodium chloride solution or lactated Ringer’s solution), or hypertonic saline-dextran combinations. The sole product that is avoided routinely in large-volume (>1500 mL/d) restoration is the hydroxy-ethyl starch product mixed in 0.9% isotonic sodium chloride solution because it has been associated with the induction of coagulopathy. The other products have not been so implicated. 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 elderly persons with impaired cardiac activity. Additional trials will be required before this combination is accepted as standard of care.

1. HAEMORRHAGE
AND SHOCK
DILINA AAREWATTE
TSMU | MEDICINE | GROUP 9A | 2021 SPRING

2. CLINICAL SIGNS OF
SHOCK
• LOW BLOOD PRESSURE (BP)
• < 90 MMHG SYSTOLIC
• FAST FEEBLE PULSE
• > 130 BPM
• LOW URINARY OUTPUT
• < 0.5 ML/KG/H
• PATIENT IS USUALLY
• PALE, COLD, SHIVERING, SWEATING,
THIRSTY, AND ANXIOUS

3. SHOCK IN A
TRAUMA
S E T T I N
G
• IN TRAUMA, SHOCK IS CAUSED BY
• BLEEDING (HYPOVOLEMIC-HEMORRHAGIC, BY FAR THE
MOST COMMON CAUSE),
• PERICARDIAL TAMPONADE, OR
• TENSION PNEUMOTHORAX.
FOR EITHER OF THE LAST TWO TO OCCUR,
THERE MUST BE TRAUMA TO THE CHEST
(BLUNT OR PENETRATING).

4. SHOCK IN A
TRAUMA
S E T T I N
G
• SHOCK CAUSED BY BLEEDING → LOW CVP (EMPTY
VEINS CLINICALLY).
• IN BOTH PERICARDIAL TAMPONADE AND TENSION
PNEUMOTHORAX, CVP IS HIGH (BIG DISTENDED HEAD
AND NECK VEINS CLINICALLY).
• PERICARDIAL TAMPONADE → THERE IS NO
RESPIRATORY DISTRESS.
• IN TENSION PNEUMOTHORAX THERE IS SEVERE
RESPIRATORY DISTRESS, ONE SIDE OF THE CHEST HAS
NO BREATH SOUNDS AND IS HYPERRESONANT TO
PERCUSSION, AND THE MEDIASTINUM IS
DISPLACED TO THE OPPOSITE SIDE (TRACHEAL
DEVIATION).

5. TREATMENT TO HAEMORRHAGIC SHOCK
• IN EMERGENCY TRAUMA CENTERS, HEMORRHAGIC SHOCK COMMONLY CAUSED BY PENETRATING
INJURIES THAT WILL REQUIRE SURGERY ANYWAY – SO TREATMENT STARTS WITH THE SURGICAL
INTERVENTION TO STOP THE BLEEDING, AND VOLUME REPLACEMENT TAKES PLACE AFTERWARD.
• IN NORMAL SETTINGS, VOLUME REPLACEMENT IS THE FIRST STEP, STARTING WITH ABOUT 2 L OF
RINGER LACTATE (WITHOUT SUGAR), FOLLOWED BY PACKED RED CELLS, FRESH FROZEN PLASMA,
AND PLATELET PACKS, IN A 1-1-1 RATIO, UNTIL URINARY OUTPUT REACHES 0.5 TO 2 ML/KG/H,
WHILE NOT EXCEEDING CVP OF 15 MM HG.
Ringer lactate
(without sugar)
(2L)
Packed Red
Cells
Platelet packs
Given in 1:1:1 ratio
Until Urinary output
is > 0.5 mL/kg/h

6. MASSIVE BLEEDING
• UNCONTROLLED MASSIVE BLEEDING IS LETHAL,
AND SO IS UNTREATED HEMORRHAGIC SHOCK.
• IN THE USUAL CIVILIAN SETTING, WHERE ONE
SINGLE PATIENT ARRIVES WITH A VISIBLE SOURCE
OF BLEEDING TO AN ER STAFFED BY TONS OF
PEOPLE, THAT BLEEDING IS BEST CONTROLLED WITH
LOCAL PRESSURE. A GLOVED FINGER PUSHES AND
OCCLUDES THE LACERATED VESSEL UNTIL IT CAN BE
REPAIRED.

7. MASSIVE BLEEDING
• IN THE MILITARY SETTING, WHERE 10 SOLDIERS MAY BE
BLOWN UP BY A ROADSIDE BOMB AND THERE IS ONLY
ONE MEDIC TO LOOK AFTER THEM, THE OBVIOUS LIFE-
SAVERS ARE TOURNIQUETS.
• THE SAME IS TRUE IN MASSIVE CIVILIAN CASUALTIES. THE
FIRST RESPONDERS ALSO HAVE TO RESORT TO
TOURNIQUETS AS THEY SORT OUT AND TRANSPORT THE
VICTIMS.
• ONCE BLEEDING IS CONTROLLED, HEMORRHAGIC SHOCK,
IF PRESENT, HAS TO BE DEALT WITH. THE OBVIOUS FINAL
THERAPY FOR LOST WHOLE BLOOD, IS WHOLE BLOOD.

8. FLUID RESUSCITATION
• PREFERRED ROUTE OF FLUID RESUSCITATION
IN THE TRAUMA SETTING IS 2 PERIPHERAL IV
LINES, 16-GAUGE.
• IF THEY CANNOT BE INSERTED, PERCUTANEOUS
FEMORAL VEIN CATHETER OR SAPHENOUS VEIN
CUT-DOWNS ARE ALTERNATIVES.
• IN CHILDREN UNDER 6 YEARS OF AGE,
INTRAOSSEUS CANNULATION OF THE PROXIMAL
TIBIA IS THE ALTERNATE ROUTE.

9. PERICARDIAL TAMPONADE
• MANAGEMENT OF PERICARDIAL TAMPONADE IS BASED
ON CLINICAL DIAGNOSIS, AND CENTERED ON PROMPT
EVACUATION OF THE PERICARDIAL SAC (BY
PERICARDIOCENTESIS, TUBE, PERICARDIAL WINDOW, OR
OPEN THORACOTOMY).
• FLUID AND BLOOD ADMINISTRATION
WHILE EVACUATION IS BEING SET UP IS HELPFUL.

10. TENSION PNEUMOTHORAX
• MANAGEMENT OF TENSION PNEUMOTHORAX IS
ALSO BASED ON CLINICAL DIAGNOSIS (NOT
RECOMMENDED TO ORDER X-RAYS OR WAIT FOR
BLOOD GASES).
• START WITH BIG NEEDLE OR BIG IV CATHETER INTO
THE AFFECTED PLEURAL SPACE.
• FOLLOW WITH CHEST TUBE CONNECTED TO
UNDERWATER SEAL (BOTH INSERTED HIGH IN THE
ANTERIOR CHEST WALL)

11. OTHER TYPES OF SHOCK
• HYPOVOLEMIC
• FROM BLEEDING OR OTHER MASSIVE FLUID LOSS (BURNS,
PANCREATITIS, SEVERE
DIARRHEA).
• THE CLASSICAL CLINICAL SIGNS OF SHOCK WILL INCLUDE A
LOW CVP. TREAT THE CAUSE, AND REPLACE
THE VOLUME.
• INTRINSIC CARDIOGENIC SHOCK
• HAPPEN WITH MASSIVE INFARCTION OR FULMINATING
MYOCARDITIS.
• IN THISCASE THE CLINICAL SIGNS WILL COME WITH A HIGH
CVP, A KEY IDENTIFYING FEATURE.
• TREAT WITH CIRCULATORY SUPPORT.

12. OTHER TYPES OF SHOCK
• VASOMOTOR SHOCK
• SEEN IN ANAPHYLACTIC REACTIONS AND HIGH SPINAL CORD TRANSECTION OR HIGH SPINAL
ANESTHETIC.
• CIRCULATORY COLLAPSE OCCURS IN FLUSHED, “PINK AND WARM” PATIENT. CVP IS LOW.
• PHARMACOLOGIC TREATMENT TO RESTORE PERIPHERAL RESISTANCE IS THE MAIN THERAPY
(VASOPRESSORS).
ADDITIONAL FLUIDS WILL HELP.
• SEPTIC SHOCK
• INCLUDES ALL THREE COMPONENTS. EARLY ON, LOW PERIPHERAL RESISTANCE AND HIGH CARDIAC
OUTPUT PREDOMINATE. LATER, CARDIOGENIC AND HYPOVOLEMIC FEATURES ARE SEEN.
• IN ADDITION TO ANTIBIOTICS, THE INITIAL TREATMENT OFTEN INCLUDES A STEROID BOLUS.
PATIENTS WHO RESPOND BEAUTIFULLY AT FIRST BUT THEN SUFFER A RELAPSE MIGHT NOT HAVE
SEPTIC SHOCK AT ALL, BUT RATHER ADRENAL INSUFFICIENCY.

13. THANK
YOU