Rosen & Barkin's 5-Minute Emergency Medicine Consult (329 page)

Underlying disease and medications may alter responses to hemorrhage and blood loss.

Thorough health and past medical history:

• Underlying disease, risk factors, age
  
• Medications
  
• Trauma
  

• Complete physical exam to determine shock class and assess for hemorrhage source
  
• Vital signs including HR, RR, BP
  
• Temperature
  
• Mental status (anxiety, confusion, lethargy, obtundation, coma)
  
• Pulse character, capillary refill and skin perfusion
  
• Pulse pressure
  
• Abdominal exam
  
• Pelvic/rectal exam for bleeding as indicated
  

• Thorough history and physical exam
  
• IV access for resuscitation
  
• Blood type and cross-match
  

• CBC
  
• Blood type and cross-match
  
• Coagulation studies:
  
  • PT, PTT
    
  • International normalized ratio
    
• Other measures of tissue hypoperfusion:
  
  • Arterial blood gas
    
  • Base deficit
    
  • Serum lactate level
    
  • Serum electrolytes
    
• Pregnancy test/β-HCG
  

• CXR:
  
  • Hemothorax:
    
    • Blunt chest injuries
      
    • Thoracic arteriovenous malformation
      
• Pelvic radiograph for possible occult fracture
  
• Focused abdominal sonography for trauma (FAST exam):
  
  • Abdominal trauma
    
  • Possible abdominal aortic aneurysm
    
  • Nontraumatic intraperitoneal hemorrhage
    
  • Fluid in Morrison pouch implies significant hemorrhage or ascites.
    
  • Negative findings do not rule out intraperitoneal hemorrhage.
    
• Endovaginal US:
  
  • Positive pregnancy test
    
  • Fluid in the cul-de-sac
    
  • Ectopic pregnancy
    
• Abdominal CT scan (once patient stable):
  
  • Detects both intraperitoneal and retroperitoneal hemorrhage
    
  • Abdominal aortic aneurysm
    

• Insert Foley catheter:
  
  • Monitor urine output.
    
• Nasogastric tube:
  
  • For undifferentiated hypovolemic shock to rule out GI hemorrhage
    
• Diagnostic peritoneal lavage:
  
  • For unstable trauma patients when US fails to show intraperitoneal hemorrhage
    
• Endoscopy:
  
  • In the setting of upper or lower GI bleeding
    
• Angiography:
  
  • Pelvic fracture
    
  • Retroperitoneal hemorrhage
    
  • Lower GI bleeding
    
  • Embolization therapy for bleeding from arterial sources can be performed.
    

• Cardiac tamponade
  
• Tension pneumothorax
  
• Cardiogenic shock
  
• Sepsis
  
• Adrenal insufficiency
  
• Neurogenic shock
  

TREATMENT

• Treatment should be initiated as soon as shock state recognized while simultaneously identifying underlying bleeding source
  
• The goal is to restore tissue and organ perfusion and to control source of hemorrhage
  
• “Balanced” or “controlled” resuscitation: Approach is to balance goal of perfusion and risk of rebleeding and may vary with patient:
  
  • In blunt trauma, BP maintenance may take precedence to reduce risk of traumatic brain injury
    
  • In penetrating trauma with hemorrhage, delayed aggressive fluid resuscitation until definitive control may reduce bleeding risk
    

• Rapid assessment and transport to appropriate care center
  
• IV access and fluid resuscitation are standard, though delayed fluid resuscitation may be warranted in cases of penetrating trauma.
  

• Airway and breathing:
  
  • Intubation as indicated by patient’s respiratory and mental status
    
  • 100% oxygen via face mask should be administered.
    
• Circulation:
  
  • 2 large-bore peripheral IV lines (16G or larger)
    
  • Central venous line or venous cutdown (saphenous) may be necessary
    
  • Intraosseous route may be considered
    
  • Fluid resuscitation with warmed, isotonic crystalloid fluid – total volume based on patient response to initial fluid bolus
    
• Early transfusion for class III or IV shock:
  
  • Type-specific and cross-matched blood preferred when time permits, often 1 hr.
    
  • Type-specific blood is usually available within 10–15 min.
    
  • Type O blood can be used in immediate, life-threatening situations (type O Rh-negative blood only for women of child-bearing age).
    

• Place patient on continuous monitor.
  
• NPO status, strict bed rest
  
• Control hemorrhage (direct pressure, pelvic fixation/stabilization, etc.).
  
• Central venous access may be indicated for CVP monitoring, but placement of such lines should not interfere with resuscitation.
  
• Continually reassess patient for clinical response/deterioration:
  
  • Vital signs, mental status, and urine output.
    
  • Follow serial blood gas, lactate level, and hemoglobin/hematocrit measurements.
    
  • Maintain urine output at 50 mL/hr.
    
• Response to initial fluid resuscitation is the key to determining subsequent therapy:
  
  • Rapid response to fluid indicates minimal (<20%) blood loss.
    
  • Transient response indicates ongoing hemorrhage or inadequate resuscitation; continue fluid and blood administration and obtain necessary studies and consultations
    
  • Minimal or no response to volume resuscitation indicates ongoing severe blood loss; immediate angiography or surgical intervention is warranted
    
• Use fluids warmed (∼39°C [102.2°F]) by microwave ovens, fluid warmers
  
• Transfuse whole blood, RBCs, platelets, and other blood products as indicated
  
• Consider autotransfusion devices with tube thoracostomy treatment of large hemothoraces.
  
• Monitor closely for coagulopathy particularly with massive transfusions
  
• Specialty consultation and additional procedures (surgery) as indicated by cause and source of hemorrhagic shock
  

• Access may be obtained by intraosseous route after 1 or 2 unsuccessful attempts at peripheral access
  
• Maintain urine output at 1 mL/kg/hr for children and 2 mL/kg/hr for infants
  

Optimizing perfusion and treatment of the mother is treatment of choice for fetus.

• IV Fluids:
  
  • Crystalloids: NS or lactated Ringer
    
  • Adults: 1–2 L bolus
    
  • Pediatric: 20 mL/kg bolus:
    
    • Reassess for clinical response/deterioration.
      
• Blood products: Cross-matched, type-specific, O-positive, or O-negative:
  
  • O-negative should be reserved for women of child-bearing age
    
  • Adult: Initiate with 4–6 U
    
  • Pediatric: 10 mL/kg
    

• Other blood products:
  
  • Platelets
    
  • Coagulation factors, such as fresh frozen plasma, cryoprecipitate
    
• Antifibrinolytic agents, hemoglobin-based oxygen carriers, perfluorocarbons:
  
  • Under study, but not yet of proven benefit
    

FOLLOW-UP

All patients with hemorrhage should be admitted to the appropriate service.

N/A

N/A

• Severity of hemorrhagic shock class and volume loss can be determined by vital signs and careful physical exam
  
• Fluid resuscitation should balance goal of restoring organ perfusion and potential risk of exacerbating bleeding before definitive control
  
• Response to fluid resuscitation should guide subsequent therapy
  

• American College of Surgeons, Committee on Trauma.
  Advanced Trauma Life Support.
  9th ed. Chicago, IL: American College of Surgeons; 2012.
  
• Curry N, Davis PW. What’s new in resuscitation strategies for the patient with multiple trauma?
  Injury.
  2012;43:1021–1028.
  
• Santry HP, Alama HB: Fluid resuscitation: Past, present and the future.
  Shock.
  2010;33:229–241.
  
• Theusinger OM, Madjdpour C, Spahn DR. Resuscitation and transfusion management in trauma patients: Emerging concepts.
  Curr Opin Crit Care
  . 2012;18:661–670.
  

CODES

• 459.0 Hemorrhage, unspecified
  
• 865.04 Injury to spleen without mention of open wound into cavity, massive parenchymal disruption
  
• 958.4 Traumatic shock
  

BASICS