Ninth Edition
INTERNATIONAL
Trauma Life Support
for Emergency Care Providers
CHAPTER 4
Hemorrhage
Control and Shock
Copyright © 2020. All Rights Reserved
Shock
© Pearson
Copyright © 2020. All Rights Reserved
Objectives
1. List the four components of the vascular
system needed for normal tissue perfusion
2. Describe the signs and symptoms of shock in order of
presentation, distinguishing from compensated to
uncompensated
3. Describe the three common clinical shock
syndromes
Copyright © 2020. All Rights Reserved
Objectives
4. Explain the pathophysiology of hemorrhagic,
mechanical (obstructive), cardiogenic, and
distributive shock
5. Describe the management of:
– Hemorrhage that can be controlled
– Hemorrhage that cannot be controlled
– Non-hemorrhagic shock syndromes
Copyright © 2020. All Rights Reserved
Objectives
6. Discuss the use of tourniquets and hemostatic
agents for uncontrolled extremity hemorrhage
7. Discuss the current indications for the use of IV
fluids and tranexamic acid in the treatment of
hemorrhagic shock
Copyright © 2020. All Rights Reserved
Shock
• A life-threatening, generalized form of acute
circulatory failure associated with inadequate oxygen
utilization by the cells
• A state in which the circulation is unable to deliver
sufficient oxygen to meet the demands of the tissues,
resulting in cellular dysfunction
• Result is cellular hypoxia
- Change to anerobic metabolism
- Associated with increased lactate levels
Copyright © 2020. All Rights Reserved
Normal Perfusion
VASCULAR AIR
SYSTEM EXCHA
NGE
Perfusion
FLUID
PUMP
VOLUME
• Blood Pressure = Cardiac Output × PVR
• Cardiac Output = Heart Rate × Stroke Volume
Copyright © 2020. All Rights Reserved
Shock Progression
Red blood cells
decreased
Inadequate
Cell death
perfusion
Catecholamine
Hypoxia worsens
increases
Anaerobic
processes
Copyright © 2020. All Rights Reserved
Classic Shock Pattern
• Compensated • Decompensated
– 15–25% blood volume – 30–45% blood volume
– Weakness – Hypotension
– Pallor § First sign of “late shock”
– Tachycardia Weak or no peripheral
– pulse
– Narrowed pulse
pressure
– Prolonged capillary
– Thirst refill
– Delayed capillary refill
Copyright © 2020. All Rights Reserved
Four Types of Shock
Type of Shock Where the Problem is:
• Hypovolemic shock • Low Volume
• Distributive shock or • Problem with the
High Space shock “pipes:
• Obstructive shock • Problem with the
• Cardiogenic shock Pump
Multiple types of shock can be present simultaneously
Copyright © 2020. All Rights Reserved
Hypovolemic Shock
• Early Shock • Late Shock
– Weakness – Hypotension
– Pallor – Altered LOC
– Tachycardia – Cardiac arrest
– Diaphoresis
– Tachypnea
– Low urinary output
– Weak peripheral
pulses
– Thirst reflex
Copyright © 2020. All Rights Reserved
Tachycardia
• Early sign of shock
– Suspect hemorrhage: sustained rate >100
– Red flag for shock: pulse rate >120
• Rule out other causes
– Transient rise with anxiety
– Determine underlying cause
• Beware “relative bradycardia”
Copyright © 2020. All Rights Reserved
Low-Volume Shock
• Absolute hypovolemia
– Loss of volume
§ Catecholamines cause vasoconstriction
– Minor blood loss: vasoconstriction sufficient
– Severe blood loss: vasoconstriction insufficient
• Clinical presentation
– “Thready” pulse; tachycardia; pale, flat neck veins
Copyright © 2020. All Rights Reserved
High-Space Shock
• Relative hypovolemia (“vasodilatory shock”)
– Interruption of sympathetic system
– Loss of normal vasoconstriction vascular space
– becomes “too large”
• Neurogenic shock
– Most typically after injury to spinal cord
§ No release of catecholamines from adrenal
Copyright © 2020. All Rights Reserved
High-Space Shock
• Neurogenic shock symptoms
– Hypotension
– Heart rate normal or slow
– Skin warm, dry, pink
– Paralysis or deficit
§ Diaphragmatic breathing
Copyright © 2020. All Rights Reserved
Mechanical Shock
• Blood flow obstruction to or through heart
– Slows venous return
– Decreases cardiac output
• Clinical signs
– Distended neck veins
– Cyanosis
– Catecholamine effects
§ Pallor, tachycardia, diaphoresis
© Pearson
Copyright © 2020. All Rights Reserved
Cardiogenic Shock
• Reduced pumping strength in part of the heart
– Decreases cardiac
output
– Decreased blood
pressure
• May be caused by:
– Cardiac contusion
– Myocardial infarction
© Pearson
Copyright © 2020. All Rights Reserved
Controllable External Hemorrhage
• Direct pressure
• Anti-shock position
High-flow oxygen (non-
rebreather/NRB)
• Rapid and safe transport
• Large-bore IV access
– Fluid bolus to maintain
– Peripheral pulses
• Cardiac monitor, SpO2, ETCO2
• ITLS Reassessment Exam
Copyright © 2020. All Rights Reserved
Uncontrollable External Hemorrhage
• Control bleeding:
- Direct pressure
- Tourniquet
• High-flow oxygen (NRB)
• Rapid and safe transport
• Large-bore IV access
– Fluid bolus to maintain peripheral
pulses
• Cardiac monitor, SpO2, ETCO2 (Courtesy of Jennifer Achay, Centre for
Emergency Health Sciences, Spring
• ITLS Reassessment Exam
Branch, Texas)
Copyright © 2020. All Rights Reserved
Uncontrollable Hemorrhage
• Immediate rapid and safe
transport
• Horizontal patient position
Administer high-flow
oxygen (via NRB)
• Large-bore IV access
– Maintain peripheral pulses
Courtesy R. Alson MD
• Cardiac monitor, SpO2, ETCO2
• ITLS Reassessment Exam
Copyright © 2020. All Rights Reserved
Special Situations
• Severe head injury hypovolemic shock
– Glasgow Coma Score of 8 or less
– Fluid administration
• BP of 110 mmHg systolic to maintain
CPP of at least 60 mmHg
• Non-hemorrhagic hypovolemic shock
– General management same as controllable
– Fluid administration for volume replacement
Copyright © 2020. All Rights Reserved
Perfusion Preservation
• Basic rules of shock management
C- Control bleeding where possible
A- Maintain airway
B- Maintain oxygenation and ventilation
C- Maintain circulation
§ Adequate heart rate and intravascular volume
Copyright © 2020. All Rights Reserved
Tranexamic Acid (TXA)
• Stabilizes fibrin clot after trauma
• TXA should be given as early as possible
to bleeding trauma patients.
For trauma patients seen late after injury
(>3h), TXA is less effective and could be
harmful
Copyright © 2020. All Rights Reserved
Emerging Trends in Shock
• Early administration of blood and products
– Whole blood is best
– Blood/blood products ratio
§ 1 PRBC to 1 Platelet to 1 Plasma
Permissive hypotension core component of
current treatment
• Using lactate levels to monitor shock in field
• REBOA: Resuscitative Endovascular Balloon
Occlusion of Aorta
– Balloon occludes aorta to maintain perfusion of heart, lung and
brain
Copyright © 2020. All Rights Reserved
Summary
• Knowledge about pathophysiology
and treatment of shock is essential
– Shock is a critical condition that can lead to death
– Assessment and intervention must be rapid
– Monitor closely for early signs
Copyright © 2020. All Rights Reserved
