Hemorrhagic Shock Management in the ED

Updated: Mar 22, 2022
  • Author: William P Bozeman, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Overview

Practice Essentials

Shock is a state of inadequate perfusion that does not sustain the physiologic needs of organ tissues. Many conditions, including blood loss but also including nonhemorrhagic states such as dehydration, sepsis, impaired autoregulation, obstruction, decreased myocardial function, and loss of autonomic tone, may produce shock or a shocklike state. Hemorrhagic shock can be rapidly fatal and is the leading cause of death in human trauma patients. Understanding the pathophysiology of hemorrhagic shock is imperative in understanding current hemostatic and resuscitative strategies and is foundational to the development of new therapeutic options. [1]

Hemorrhagic shock occurs when cellular oxygen demand outweighs supply. Hemorrhagic shock remains the most common cause of preventable death after injury. [2]  A majority of potentially preventable deaths after trauma are related to hemorrhage and occur early after injury, with the largest number of deaths occurring before hospital arrival. Approximately 25% of trauma deaths may be preventable through early medical and surgical interventions. [3]  Standard care consists of rapid assessment and expeditious transport to an appropriate center for evaluation and definitive 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 determine 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. 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]

Optimal management of trauma-related hemorrhagic shock begins at the point of injury and continues throughout all hospital settings. [5]  The fourth edition of the guideline on management of major bleeding and coagulopathy following trauma by the pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma provides treatment guidelines, [6]  including the following:

  • Early imaging (ultrasonography or contrast-enhanced CT) should be used for detection of free fluid in patients with suspected torso trauma.

  • CT assessment should be provided for hemodynamically stable patients.

  • Low initial Hb should be considered an indicator for severe bleeding associated with coagulopathy.

  • Repeated Hb measurements should be used as a laboratory marker for bleeding, as an initial Hb value in the normal range may mask bleeding.

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Pathophysiology

Shock is a state of inadequate cellular energy production that can be triggered by many causes. Both traumatic and nontraumatic causes of hemorrhage can lead to the development of hemorrhagic shock. Prompt recognition and attenuation of hemorrhage is paramount in preventing the onset or potentiation of hemorrhagic shock. [1]

In hemorrhagic shock, blood loss exceeds the body's ability to compensate and provide adequate tissue perfusion and oxygenation. This frequently is due to trauma, but it may result from spontaneous hemorrhage (eg, GI bleeding, childbirth), surgery, and other causes.

Most frequently, clinical hemorrhagic shock is caused by an acute bleeding episode with a discrete precipitating event. Less commonly, hemorrhagic shock may be seen in chronic conditions with subacute blood loss.

Physiologic compensation mechanisms for hemorrhage include initial peripheral and mesenteric vasoconstriction to shunt blood to the central circulation. This is augmented by progressive tachycardia. Invasive monitoring may reveal an increased cardiac index, increased oxygen delivery (ie, DO2), and increased oxygen consumption (ie, VO2) by tissues. Lactate levels, acid-base status, and other markers may provide useful indicators of physiologic status. Age, medications, and comorbid factors all may affect a patient's response to hemorrhagic shock.

Acute hemorrhage produces distinct physiologic responses depending on the magnitude and rate of hemorrhage. Hemorrhagic shock may be directly related to the initial injury but also may be exacerbated and complicated by a posttraumatic coagulopathy, termed acute traumatic coagulopathy. [1]

Failure of compensatory mechanisms in hemorrhagic shock can lead to death. Without intervention, a classic trimodal distribution of deaths is seen in severe hemorrhagic shock. An initial peak of mortality due to immediate exsanguination occurs within minutes of hemorrhage. Another peak occurs due to progressive decompensation after 1 to several hours. A third peak due to sepsis and organ failure occurs days to weeks later.

Understanding the pathophysiology of hemorrhagic shock is imperative in understanding current hemostatic and resuscitative strategies and is foundational to the development of new therapeutic options. [1]

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Epidemiology

Accidental injuries remain the leading cause of death in individuals 1-44 years of age. [7] Hemorrhagic shock is a leading cause of death among trauma patients. [8]  A majority of potentially preventable deaths after trauma are related to hemorrhage and occur early after injury, with the largest number of deaths occurring before hospital arrival. Approximately 25% of trauma deaths may be preventable through early medical and surgical interventions. [3]

Sparse data on the association between age and mortality in hemorrhagic shock show that in blunt hemorrhagic shock, mortality parallels increasing age, with the inflection point at 65 years. Multiple organ dysfunction score (MODS) and cardiac arrest uniformly predict mortality across all age groups. Craniotomy and thoracotomy are associated with mortality in middle age, whereas laparotomy is associated with mortality among the elderly. [9]

Injured patients with traumatic hemorrhagic shock often require resuscitation with transfusion of red blood cells, plasma, and platelets. Resuscitation with whole blood has been used in military settings, and its use is increasingly common in civilian practice. [10]

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Prognosis

Sparse data on the association between age and mortality in hemorrhagic shock show that in blunt hemorrhagic shock, mortality parallels increasing age, with the inflection point at 65 years. Multiple organ dysfunction score (MODS) and cardiac arrest uniformly predict mortality across all age groups. Craniotomy and thoracotomy are associated with mortality in middle age, whereas laparotomy is associated with mortality among the elderly. [9]

A majority of potentially preventable deaths after trauma are related to hemorrhage and occur early after injury, with the largest number of deaths occurring before hospital arrival. Approximately one-fourth of trauma deaths may be preventable through early medical and surgical interventions. Interventions dedicated to bleeding control and hemostatic resuscitation have demonstrated merit in decreasing hemorrhagic injury mortality. [3]

Advancing these novel strategies to the casuality in the prehospital phase of care, particularly in tactical or austere environments, may prove beneficial for hemorrhage mitigation to temporize the window of survival to definitive care. Future studies of resuscitation and survival after traumatic injury must include analysis of prehospital deaths to fully understand the outcomes of early interventions. [3]

 

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