1. Management of Blood Loss and Hypovolemic Shock
Troy Phillips DO
Assistant Professor
VCOM Carolinas &
Spartanburg Family Medicine Residency

2. Objectives Define shock Discuss physiology of shock
Review the clinical presentation of shock
Discuss normal blood volume of pediatric and adult patients
Discuss the body’s compensatory responses to shock
Review hemorrhage classification
Describe appropriate IV access and initial fluid management in shock
Discuss hemorrhage control

3. Definitions Shock Hypovolemic shock Hemorrhagic shock
clinical syndrome that results from inadequate tissue perfusion
an imbalance between tissue oxygen supply and demand
Hypovolemic shock
Shock resulting from the loss of either red blood cell mass or plasma volume alone
Hemorrhagic shock
Hypovolemic shock secondary to either internal or external hemorrhage

4. Meh

5. Physiology of Shock heart rate X stroke volume = cardiac output
Know that if your stroke vol dec then your HR needs to inc
You should prob know this….I mean, even I know this….and I hate all that is cardio

6. Physiology of Shock
Meh

7. Physiology of Shock Shock at the Cellular Level
Anaerobic metabolism > lactic acid & metabolic acidosis
Loss of cell membrane integrity & electrical gradient
Swelling of ER & mitochondrial damage,
Lysosomal rupture & enzyme release,
Fluid influx, cellular edema and death
Meh

8. Physiology of Shock Shock at the Systemic Level
Moderate hypoperfusion may be tolerated - compensation
Prolonged /severe hypoperfusion leads to progressive cellular and organ dysfunction
Aaaaaaaaaannnnnnnnnnd meh

9. Clinical Presentation
Initial Findings
Tachycardia
Decreased peripheral perfusion (cool skin)
Increased respiratory rate
Mental status changes (anxiety)
What finding is absent? Hypotension
Know that with tachycardia, it is bc your HR increased to compensate = test question
Hypotension is not an initial finding

10. By III  start to see bp drop bc lost 1.5 to 2 L blood
So know that the level at which you see hypotension is level 3
Your pt is bad before they get to this pt

11. Do not wait for hypotension!
An injured patient with tachycardia and cool skin is in shock until proven otherwise.
Hypotension is a late finding in shock (Class III)
Hypotension usually doesn’t present until a loss of 1/3 of total blood volume
Normal MAP = 70 – 110
60 is our cut off where we start to see end organ perfusion issues
Start to drop off at about 1.5L loss

12. Normal Blood Volume Normal blood volume in adult
70cc/kg
Use ideal body weight, not actual
Normal blood volume in child
80-90cc/kg
About 5 L in adults

13. Compensatory Responses
Microcirculation
Systemic vascular resistance rises
Maintain systemic pressure to perfuse heart and brain at expense of muscle, skin and GI tract
2/3 of circulating blood is contained in the venous system
Cardiovascular
Increased heart rate to maintain cardiac output in setting of decreased stroke volume
Systemic vascular resistance rises
Forces blood out of your venous system (which holds about 2/3 of your blood)

14. Compensatory Responses
Neuroendocrine
Increased adrenergic output and reduced vagal tone.
Norepinephrine causes peripheral and splanchnic vasoconstriction
Hypothalamic release of ACTH stimulating cortisol secretion
Hepatic
Increased gluconeogenesis further elevating blood glucose
No neuroendocrine questions
Elevated blood glucose is just a stress resp to shock (not because normally a DM pt)

15. Compensatory Responses
Pulmonary
Tachypnea in response to relative hypoxia. However, this eventually leads to respiratory alkalosis from increased dumping of CO2
Renal
Conservation of salt and water by increased afferent arteriolar resistance leading to reduced urine formation

16. Know the (for the 1000th time) HR inc and the peripheral venous constriction occurs to keep MAP normal

17. Treatment Stop the bleeding. Replace fluids.
Diagnosis and treatment occur simultaneously.

18. Treatment Airway and Breathing Circulation
Provide high flow O2 for all patients in shock
Circulation
Find and control bleeding
Obtain IV access
Replace volume

19. Hemorrhage Control External Bleeding Direct Pressure (first!)
Elevation
Pressure points
Immobilization (especially fractures)
Hemostatic agents
Tourniquet (expect limb loss)
If you feel a pulse you can use that as a pressure pt
Don’t use the carotid (or you’re an idiot)

20. Hemorrhage Control Internal bleeding Have to find it first
Think chest, abdomen and retroperitoneum
Surgical intervention or angiographic embolization
“can’t do much about it until you find it”…This dude cracks me up

21. IV Access Establish adequate IV access 2 large bore peripheral IVs
Central access (central line or IO)
IO is intraosseous  drill a hole into the bone, like the tibia (cool stuff)

22. IV Fluids Give warmed NS or LR quickly
Only 1/3 of crystalloid volume stays intravascular
NS – normal saline
LR – lactate ringers (surgeons like this better)
He could give a crap
Just know these are what you normally give, but normally only get about 1/3 into the intravasc space for what you give

23. meh

24. IV Fluids Adults Pediatrics Give 1-2L of NS or LR Repeat if needed
No improvement after 3L, give blood
Pediatrics
20cc/kg bolus
Repeat if needed. If no relief, give blood.
Know peds

25. Practice Questions What is the first sign of shock?
Tachycardia (and cool skin, inc respiration, and axiety but NOT hypotension)
What is an unreliable sign of early shock?
Hypotension
What is the blood volume in an adult with an ideal body weight of 70kg?
70cc/kg = about 5 L
What is the blood volume in a child with a weight of 20kg?
(take 80 – 90 cc/kg, they weigh 20Kg = 1600 – 1800 cc)
What is the initial IV fluid of choice?
NS or LR
What is the initial bolus amount for a child?
20cc/kg bolus
Test questions:
One of the test questions are here verbatim
HTN appears in class 3
Initial IV fluid and bolus amts  NS or LR, initial bolus amt for kids are 20cc/kg (see slide 24)
What does the heart do to inc cardiac output in the setting of shock = inc heart rate (see like every other slide in the lecture)
After given appropriate amt of NS or LR, your next IV fluid of choice = blood

26. Questions?

27. References
UpToDate.com Shock in adults: Types, presentation, and diagnostic approach
Hemorrhagic Shock lecture, Dr. Jim Powers 2/23/12 – VCOM
Harrison’s Principle of Internal Medicine
Kaplan Medical COMLEX Review – Pathology
Emergency Care and Transportation of the Sick and Injured (6th edition)