Treatment of hemorrhagic shock includes volume resuscitation and control of bleeding,
in the OR or ED depending on the injury and available resources. Volume resuscitation
is initially with 2L of lactated Ringer’s solution unless blood products are immediately
available.
In the setting of trauma, transfusion of blood products should be in a 1:1:1 ratio between
packed RBCs, fresh frozen plasma, and platelets. Resuscitation should be continued
until BP and heart rate normalize and urine output reaches 0.5–1.0 ml/kg/hr. In the
setting of uncontrolled hemorrhage, permissive hypotension is recommended to prevent
further blood loss while awaiting definitive surgical repair, but a mean arterial pressure
>60 mm Hg should be maintained to ensure adequate cerebral perfusion.
The preferred route of fluid resuscitation in the trauma setting is 2 large bore peripheral
IV lines, 16-gauge or greater. If this cannot be obtained, percutaneous femoral vein
catheters should be inserted; saphenous vein cutdown and placement of ≥1 intraosseous
cannulas are acceptable alternatives. In children age <6, intraosseous cannulation of the
proximal tibia or femur is the alternate route.
Pericardial tamponade is generally a clinical diagnosis that can be confirmed with
U/S. Management requires evacuation of the pericardial space by pericardiocentesis,
subxiphoid pericardial window, or thoracotomy. Fluid and blood administration while
evacuation is being set up is helpful to maintain an adequate cardiac output.
Tension pneumothorax is a clinical diagnosis based on physical exam. Signs include
absent breath sounds, tracheal deviation, “hyperresonance,” and distended neck veins.
May also be hypotension and shock. Management requires immediate decompression of
the pleural space, initially with a large-bore needle (needle thoracostomy) which
converts the tension to a simple pneumothorax and followed by chest tube placement.
In the non-trauma setting, hypovolemic shock can also arise because of massive fluid
loss such as bleeding, burns, peritonitis, pancreatitis, or massive diarrhea. The clinical
picture is similar to trauma, with hypotension, tachycardia, and oliguria with a low
CVP. Stop the bleeding and replace the blood volume.
Non-traumatic (intrinsic) cardiogenic shock is caused by myocardial damage (e.g.
myocardial infarction or fulminant myocarditis). The clinical picture is hypotension,
tachycardia, and oliguria with a high CVP (presenting as distended neck veins). Treat
ment acutely consists of pharmacologic circulatory support, followed by attempts to
restore perfusion and/or cardiac function. Differential diagnosis is essential, because
additional fluid and blood administration in this setting could be lethal, as the failing
heart becomes easily overloaded.
Neurogenic/spinal shock is often associated with low BP and bradycardia. It can also
result in circulatory collapse. Patients are flushed, “pink and warm” with a low CVP.
Treatment with phenylephrine and fluids is aimed at filling dilated veins and restoring
peripheral resistance