• Fractures can produce massive bleeding. Retroperitoneal bleeding must be suspected.

   

• Flank ecchymosis may indicate retroperitoneal hemorrhage.

Lab Studies:
 

• Laboratory studies are essential in management of many forms of hemorrhagic shock. Baseline levels are determined frequently, but these infrequently change the initial management after trauma. Serial evaluations of the following can help guide ongoing therapy.

• CBC

• Prothrombin time and/or activated partial thromboplastin time

• Urine

• ABGs (Levels reflect acid-base and perfusion status.)

• Lactate and base deficit are used in some centers.

• Typed and cross-match packed red blood cells should be obtained immediately.

• Fresh frozen plasma and platelets also may be required to correct coagulopathies that develop in severe hemorrhagic shock.

Imaging Studies:
 

• Standard radiography

• Cervical spine, chest, and pelvis radiographs are the standard screening images for severe trauma.

• Other radiographs may be indicated for orthopedic injuries.

• Computed tomography

• Image the appropriate for region of suspected injury.

• CT scanning frequently is the method of choice for evaluating possible intra-abdominal and/or retroperitoneal sources of hemorrhage in stable patients.

• Oral contrast material may not increase the diagnostic yield of abdominal CT scanning in blunt trauma. Scanning should not be delayed to administer oral contrast material.

• Ultrasonography

• Bedside abdominal ultrasonography can be useful for the rapid detection of free intra-abdominal fluid and, sometimes, specific parenchymal injury.

• Thoracic ultrasonographic findings can immediately confirm hemothorax or pericardial tamponade.

• Directed angiography may be diagnostic and therapeutic. Interventional radiologists have had good success achieving hemostasis in hemorrhage caused by a variety of vessels and organs.

Other Tests:
 

• An ECG can be useful for detecting dysrhythmias and cardiac sequelae of shock.

Procedures:
 

• Tube thoracostomy is necessary in hemothorax and hemothorax with or without pneumothorax.

• Central venous access facilitates fluid resuscitation and monitoring of central venous pressure and is necessary if peripheral intravenous access is inadequate or impossible to obtain.

• Diagnostic peritoneal lavage is used to detect intra-abdominal blood, fluid, and intestinal contents. It is sensitive but not specific for abdominal injury. It is not used to evaluate the retroperitoneum, which can hold significant hemorrhage, and does not identify the source of hemorrhage.

Prehospital Care:

• The 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. Recent studies of urban patients with penetrating trauma have shown that mortality increases with these interventions; these findings call these practices into question.

• Reversal of hypotension prior to the 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 been established yet.

Emergency Department Care:

• Management of hemorrhagic shock should be directed toward optimizing perfusion of and oxygen delivery to vital organs.

• Diagnosis and treatment of the underlying hemorrhage must be performed rapidly and concurrently with management of shock.

• Supportive therapy, including oxygen administration, monitoring, and establishment of intravenous access (eg, 2 large-bore catheters in peripheral lines, central venous access) should be initiated.

• Intravascular volume and oxygen-carrying capacity should be optimized.

• In addition to crystalloids, some colloid solutions, hypertonic solutions, and oxygen-carrying solutions (eg, hemoglobin-based and perfluorocarbon emulsions) are used or being investigated for use in hemorrhagic shock.

• Blood products may be required.

• Determination of the site and etiology of hemorrhage is critical to guide further interventions and definitive care.

• Control of hemorrhage may be achieved in the ED, or control may require consultations and special interventions.

Further Inpatient Care:
 

• Admit the patient to an ICU, surgical ICU, or pediatric ICU.

• Patients with hemorrhagic shock should be admitted to an intensive care or monitored setting appropriate for the underlying condition and physiologic state.

Transfer:
 

• In hospitals without facilities to provide definitive care, patients should be stabilized as much as possible and transferred to a facility with a higher level of care.

Complications:
 

• Coagulopathies may occur in severe hemorrhage. Fluid resuscitation, while necessary, may exacerbate coagulopathies.

• Sepsis and multiple organ system failure occur days after acute hemorrhagic shock.

• Death is a possible complication.

Medical/Legal Pitfalls:
 

• Failure to recognize occult hemorrhage

• Assumption that hypotension after trauma is due to head injury

• Failure to perform a rectal examination

• Failure to diagnose the cause(s) of hemorrhage

• Inadequate resuscitation (Therapy for hemorrhagic shock should be rapidly initiated and aggressively pursued.)

• Failure to make appropriate consultations in a timely fashion

Special Concerns:
 

• Pregnancy: Optimization of perfusion in the mother is the treatment of choice for the fetus.

• Pediatric: Compensatory mechanisms may be effective in children. Hypotension is a late finding and represents significant hemorrhage.

• Geriatric: Medications and underlying diseases may modify responses to hemorrhage.