Hemorrhagic Shock in Emergency Medicine Guidelines

Updated: May 06, 2016
  • Author: William P Bozeman, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Guidelines Summary

The fourth edition of the guideline on management of major bleeding and coagulopathy following trauma by the pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma includes the following [16] :

  • Early imaging (ultrasonography or contrast-enhanced CT) for the detection of free fluid in patients with suspected torso trauma.

  • CT assessment for hemodynamically stable patients.

  • A low initial Hb be considered an indicator for severe bleeding associated with coagulopathy.

  • Use of repeated Hb measurements as a laboratory marker for bleeding, as an initial Hb value in the normal range may mask bleeding.

  • Serum lactate and/or base deficit measurements as sensitive tests to estimate and monitor the extent of bleeding and shock.

  • Repeated monitoring of coagulation, using either a traditional laboratory determination [prothrombin time (PT), activated partial thromboplastin time (APTT), platelet counts, and fibrinogen] and/or a viscoelastic method.

  • Target systolic blood pressure of 80-90 mm Hg until major bleeding has been stopped in the initial phase following trauma without brain injury.

  • In patients with severe TBI (GCS ≤8), a mean arterial pressure ≥80 mmHg should be maintained.

  • Fluid therapy using isotonic crystalloid solutions should be initiated in the hypotensive bleeding trauma patient.

  • Excessive use of 0.9 % NaCl solution should be avoided.

  • Hypotonic solutions such as Ringer’s lactate should be avoided in patients with severe head trauma.

  • Use of colloids should be restricted due to the adverse effects on hemostasis.

  • A target Hb of 7-9 g/dl.

  • In the initial management of patients with expected massive haemorrhage, one of the following strategies: Plasma (FFP or pathogen-inactivated plasma) in a plasma-RBC ratio of at least 1:2 as needed; fibrinogen concentrate and RBC according to Hb level.

  • Tranexamic acid should be administered as early as possible to the trauma patient who is bleeding or at risk of significant hemorrhage, at a loading dose of 1 g infused over 10 min, followed by an IV infusion of 1 g over 8 hr.

  • Tranexamic acid should be administered to the bleeding trauma patient within 3 hr after injury.

  • Protocols for the management of bleeding patients should consider administration of the first dose of tranexamic acid en route to the hospital.

  • If a plasma-based coagulation resuscitation strategy is used, plasma (FFP or pathogen-inactivated plasma) should be administered to maintain PT and APTT <1.5 times the normal control.

  • Plasma transfusion should be avoided in patients without substantial bleeding.

  • If a concentrate-based strategy is used, treatment with fibrinogen concentrate or cryoprecipitate if significant bleeding is accompanied by viscoelastic signs of a functional fibrinogen deficit or a plasma fibrinogen level of less than 1.5–2.0 g/L.

  • An initial fibrinogen supplementation of 3-4 g, which is equivalent to 15–20 single donor units of cryoprecipitate or 3-4 g fibrinogen concentrate. Repeat doses must be guided by viscoelastic monitoring and laboratory assessment of fibrinogen levels.

  • Platelets should be administered to maintain a platelet count above 50 × 109/L.

  • Maintenance of a platelet count above 100 × 109/L in patients with ongoing bleeding and/or TBI. (Grade 2C)

  • Initial dose of 4 to 8 single platelet units or one aphaeresis pack.