Initial Management in
Hemorrhagic Shock
dr. M. Jalaluddin A Chalil, M.Ked(An),SpAn
Dept. Anestesiologi dan Terapi Intensif
Fakultas Kedokteran Universities Muhammadiyah Sumatera
Utara
Definition
An abnormality of the circulatory system that
results in inadequate organ perfusion and
tissue oxygenation
Circulatory shock means generalized
inadequate blood flow through the body,
especially because of too little oxygen and
other nutrients delivered to the tissue cells
Oxygen Delivery
Oxygen
Delivery
Patophysiology of Shock
Illustration Of The Factors That Determine
The Energy Yield From Glucose Metabolism
Shock in the Injured Patient
Hypovolemia (Hemorrhage)
Cardiogenic
Obstructive
Neurogenic
Septic shock (rarely)
Definition Of Hemorrhage
Hypovolemia means diminished blood volume.
Hemorrhage is defined as an acute loss of circulating
blood volume
Hemorrhage is the most common cause of hypovolemic
shock.
Hemorrhage decreases the filling pressure of the
circulation and, as a consequence, decreases venous
return. As a result, the cardiac output falls below normal
and shock may ensue.
Total Body Water
TOTAL BODY WATER : 60% TBW
Hemorrhage
Compensatory Responses
“Acute blood loss triggers two
compensatory responses aimed at
restoring volume deficits”
The Earliest Response
Movement of interstitial fluid into the
bloodstream.
This transcapillary refill can add as
much as one liter to the plasma volume
It leaves an interstitial fluid deficit
The Second Response
Activation of the renin–angiotensin–
aldosterone system (from decreased renal
perfusion), which results in sodium
conservation by the kidneys.
The retained sodium will primarily enhance
the interstitial volume, and thus will help to
replace the interstitial fluid deficits created by
transcapillary refill
Pathophysiology in
Hemorrhagic Shock
Pathophysiology
Triad of Death
Etiology
Hemorrhage is the most common
cause of shock in the injured
patient
The first step in the initial
management of shock in trauma
patients is to recognize its presence
Cardiovascular response to
haemorrhage
Classification of Hemorrhage
The second step in the initial
management of shock is to identify
the probable cause of the shock state
Sources of Potential Blood Loss
Chest
Abdomen
Pelvis
Retroperitoneum
Extremities
External bleeding
Adjunctive Examination
Chest x-ray, pelvic x-ray
Abdominal assessment: Focused Assessment
Sonography in Trauma (FAST) or Diagnostic
Peritoneal Lavage (DPL)
Bladder catheterization
Initial Management of
Hemorrhagic Shock
Primary Survey
The basic management principle is
to stop the bleeding and replace the
volume loss
Airway and Breathing
Circulation—Hemorrhage Control
Priorities for managing circulation include:
Controlling obvious hemorrhage
Obtaining adequate intravenous access
Replace the volume loss
Assessing tissue perfusion
Bleeding Control
Bleeding from external wounds usually can be controlled by direct
pressure to the bleeding site
Massive blood loss from an extremity may require a tourniquet.
A sheet or pelvic binder from an extremity may be used to control
bleeding from pelvic fractures.
The adequacy of tissue perfusion dictates the amount of fluid resuscitation
required.
Surgical or angiographic control may be required to control internal
hemorrhage.
The priority is to stop the bleeding, not to calculate the volume of fluid lost
Disability—Neurologic
Examination
Gastric Dilation—
Decompression
Urinary Catheterization
INITIAL TREATMENT
Definitive control of hemorrhage and
restoration of adequate circulating volume are
the goals of treatment of hemorrhagic shock
Initial Fund Therapy
An initial, warmed fluid bolus is given.
The usual dose is 1 to 2 L for adults
and 20 mL/kg for pediatric patients.
Absolute volumes of resuscitation
fluids should be based on patient
response
Standard Resuscitation Regimen
Different Type of Resuscitation
Fluid
Vascular Access Lines
Theoretical Maximum Flow Rates
Stages of Shock
1. Compensated stage (nonprogressive stage) : normal
circulatory compensatory mechanisms eventually cause
full recovery without help from outside therapy.
2. Progressive stage: without therapy, the shock becomes
steadily worse until death.
3. Irreversible stage: the shock has progressed to such an
extent that all forms of known therapy are inadequate
to save the person’s life, even though, for the moment,
the person is still alive
