Haemorrhagic Shock

KAREENA (GRP:45)
Shock

• Shock is the clinical syndrome that results from

inadequate tissue perfusion which leads to hypoxia
and ultimately cellular dysfunction.

• The cellular dysfunction is manifested as aerobic to

anaerobic leading to lactic acidosis.
Haemorrhagic shock

• It is one of the commonest form of hypovolemic shock

• Hypovolemia leads to decreased preload which leads to
increased sympathetic activity and vasoconstriction
• Vasoconstriction leads to decreased mean arterial
pressure and ischemia which ultimately leads to
multiorgan failure-ARDS,HEPATIC FAILURE,STRESS,GI
BLEEDING.RENAL FAILURE .
• Ischemia leads to myocardial insufficiency and severe
decrease in Systemic Vascular Resistance and finally
death
Hemorrhage Classification
External Hemorrhage
• Results from soft tissue injury.

• Most soft tissue trauma is accompanied by mild hemorrhage

and is not life threatening.
– Can carry significant risks of patient morbidity and disfigurement
• The seriousness of the injury is dependent on:
– Anatomical source of the hemorrhage (arterial, venous,
capillary)
– Degree of vascular disruption
– Amount of blood loss that can be tolerated by the
patient
Internal Hemorrhage

• Can result from:

– Blunt or penetrating trauma
– Acute or chronic medical illnesses
• Internal bleeding that can cause hemodynamic
instability usually occurs in one of four body cavities:
– Chest
– Abdomen
– Pelvis
– Retroperitoneum
Internal Hemorrhage
• Signs and symptoms that may suggest significant
internal hemorrhage include:
– Bright red blood from mouth, rectum, or other
orifice
– Coffee-ground appearance of vomit
– Melena (black, tarry stools)
– Dizziness or syncope on sitting or standing
– Orthostatic hypotension
• Internal hemorrhage is associated with higher
morbidity and mortality than external hemorrhage
Compensated shock

– 0-20% of blood loss

– Blood pressure is maintained via increased

vascular tone and increased blood flow to vital
organs
The body’s response:

Compensated shock Baroreceptor mediated

vasoconstriction!
• Increased epinephrine, vasopressin, angiotensin
• Results in:
– Tachycardia
– Tachypnoea
– Lowered pulse pressure
– Slightly lowered urine output
The Organs which well perfused :
• Brain
• Heart
• Kidneys
• Liver

The Organs which are less perfused:

• Skin
• GI tract
• Skeletal Muscle
Uncompensated shock

• 20-40% loss of blood volume

• Decrease in BP

• Tachycardia
The body’s response
Uncompensated shock
• The intravascular volume deficit exceeds the capacity
of vasoconstrictive mechanisms to maintain systemic
perfusion pressure.
• Increased cardiac output
• Increased respiration
• Sodium retention
Classification

Class I
A. Loss of up to 15% of total blood volume (0 to 750
ml in 70 kg person).
B. Characterized by normal blood pressure, urine
output, slight tachycardia, tachypnea, slight anxiety.
 Class II
A. Loss of 15 % to 30% of total blood volume
(750 to 1,500 ml )
B. Characterized by normal blood pressure,
tachycardia, mild tachypnea, decrease urine
output and mild anxiety.
 Class III
A. Loss of 30% to 40% of total blood volume
(1,500 to 2,ooo)
B. Characterized by hypotension, tachycardia,
tachypnea, decreased urine output , anxiety and
confusion.
 Class IV
A. Loss of > 40% of total blood volume (>2,ooo)
B. Characterized by severe hypotension and
tachycardia, tachypnea, negligible urine output
and lethargy
Hemorrhage Assessment

• Blood loss at the scene

• Mechanism of Injury/Nature of Illness
• Should only be used in conjunction with vital signs and
other clinical signs of injury to determine the
probability of injury
• Need for Additional Resources
• Initial Assessment
– General Impression
• Obvious bleeding
– Mental Status
– Interventions
• Manage as you go
– O2
– Bleeding control
– Shock
– BLS before ALS!
• Focused History & Physical examination
– Rapid Trauma Assessment
• Full head to toe
• Consider air medical if stage 2+ blood loss
– Focused Physical Exam
• Guided by c/c
– Vitals, SAMPLE, and OPQRST
– Additional Assessment
• Orthostatic hypotension
• Tilt test: 20
– BP or P from supine to sitting
• Ongoing Assessment
– Reassess vitals and mental status:
• Q 5 min: UNSTABLE patients
• Q 15 min: STABLE patients
– Reassess interventions:
• Oxygen
• ET
• IV
• Medication actions
– Trending: improvement vs. deterioration
• Pulse oximetry
• End-tidal CO2 levels
Management
• C-ABCs of trauma
• Control hemorrhage (splint the limb!!)
• Obtain IV access and resuscitate with fluids and
blood
– 2 liters crystalloid for adults
– 20 cc/kg crystalloid x 2 for kids

• Blood vs. Crystalloid??

• Long term critical care management

Management goals AFTER securing the ABCs:

• stop the bleeding!

• restore volume!

• correct any electrolyte/acid-base disturbances!

MASSIVE BLOOD TRANSFUSION
 Definition of MBT …

Massive BT is loosely defined as the transfusion of more than 10 units

of PRBCs in a 24-hour period. (ARCH SURG/VOL 143 (NO. 7), JULY 2008)

Massive BT , defined as the replacement of more than 50 % of a

patient's blood volume in 12 to 24 hours, (Massive blood transfusion by Steven
Kleinman, MD up to date article Sept. 2009)

•
Massive BT is defined as a volume equivalent or exceeding the
patients own volume transfused within a 12 hour period ( Clinical
Surgery ,A.Cuscheieri, 2nd ed)

Massive transfusion implies a single transfusion greater than 2500

mL or 5000 mL transfused over a period of 24 hours (Schwartz’s
Principles of Surgery, 8th ed)
 Definition of MBT …

Massive transfusion is defined as replacement of the patient's blood volume with

packed RBCs in 24 hours or transfusion of more than 10 units of blood over a
period of a few hours (Sabiston Textbook of surgery, 8th ed.)
 General Indications …

• In Hemorrhagic shock and ongoing hemorrhage

and anemia (to increase oxygen carrying
capacity)

• In hemorrhage, the goal of transfusion is

restoration of the oxygen-carrying capacity and
NOT restoration to a specific hemoglobin level.
 General Indications ……

• Anemia in critical illness is a distinct clinical

entity resulting from:
1) excessive phlebotomy for labs
2) active hemorrhage
3) reduced erythropoiesis

Most BT in ICU patients is used for treatment of

anemia.
• 40-50% of ICU patients receive at least 1, and on
average close to 5 units of RBCs

• Transfusion is not risk free and there is little evidence

that routine BT is beneficial to hemodynamically
stable critically ill patients*
 General Indications …
Perioperative Transfusion
• Several factors are involved in the decision to transfuse a
patient before surgery
• Are generally not recommended when the hemoglobin
is
≥10 g/dL should be given when less than 7 g/dL *
• No specific hematocrit is an indication for preoperative
transfusion in a stable patient
*
 Indication for MBT …

• There is no clear indication for MBT in any case

• The decision to transfuse in poly trauma or other
critical cases is based on
- the physiological state of the patient,
- evidence of amount of blood loss
- potential for ongoing hemorrhage