Hemorrhagic shock is a potentially life threatening condition in which blood loss
leads to hemodynamic instability, tissue hypoperfusion, organ damage and homeostatic
collapse or death. Massive blood loss is the most common cause of hypovolemic shock
in the injured/trauma patient, and while a narrowed pulse pressure is suggestive of
significant blood loss, early manifestations include tachycardia and vasoconstriction.
leads to hemodynamic instability, tissue hypoperfusion, organ damage and homeostatic
collapse or death. Massive blood loss is the most common cause of hypovolemic shock
in the injured/trauma patient, and while a narrowed pulse pressure is suggestive of
significant blood loss, early manifestations include tachycardia and vasoconstriction.
The normal blood volume of an adult is roughly 7% of the total body weight or 5 liters in
a 70kg adult. Blood loss can be estimated based on the patient’s presentation.
a 70kg adult. Blood loss can be estimated based on the patient’s presentation.
Class
|
Blood Loss
|
Pulse
|
SBP
|
Pulse pressure
|
Capillary Refill
|
Mental Status
|
Treatment
|
I
|
<15%
|
<100
|
Normal
|
Normal
|
Normal
|
Normal
|
Fluids
|
II
|
15-30%
|
>100
|
Normal
|
Narrowed
|
Delayed
|
+/-Anxious
|
Fluids
|
III
|
30-40%
|
>120
|
<90
|
Narrowed
|
Delayed
|
Anxious
|
Fluids/Blood
|
IV
|
> 40%
|
>140
|
<70
|
Very Narrowed
|
Delayed
|
Depressed
|
Fluids/Blood
|
The type of fluid, how much to give, how fast and to what end point, are questions to
consider when replenishing volume. Marked and prolonged hypovolemia can lead to
hypoperfusion and lactic acidosis; this may be exacerbated by the hyperchloremic
metabolic acidosis brought on by large volume resuscitation with normal saline. This
has lead many to suggest lactated rings solution may be the fluid of choice because
of its physiologic buffer, however the evidence to support lactated ringer over normal
saline is not strong.
consider when replenishing volume. Marked and prolonged hypovolemia can lead to
hypoperfusion and lactic acidosis; this may be exacerbated by the hyperchloremic
metabolic acidosis brought on by large volume resuscitation with normal saline. This
has lead many to suggest lactated rings solution may be the fluid of choice because
of its physiologic buffer, however the evidence to support lactated ringer over normal
saline is not strong.
Historically the 3 to 1 rule (3ml fluid for every 1ml blood loss) has been used to help
guide volume resuscitation this is merely a guide and patients should receive fluid until
resuscitation is deemed adequate by vital sign stabilization.
guide volume resuscitation this is merely a guide and patients should receive fluid until
resuscitation is deemed adequate by vital sign stabilization.
Patients with massive blood loss should initially receive 2 liters of fluid infused as
quickly as possible to prevent ischemia and end organ failure. Infusion should continue
at this rate until the systolic blood pressure in above 100.
quickly as possible to prevent ischemia and end organ failure. Infusion should continue
at this rate until the systolic blood pressure in above 100.
The cornerstone of hypovolemic shock treatment is immediate hemorrhage control and
volume resuscitation in order to ensure adequate organ perfusion. Patients in class
III and IV shock should receive O-positive blood until type-specific blood is available.
The exception to this is women of childbearing age in which O-negative blood is used.
Evidence continues to support immediate surgery if direct vascular control cannot be
obtained.
volume resuscitation in order to ensure adequate organ perfusion. Patients in class
III and IV shock should receive O-positive blood until type-specific blood is available.
The exception to this is women of childbearing age in which O-negative blood is used.
Evidence continues to support immediate surgery if direct vascular control cannot be
obtained.
Sorces
1. Adams, Barsan, Biros, Danzl, Ling and Newton. Rosen’s Emergency Medicine: Concepts and Clinical
Practice 7th edition. Philidelphia, PA. Mosby Elsevier
2. Up to Date: Adult Hypovolemic Shock
3. Guillermo Gutierrez, H David Reines and Marian E Wulf-Gutierrez: Clincal Review of hemorrhagic
Shock. Critical Care. Volume 8, Issue 5, 2004. Pgs 373-381
1. Adams, Barsan, Biros, Danzl, Ling and Newton. Rosen’s Emergency Medicine: Concepts and Clinical
Practice 7th edition. Philidelphia, PA. Mosby Elsevier
2. Up to Date: Adult Hypovolemic Shock
3. Guillermo Gutierrez, H David Reines and Marian E Wulf-Gutierrez: Clincal Review of hemorrhagic
Shock. Critical Care. Volume 8, Issue 5, 2004. Pgs 373-381
This post from Dr. Dina Kacick
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