← Diagnosis and Management Guides
Hemorrhagic Shock
Key considerations: Class III-IV shock (>30% blood volume loss), Occult hemorrhage (retroperitoneal, pelvic, thoracic), Coagulopathy of trauma
Cannot miss
- Class III-IV shock (>30% blood volume loss)
- Occult hemorrhage (retroperitoneal, pelvic, thoracic)
- Coagulopathy of trauma
Likely diagnoses
- Traumatic hemorrhage
- GI hemorrhage
- Ruptured AAA
- Ectopic pregnancy rupture
Red flags
- Shock index >=1
- HR >120
- SBP <90
- Altered mental status
- Pale/cold/clammy skin
- No response to initial fluid bolus
Workup
- history: Mechanism, estimated blood loss, anticoagulant use, prior surgeries; exam: Hemorrhagic shock class assessment (I-IV), FAST exam, source identification; labs: CBC, coags, type and crossmatch, lactate, ABG, TEG/ROTEM if available, fibrinogen; imaging: FAST exam, CXR, pelvic XR, CT if hemodynamically stable; bedside: Shock index, FAST, continuous vitals monitoring
Management
- immediate: Hemorrhage control first — direct pressure, tourniquet, pelvic binder, chest tube; 1:1:1 blood product resuscitation (pRBC:FFP:PLT); TXA within 3 hours of injury; general: Permissive hypotension (SBP 80-90) until surgical hemorrhage control; Activate MTP for Class III-IV; Damage control surgery; Correct lethal triad (hypothermia, acidosis, coagulopathy); Calcium replacement with massive transfusion
Disposition
- admit: OR urgently for Class III-IV, ICU for all significant hemorrhage; discharge: Class I with controlled hemorrhage after observation; consults: Trauma surgery, IR for angioembolization
Clinical pearls
- Crystalloid resuscitation in hemorrhagic shock is harmful — dilutes clotting factors, worsens coagulopathy
- Blood products are the resuscitation fluid of choice — not crystalloid
- 1:1:1 ratio (PROPPR trial) demonstrated reduced 24-hour mortality compared to 2:1:1
Source and review
- ATLS 10th Edition, PROPPR Trial 2015. Last reviewed: 2024-11-01