haemorrhagic shock

1. Haemorrhagic shock
DR. YOGESH RATHOD
MODERATOR- DR PRITISH KORULA

2. 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.

3. 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

4. Hemorrhage Classification

5. 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

6. 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

7. 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

8. Compensated shock
– 0-20% of blood loss
– Blood pressure is maintained via increased
vascular tone and increased blood flow to vital
organs

9. The body’s response:
Compensated shock Baroreceptor mediated
vasoconstriction!
• Increased epinephrine, vasopressin, angiotensin
• Results in:
– Tachycardia
– Tachypnoea
– Lowered pulse pressure
– Slightly lowered urine output

10. The Organs which well perfused :
• Brain
• Heart
• Kidneys
• Liver
The Organs which are less perfused:
• Skin
• GI tract
• Skeletal Muscle

11. Uncompensated shock
• 20-40% loss of blood volume
• Decrease in BP
• Tachycardia

12. 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

13. 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.

14. 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.

15. 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.

16. 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

17. Class 4Class 3Class 2Class 1
>20001500-2000750-1500<750 mlBlood loss (in
ml)
>4030-4015-30<15Blood volume
(in%)
>140>120>100<100Heart rate
decreasedDecreased
mean arterial
pressure<60
Normal (+tilt )Normal or
increased
Blood pressure
decreasedDecreaseDecreasedNormalPulse pressure
Always delayedUsually delayedMay be
delayed
NormalCapillary refill
Always delayedUsually delayedMildly delayednormalRespirations
Essentially
anuric
5-1520-30>30Urinary output
(ml/hr)
Lethargic,obtun
ded
confusedAnxiousNormal or
anxious
Mental status

18. 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

19. • Initial Assessment
– General Impression
• Obvious bleeding
– Mental Status
– Interventions
• Manage as you go
– O2
– Bleeding control
– Shock
– BLS before ALS!

20. • 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

21. • 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

22. 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

23. Management goals AFTER securing the ABCs:
• stop the bleeding!
• restore volume!
• correct any electrolyte/acid-base disturbances!

24. MASSIVE BLOOD TRANSFUSION

25. 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)
•
•

26. Definition of MBT…
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)

27. 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.)

28. 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.

29. 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.

30. General Indications ……
• 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*
* Clinical practice guideline: RBC transfusion in adult trauma and critical care. Crit Care Med 2009 vol.37 No.12

31. 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
* Indications for red cell transfusion in the adult, by Steven Kleinman, MD
Addison K May, MD, Sept 2009 uptodate article.

32. 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