II. Precautions

  1. Recognize and definitively manage signs of shock early (see above)
    1. Most cases are Hemorrhagic Shock in the Trauma patient
    2. Paramount to locate and stop the source of bleeding (and replace losses)
  2. Comprehensive examination of the patient may be best evaluation tool in Hemorrhagic Shock
    1. Check distal extremity warmth and pulses
    2. Continue to assess occult bleeding sites (see causes of below)
  3. Hemorrhage Classification is a documentation and coding tool (not a Hemorrhage Management tool)
    1. Degree of Hemorrhage is often difficult to quantify or grade until retrospect
    2. Do not delay definitive management before patient meets a precise classification
  4. Blood Pressure is unreliable for reassurance in a Trauma patient
    1. Frequently repeat Blood Pressure readings during Resuscitation
    2. Blood Pressure is the last hemodynamic marker to fall
      1. Vasoconstriction and Tachycardia are earlier compensation
    3. Hypotension in Trauma suggests Class II Hemorrhage or worse (15-30% blood loss)
  5. Heart Rate may also be unreliable for reassurance in a Trauma patient
    1. See Delayed Tachycardia
    2. Patient may have lost ability to mount a tachycardic response
    3. Autonomic Dysfunction may limit compensatory Tachycardia reflex
    4. Abdominal Hemorrhage may cause vagal response (Bezold-Jarisch)

III. Risk Factors: Massive Hemorrhage (requiring massive transfusion)

  1. Assessment of Blood Consumption Score (ABC Hemorrhage Score) >2
  2. Positive Focused Assessment Sonography for Trauma (FAST)
  3. Hypotension with Blood Pressure 90 mmHg or less
  4. Tachycardia with Heart Rate 120 bpm or higher
  5. Penetrating Injury

IV. Causes: Occult Traumatic Hemorrhage sites (Mnemonic: "Blood on the floor, and 4 more")

V. Exam

  1. Reassess frequently
    1. Young healthy patients may with little warning, precipitously decompensate into catastrophic cardiovascular collapse
  2. Tachycardia
    1. See Heart Rate for normal ranges for age
    2. Early warning sign of shock in most cases
    3. Cold and tachycardic is shock until proven otherwise
    4. However Heart Rate can be misleadingly normal in cases of Delayed Tachycardia (see above)

VI. Differential Diagnosis

  1. Cardiogenic Shock
    1. Tension Pneumothorax
    2. Cardiac Tamponade
  2. Neurogenic Shock secondary to spinal cord injury
    1. Neurogenic Shock does not occur in isolated intracranial injury

VII. Management

  1. Emergent Trauma surgery Consultation
    1. Poor response to Fluid Replacement or blood replacement indicates surgical management (or via angiography)
  2. Stop external bleeding immediately
    1. Apply direct manual pressure to external bleeding sites
    2. Pressure dressing may replace manual pressure if it adequately controls bleeding
      1. Israeli Bandage is elastic wrap with gauze impregnated with clotting agent
      2. Sanitary napkins or pads may also be used with overlying direct pressure at wound site
      3. Maintain direct pressure over bandage as needed to control bleeding
    3. Certain rapidly bleeding sites (e.g. Scalp Wounds) may be temporized with staples or Suture
    4. Consider occult Hemorrhage sources (see above)
    5. Bleeding refractory to manual pressure
      1. Notify Trauma surgery of emergent surgical intervention for rapid, uncontrolled bleeding
      2. Tourniquet (Pneumatic Tourniquet or Windlass Tourniquet)
        1. Indicated for rapid extremity bleeding not controlled with direct manual pressure
        2. Temporizing only until surgical intervention within 1-2 hours
        3. Ineffective in junctional sites (e.g. axilla, groin, adductor canal)
        4. Obviously unusable at neck and trunk
      3. Topical Hemostatic Agent (Chitosan Dressing, Zeolite Mineral Dressing, Kaolin Mineral Dressing)
        1. Indicated for rapid bleeding in sites where Tourniquets cannot be used (see above)
        2. Not widely available outside of military and large Trauma Centers as of 2013
        3. Risk of wound contamination with hemostatic agent
      4. Foley Catheter
        1. Inserted into a bleeding wound site
        2. Balloon inflated with Normal Saline
        3. May be effective at bleeding sites where Tourniquets may not be used (e.g. junctional sites)
      5. XStat (RevMedX, limited efficacy and safety data)
        1. FDA approved for gun shot wounds in 2014
        2. Syringe filled with small, compressed cellulose sponges
        3. Syringe applicator inserted at exsanguinating gun shot wound
  3. Two large bore IVs (14 or 16 gauge)
    1. Shorter tubing and larger bore provides faster IV rate
    2. Intraosseous Access if peripheral IV not immediately attainable
    3. Obtain Central Venous Line as available
      1. Large catheter introducer (8F or 9F) is preferred over multilumen
  4. Intravenous Fluids and Packed Red Blood Cells
    1. Judicious use of crystalloid in Class II Hemorrhage or higher
      1. React to early signs and symptoms of acute blood loss with Hemorrhage control and blood replacement
      2. ATLS and textbooks still describe the use of NS or LR for 1-2 Liter bolus
      3. However, new practices suggest limiting crystalloid in favor of Blood Products (permissive Hypotension)
        1. IV fluids may artificially increase local pressure at non-compressible clot sites causing rebleeding
        2. IV fluids may dilute Coagulation Factors and platelets
        3. Bickwell (1994) N Engl J Med 331(17): 1105-9 +PMID:7935634 [PubMed]
      4. Restrictive Resuscitation (pernmissive Hypotension) contraindications
        1. Prolonged transport time
        2. Transfer to Trauma Center
        3. Traumatic Brain Injury
        4. Hypotension, negative FAST Exam and normal Hemoglobin
      5. References
        1. Spanger and Inaba in Herbert (2015) EM:RAP 15(3):6-8
    2. Hemorrhage should be replaced with Blood Products
      1. Indications
        1. Mean arterial pressure 65 (or systolic Blood Pressure 70-90 mmHg)
        2. Poor response to IV fluids
          1. Persistent Tachycardia, Hypotension or Tachypnea
          2. Urine output <50 ml/hour (<1ml/kg/hour)
      2. Start with 2-4 units (prepare at least 4 units pRBC for more severe Hemorrhage)
        1. Type specific blood can be ready within 30-40 minutes
        2. In the crashing patient give unmatched type-specific blood, Low titer O or O negative blood
          1. Men may be given O+ Blood (and are given RhoGAM prior to discharge to prevent future reactions)
      3. Massive Hemorrhage with administration of more than 4 units requires matching Blood Products
      4. Consider autotransfusion (e.g. Hemovac or Cell Saver)
        1. Indicated for massive bleeding if blood can be drained and not contaminated)
      5. Use blood warmer when available
        1. Prevents Hypothermia with transfusion
  5. Coagulopathy correction for Massive Blood Transfusion
    1. See Massive Blood Transfusion for protocol
    2. Massive Blood Transfusion is typically accompanied by platelet and Plasma Transfusion
    3. Replace 1 unit of plasma for every 1 unit of Packed Red Blood Cells
    4. Replace 1 unit of apheresis platelets for every 8 units of Packed Red Blood Cells
    5. Consider Fibrinogen replacement to 1.5 to 2.0 g/L
    6. Prothrombin Complex Concentrate (PCC) 1-2 doses
      1. Do not use beyond 6-7 hours from bleeding onset (due to increased bleeding risk)
    7. Holcomb (2012) Arch Surg 15:1-10 [PubMed]
  6. Coagulopathy correction for underlying disorder or medication
    1. Reverse Anticoagulants
      1. See Emergent Reversal of Anticoagulation
      2. Platelet Transfusion for antiplatelet agents (e.g. Aspirin, Clopidogrel)
      3. Protamine for Heparin
      4. Vitamin K, FFP and PCC4 for Warfarin
    2. Specific management for Congenital Blood Coagulation Disorders
      1. Von Willebrand Disease
      2. Hemophilia A
      3. Hemophilia B (Factor IX Deficiency)
    3. Specific management for Acquired Blood Coagulation Disorders
      1. Cirrhosis
        1. Consider Vitamin K supplementation
        2. Decreased Anticoagulant and coagulant factors
          1. Therefore, not typically coagulopathic despite abnormal PT/INR and PTT
      2. Disseminated Intravascular Coagulation (DIC)
        1. Platelet Transfusion to Platelet Count >50,000/mm3
        2. FFP transfusion until PTT and PT/INR are each <1.5x normal
        3. Do not administer Tranexamic Acid (or other antifibrinolytic)
      3. Thrombotic ThrombocytopeniaPurpura
        1. Plasmaphoresis
      4. Drug induced Thrombocytopenia
        1. Withdraw offending medication
      5. End-stage renal disease
        1. Results in Anemia and Thrombocytopenia
        2. Hemodialysis
        3. Erythropoietin
        4. Cryoprecipitate
        5. Conjugated Estrogen
        6. Desmopressin
        7. Tranexamic Acid
  7. Additional stabilization measures while temporizing until definitive surgical management
    1. Tranexamic Acid (Cyklokapron)
      1. Blocks plasmin formation (preventing Fibrinolysis)
      2. May be indicated in first hour following onset of Hemorrhage when other measures fail and surgical intervention delayed
        1. Small mortality benefit in these cases
        2. Roberts (2011) Lancet 377(9771):1096-101 [PubMed]
    2. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
      1. Percutaneous balloon delivered via groin catheter and inflated in aorta above level of Hemorrhage
      2. Indicated in severe bleeding Pelvic Fractures who have not had Cardiac Arrest
        1. Used as an immediate temporizing measures, pending emergent definitive surgical management

VIII. Management: Disposition

  1. Immediately stabilize and transfer to Trauma Center or to proper hospital service (e.g. Trauma service)
    1. Limit unnecessary studies that delay transfer
    2. Goal for disposition and transfer is 20 minutes

IX. Complications: Uncontrolled Hemorrhage

  1. Mortality
    1. Leading cause of death in both military and civilian traums
  2. Hypothermia
  3. Metabolic Acidosis
  4. Coagulopathy
  5. Sepsis
  6. Multi-system organ failure

X. Complications: Massive Blood Transfusion

  1. Hypothermia
  2. Coagulopathy
  3. Metabolic Acidosis
  4. Electrolyte abnormalities
    1. Hypocalcemia
    2. Hyperkalemia

XI. References

  1. (2012) ATLS Manual, 9th ed, American College of Surgeons
  2. Mel and Alson in Herbert (2016) EM:Rap 16(2): 18
  3. Majoewsky (2012) EM:RAPC3 2(1): 1-2
  4. Shinkle and Ponce (2016) Crit Dec Emerg Med 30(8): 13
  5. Swaminathan and van de Leuv (2013) Crit Dec in Emerg Med 27(8): 11-17
  6. Swadron and Inaba in Herbert (2014) EM:Rap 14(12): 5

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Ontology: Hemorrhage (C0019080)

Definition (MEDLINEPLUS)

Bleeding is the loss of blood. It can happen inside or outside the body. Bleeding can be a reaction to a cut or other wound. It can also result from an injury to internal organs.

There are many situations in which you might bleed. A bruise is bleeding under the skin. Some strokes are caused by bleeding in the brain. Other bleeding, such as gastrointestinal bleeding, coughing up blood, or vaginal bleeding, can be a symptom of a disease.

Normally, when you bleed, your blood forms clots to stop the bleeding. Severe bleeding may require first aid or a trip to the emergency room. If you have a bleeding disorder, your blood does not form clots normally.

Definition (NCI_NCI-GLOSS) In medicine, loss of blood from damaged blood vessels. A hemorrhage may be internal or external, and usually involves a lot of bleeding in a short time.
Definition (NCI) The flow of blood from a ruptured blood vessel.
Definition (MSH) Bleeding or escape of blood from a vessel.
Definition (CSP) escape of blood from the vessels; bleeding.
Concepts Pathologic Function (T046)
MSH D006470
ICD9 459.0
ICD10 R58
SnomedCT 123106001, 303123004, 155459009, 195511004, 131148009, 50960005
LNC LA7418-2, LA7441-4
English Hemorrhages, Bleeding, Hemorrhage, HAEMORRHAGE NOS, HEMORRHAGE NOS, Haemorrhage NOS, Hemorrhage, unspecified, Hemorrhage NOS, hemorrhage, hemorrhage (diagnosis), bleeding (symptom), bleeding, Extravasation blood, Blood loss of (NOS), Haemorrhage, unspecified, Hem, Hemorrhage (NOS), Hemorrhage term, Hemorrhage [Disease/Finding], bleeding problem, bleeding problems, bleeds, hemorrhages, bleed, haemorrhages, blood loss, Haemorrhage NOS (disorder), Bleeding (disorder), Hemorrhage NOS (disorder), HEMORRHAGE, BLEEDING, Extravasation of blood, Blood loss, Haemorrhage, Hemorrhage (morphologic abnormality), Bleeding (finding), blood; extravasation, extravasation; blood, Bleeding, NOS, Haemorrhage, NOS, Hemorrhage, NOS, Bleeding -RETIRED-, haemorrhage
Italian Stravaso di sangue, Emorragia NAS, Emorragia (NAS), Emorragia terminale, Emorragia, non specificata, Fuoriuscita di sangue dai vasi sanguigni, Fuoriuscita di sangue, Perdita ematica, NAS, Sanguinamento, Emorragia
Dutch niet-gespecificeerde bloeding, hem, bloedingsperiode, bloeding, niet-gespecificeerde hemorragie, bloedverlies (NAO), hemorragie NAO, hemorragie (NAO), bloed; extravasatie, extravasatie; bloed, extravasatie bloed, hemorragie, Bloeding
French Hémorragie SAI, Hémorragie, non précisée, Hém, Hémorragie terminée, Effusion sanguine SAI, HEMORRAGIE SAI, Extravasation sanguine, Hémorragie, Saignement
German Blutung, unspezifisch, Hem, Bluten, Blutverlust (NNB), Blutung (NNB), Blutung, term, Blutung NNB, BLUTUNG NNB, Austritt von Blut, Blutung, Hämorrhagie
Portuguese Hemorragia NE, Heme, Perda de sangue NE, Hemorragia de termo, HEMORRAGIA NE, Extravasão de sangue, Hemorragia, Sangramento
Spanish Pérdida de sangre (NEOM), Hemorragia NEOM, Hemorragia no especificada, Hem, Hemorragia (NEOM), HEMORRAGIA SE, sangrante (concepto no activo), Haemorrhage NOS, hemorragia, SAI, sangrante, hemorragia, SAI (trastorno), Hemorrhage NOS, Sangrado, extravasación de sangre, hemorragia (anomalía morfológica), hemorragia (hallazgo), hemorragia, sangrado, Extravasación sanguínea, Hemorragia, Sangramiento
Japanese 出血NOS, 出血(NOS), 血液溢出, ケツエキイツシュツ, シュッケツ, シュッケツNOS, ケツエキイッシュツ, シュッケツショウサイフメイ, 出血、詳細不明, 失血, 出血
Swedish Blödning
Czech hemoragie, krvácení, Ztráta krve z (NOS), Krevní výron, Krvácení, blíže neurčené, Krvácení (NOS), Krvácení, Hem, Krvácení NOS
Finnish Verenvuoto
Latvian Not Translated[Hemorrhage]
Polish Krwotok
Hungarian Vérzés k.m.n., Vérző, Vérzés, Vérzés (k.m.n.), Haemorrhagia, nem meghatározott, Hem, Vérzés ideje, Vérzés, nem meghatározott, Vér extravasatio, Vérvesztés (k.m.n.)
Norwegian Blødning, Hemoragi, Blødninger

Ontology: Shock, Hemorrhagic (C0036982)

Definition (MSH) Acute hemorrhage or excessive fluid loss resulting in HYPOVOLEMIA.
Definition (CSP) hemorrhage decreases the mean systemic filling pressure, therefore decreasing venous return; as a result, the cardiac output falls below normal, and shock ensues.
Concepts Pathologic Function (T046)
MSH D012771
SnomedCT 355001
English Shock, Hemorrhagic, Hemorrhagic Shock, hemorrhagic shock, hemorrhagic shock (diagnosis), Shock, Hemorrhagic [Disease/Finding], haemorrhagic shock, Shock haemorrhagic, Shock hemorrhagic, Hemorrhagic shock, Haemorrhagic shock, Hemorrhagic shock (disorder)
Dutch hemorragische shock, shock hemorragisch, Hemorragische shock, Shock, hemorragische
German Schock haemorrhagisch, haemorrhagischer Schock, Haemorrhagischer Schock, Hämorrhagischer Schock, Schock, hämorrhagischer
Swedish Blödningschock
Japanese シュッケツセイショック, ショック-出血性, 出血ショック, 出血性ショック
Czech šok hemoragický, Hemoragický šok, Šok hemoragický
Finnish Verenvuotosokki
Spanish Shock Hemorrágico, Choque Hemorrágico, choque hemorrágico (trastorno), choque hemorrágico, shock hemorrágico, Shock hemorrágico
Polish Wstrząs krwotoczny
Hungarian Haemorrhagiás shokk, Sokk haemorrhagica, Haemorrhagiás shock, Vérzéses shock
Norwegian Hemoragisk sjokk, Blødningssjokk, Sjokk, hemoragisk
Portuguese Choque hemorrágico, Choque Hemorrágico
French Choc hémorragique
Italian Shock emorragico

Ontology: Exsanguination (C0232100)

Definition (MSH) Rapid and extreme blood loss leading to HEMORRHAGIC SHOCK.
Definition (NCI) Extensive loss of blood due to internal or external hemorrhage.
Definition (NCI_FDA) Extensive loss of blood due to internal or external hemorrhage.
Concepts Pathologic Function (T046)
MSH D058734
SnomedCT 48149007
LNC LA17979-8
Japanese 失血, シッケツ
Czech Vykrvácení, vykrvácení, exsanguinace
English Exsanguination, Hemorrhage, Exsanguinating, Exsanguinating Hemorrhage, Exsanguinating Hemorrhages, Hemorrhages, Exsanguinating, exsanguination, Exsanguination [Disease/Finding], EXSANGUINATION, Total blood loss, Exsanguination (finding)
French Hémorragie exsanguinante, Exsanguination
German Ausbluten, Verbluten, Massivblutung
Italian Dissanguamento
Spanish Exsanguinación, exanguinación (hallazgo), exanguinación, pérdida sanguínea total, Exanguinación
Portuguese Exsanguinação
Hungarian Exsanguinatio
Polish Skrwawienie, Wykrwawienie
Norwegian Massivt blodtap, Exsanguinatio, Stort blodtap
Dutch exsanguinatie

Ontology: Massive hemorrhage (C0333279)

Concepts Pathologic Function (T046)
SnomedCT 112648003
English massive bleeding, massive hemorrhage, blood loss massive, massive blood loss, Massive bleeding, Massive blood loss, Massive hemorrhage, Massive haemorrhage, Massive hemorrhage (morphologic abnormality)
Spanish hemorragia masiva (anomalía morfológica), hemorragia masiva, pérdida masiva de sangre, sangrado masivo