Traumatic Hemorrhagic Shock

An Evidence-Based Approach November 2020
Volume 22, Number 11

to Nonoperative Management Authors
Christopher Pitotti, MD, FACEP

of Traumatic Hemorrhagic Shock Associate Program Director, University of Nevada-Las Vegas Emergency
Medicine Residency, Las Vegas, NV; Assistant Professor of Military
in the Emergency Department

and Emergency Medicine, Uniformed Services University of the Health
Sciences, Bethesda, MD
Jason David, MD
Department of Emergency Medicine, University of Nevada, Las Vegas,
Abstract Las Vegas, NV
Peer Reviewers
The management of traumatic hemorrhagic shock has Ryan M. Knight, MD

evolved, with increasing emphasis on damage control resusci- Assistant Professor of Emergency Medicine, Uniformed Services
University of the Health Sciences, Bethesda, MD; Clinical Staff, University
tation principles. Despite these advances, hemorrhage is still of Cincinnati, Cincinnati, OH
the leading preventable cause of death in trauma. This issue Leslie V. Simon, DO
provides evidence-based recommendations for the assessment Associate Professor, Mayo Clinic Alix School of Medicine; Chair,
Department of Emergency Medicine, Mayo Clinic Florida, Jacksonville, FL
and treatment of traumatic hemorrhagic shock. Hemostatic
techniques as well as correction of hemorrhagic hypovolemia Prior to beginning this activity, see “CME Information”
and traumatic coagulopathy are presented. The safety and ef- on the back page.
ficacy of practices such as resuscitative endovascular balloon This issue is eligible for 4 Trauma CME credits.
occlusion of the aorta (REBOA), viscoelastic clot testing, and
whole blood resuscitation are also reviewed.
Editor-In-Chief Deborah Diercks, MD, MS, FACEP, Eric Legome, MD Robert Schiller, MD International Editors
Andy Jagoda, MD, FACEP FACC Chair, Emergency Medicine, Mount Chair, Department of Family Medicine,
Peter Cameron, MD
Professor and Chair Emeritus, Professor and Chair, Department of Sinai West & Mount Sinai St. Luke's; Beth Israel Medical Center; Senior
Academic Director, The Alfred
Department of Emergency Medicine; Emergency Medicine, University of Vice Chair, Academic Affairs for Faculty, Family Medicine and
Emergency and Trauma Centre,
Director, Center for Emergency Texas Southwestern Medical Center, Emergency Medicine, Mount Sinai Community Health, Icahn School of
Monash University, Melbourne,
Medicine Education and Research, Dallas, TX Health System, Icahn School of Medicine at Mount Sinai, New York, NY
Australia
Icahn School of Medicine at Mount Medicine at Mount Sinai, New York, NY
Daniel J. Egan, MD Scott Silvers, MD, FACEP
Sinai, New York, NY Keith A. Marill, MD, MS Associate Professor of Emergency Andrea Duca, MD
Associate Professor, Vice Chair of Attending Emergency Physician,
Education, Department of Emergency Associate Professor, Department Medicine, Chair of Facilities and
Associate Editor-In-Chief Medicine, Columbia University of Emergency Medicine, Harvard Planning, Mayo Clinic, Jacksonville, FL Ospedale Papa Giovanni XXIII,
Kaushal Shah, MD, FACEP Medical School, Massachusetts Bergamo, Italy
Vagelos College of Physicians and Corey M. Slovis, MD, FACP, FACEP
Associate Professor, Vice Chair Surgeons, New York, NY General Hospital, Boston, MA Suzanne Y.G. Peeters, MD
for Education, Department of Professor and Chair, Department
Angela M. Mills, MD, FACEP Attending Emergency Physician,
Emergency Medicine, Weill Cornell Marie-Carmelle Elie, MD of Emergency Medicine, Vanderbilt
Professor and Chair, Department Flevo Teaching Hospital, Almere,
School of Medicine, New York, NY Associate Professor, Department University Medical Center, Nashville, TN
of Emergency Medicine, Columbia The Netherlands
of Emergency Medicine & Critical Ron M. Walls, MD
University Vagelos College of Edgardo Menendez, MD, FIFEM
Editorial Board Care Medicine, University of Florida
Physicians & Surgeons, New York, Professor and COO, Department of
Professor in Medicine and Emergency
Saadia Akhtar, MD, FACEP College of Medicine, Gainesville, FL NY Emergency Medicine, Brigham and
Medicine; Director of EM, Churruca
Associate Professor, Department of Women's Hospital, Harvard Medical
Nicholas Genes, MD, PhD Charles V. Pollack Jr., MA, MD, Hospital of Buenos Aires University,
Emergency Medicine, Associate Dean School, Boston, MA
Associate Professor, Department of FACEP, FAAEM, FAHA, FACC, Buenos Aires, Argentina
for Graduate Medical Education,
Emergency Medicine, Icahn School FESC Critical Care Editors Dhanadol Rojanasarntikul, MD
Program Director, Emergency
of Medicine at Mount Sinai, New Clinician-Scientist, Department of Attending Physician, Emergency
Medicine Residency, Mount Sinai
York, NY Emergency Medicine, University William A. Knight IV, MD, FACEP, Medicine, King Chulalongkorn
Beth Israel, New York, NY
of Mississippi School of Medicine, FNCS Memorial Hospital; Faculty of
Michael A. Gibbs, MD, FACEP Associate Professor of Emergency
William J. Brady, MD Professor and Chair, Department Jackson MS Medicine, Chulalongkorn University,
Professor of Emergency Medicine Medicine and Neurosurgery, Medical Thailand
of Emergency Medicine, Carolinas Ali S. Raja, MD, MBA, MPH Director, EM Advanced Practice
and Medicine; Medical Director, Medical Center, University of North Executive Vice Chair, Emergency Provider Program; Associate Medical Stephen H. Thomas, MD, MPH
Emergency Management, UVA Carolina School of Medicine, Chapel Medicine, Massachusetts General Director, Neuroscience ICU, University Professor & Chair, Emergency
Medical Center; Operational Medical Hill, NC Hospital; Associate Professor of of Cincinnati, Cincinnati, OH Medicine, Hamad Medical Corp.,
Director, Albemarle County Fire
Steven A. Godwin, MD, FACEP Emergency Medicine and Radiology, Weill Cornell Medical College, Qatar;
Rescue, Charlottesville, VA
Professor and Chair, Department Harvard Medical School, Boston, MA Scott D. Weingart, MD, FCCM Emergency Physician-in-Chief,
Calvin A. Brown III, MD Professor of Emergency Medicine;
of Emergency Medicine, Assistant Robert L. Rogers, MD, FACEP, Chief, EM Critical Care, Stony Brook Hamad General Hospital,
Director of Physician Compliance, Dean, Simulation Education, FAAEM, FACP Doha, Qatar
Credentialing and Urgent Care Medicine, Stony Brook, NY
University of Florida COM- Assistant Professor of Emergency
Services, Department of Emergency Jacksonville, Jacksonville, FL Edin Zelihic, MD
Medicine, Brigham and Women's
Medicine, The University of Research Editors Head, Department of Emergency
Joseph Habboushe, MD MBA Maryland School of Medicine,
Hospital, Boston, MA Aimee Mishler, PharmD, BCPS Medicine, Leopoldina Hospital,
Assistant Professor of Emergency Baltimore, MD
Emergency Medicine Pharmacist, Schweinfurt, Germany
Peter DeBlieux, MD Medicine, NYU/Langone and Alfred Sacchetti, MD, FACEP Program Director, PGY2 EM
Professor of Clinical Medicine, Bellevue Medical Centers, New York, Assistant Clinical Professor, Pharmacy Residency, Valleywise
Louisiana State University School of NY; CEO, MD Aware LLC Department of Emergency Medicine, Health, Phoenix, AZ
Medicine; Chief Experience Officer, Thomas Jefferson University,
University Medical Center, New Philadelphia, PA Joseph D. Toscano, MD
Orleans, LA Chief, Department of Emergency
Medicine, San Ramon Regional
Medical Center, San Ramon, CA
Case Presentations hemorrhagic shock: American College of Emergency
Physicians (ACEP) (0), American Academy of
Your first patient of the night is a 45-year-old man who Emergency Medicine (AAEM) (1),2 Eastern Associa-
was involved in a highway motorcycle crash. He is com- tion for the Surgery of Trauma (EAST) (1),3 Ameri-
plaining of abdominal and pelvic pain and had a 30-min- can College of Surgeons Committee on Trauma
ute helicopter transport time. On arrival, his vital signs (ACS COT) (2),4,5 Advanced Trauma Life Support®
are: heart rate, 130 beats/min; blood pressure, 100/60 (ATLS®) guidelines,6 Western Trauma Association
mm Hg; respiratory rate, 26 breaths/min; temperature, (WTA) (2),7,8 and Committee on Tactical Combat
37°C; oxygen saturation, 96% on room air; and GCS, Casualty Care (CoTCCC) (TCCC guidelines).9 From
14. You know this patient will need fluid resuscitation, this search, 124 articles, guidelines, and policies were
but you are unsure whether you should start with crys- selected for further review. Most of the literature
talloid or blood… consists of review articles, editorials, and consensus
While stabilizing the first patient, a second patient guidelines. Randomized trials are few, and often
is dropped off in the ambulance bay with an inguinal utilize disparate and restrictive exclusion criteria
gunshot wound. This 22-year-old man has a heart rate of and endpoints for resuscitation, limiting the applica-
140 beats/min; blood pressure, 80/40 mm Hg; respiratory bility of meta-analyses and reducing the strength of
rate, 28 breaths/min; temperature, 36.8°C; and oxygen recommendations in guidelines.
saturation, 98%. He has been applying his sweatshirt to
the wound, which is soaked with blood. You attempt direct Etiology and Pathophysiology
pressure as the team wheels him to the trauma bay and
consider your options to stop this junctional bleeding... In hemorrhagic shock, the loss of blood triggers both
Then you get a request for online medical command the typical response to hypovolemia (tachycardia,
from EMS responding to a conveyor belt accident with increased vascular resistance, fluid mobilization, and
obvious amputation and pelvic fracture. The patient is eventual low pulse pressure and hypotension) and
hypotensive and tachycardic, with a 10-minute transport cellular responses including the activation of hemo-
time. You ponder whether to activate the massive trans- static and fibrinolytic systems. In cases of extreme
fusion protocol now and whether he is a candidate for exsanguination, eventual hypoperfusion of the brain
REBOA… and myocardium results in cerebral anoxia and fatal
And this night is just getting started. arrhythmias, leading to death.
Introduction The Lethal Triad

The “lethal triad” in hemorrhagic shock is coagu-
Hemorrhagic shock is the major preventable cause of lopathy, hypothermia, and acidosis. At the site of the
morbidity and mortality in patients suffering major hemorrhage, the classic clotting cascade and platelet
trauma.1 Hemorrhagic shock is defined as a form of activation pathway form a clot. However, remote
hypovolemic shock in which severe traumatic blood from the clotting site, concurrent fibrinolytic activity
loss leads to inadequate oxygen delivery to tissues. also occurs, likely to prevent microvascular throm-
While the ultimate goal is definitive bleeding con- bosis.10 Acute traumatic coagulopathy (ATC) occurs
trol, the resuscitative decisions up to this point are when these factors become dysregulated: tissue
complex and frequently changing, in terms of medi- injury and hypoperfusion cause release of protein
cation and fluid choice, procedural indications, and C, deactivation of clotting factors V and VIII, auto-
treatment goals. This issue of Emergency Medicine heparinization from endothelial glycocalyx degrada-
Practice will review the evaluation and management tion, fibrinogen depletion, and platelet dysfunction.
decisions unique to the subset of trauma patients The resulting coagulopathic phenotypes range from
with hemorrhagic shock. hyperfibrinolysis to hypercoagulability with fibrino-
lysis shutdown.11 Additionally, iatrogenic factors can
Critical Appraisal of the Literature contribute to ATC, including overresuscitation with
crystalloid solutions, which can dilute clotting fac-
A literature search was performed in PubMed, Ovid tors and contribute to acidosis. Hypothermia from
MEDLINE®, EMBASE, multiple evidence-based exposure, fluid resuscitation, and blood loss further
medicine reviews, and the Cochrane Database of impede proper coagulation and perfusion. Failure
Systematic Reviews. The search terms included: of oxygen and nutrient delivery at the cellular level
traumatic hemorrhagic shock, damage control resuscita- causes a transition to anaerobic metabolism, with ac-
tion, massive transfusion, whole blood transfusion, and cumulation of lactic acid, inorganic phosphates, and
pre-hospital trauma resuscitation, with a date range oxygen free radicals, which further impede coagu-
from 1996 to September 2020. The following organi- lation and other compensatory processes. Platelet
zations‘ publications were also consulted for poli- and fibrinogen dysfunction follows the increasing
cies related directly to the management of traumatic metabolic acidosis.12
Copyright © 2020 EB Medicine. All rights reserved. 2 Reprints: www.ebmedicine.net/empissues

Differential Diagnosis irreversible effects occur.15 This time frame necessi-
tates bystander supplies and training programs such
Though typical presentations of traumatic hemor- as the “Stop the Bleed” campaign. (See Figure 1.)
rhagic shock will be obvious, based on the history
and physical examination, other causes of hypo-
tension must be considered. (See Table 1.) These Figure 1. Bystander Awareness Campaign
alternate types of shock may have precipitated the Information
injury and require laboratory testing, imaging, or
procedures in parallel with the trauma resuscita-
tion. Antiplatelet or anticoagulant use will indicate a
bleeding diathesis that may be discovered only by a
thorough history.
Prehospital Care
Prehospital care centers on rapid triage, stabiliza- 1 APPLY PRESSURE WITH HANDS
tion, and transport, with shorter scene and transport
times linked to improved survival.13 Identifying pa-
tients needing prehospital transfusion and advanced
resuscitative skills is an area of intense study of
rapid triage of hemorrhagic shock.
Stabilization
2 APPLY DRESSING AND PRESS
Prehospital stabilization begins with addressing ex-

sanguinating hemorrhage. If initial direct pressure is
ineffective or impractical, rapid tourniquet applica-
tion is a critical action, while reserving hemostatic
dressings with pressure for wounds not amenable
to tourniquet.5 Management may then be guided
3 APPLY TOURNIQUET
through standard ATLS® or Prehospital Trauma Life

Support principles.
Tourniquet Use WRAP WIND SECURE TIME

Proximal tourniquet application for exsanguinating
extremity hemorrhage is lifesaving and should not CALL 911
The ‘Stop the Bleed’ campaign was initiated by a federal interagency workgroup convened by the National Security Council Staff, The White House. The purpose of the campaign is to build national resilience by better preparing the public to save lives by raising awareness of basic actions to stop life threatening bleeding following everyday emergencies
be delayed. Amputation and extremity dysfunction

and man-made and natural disasters. Advances made by military medicine and research in hemorrhage control during the wars in Afghanistan and Iraq have informed the work of this initiative which exemplifies translation of knowledge back to the homeland to the benefit of the general public. ‘Stop the Bleed’ is a registered service mark of the Department
of the Defense. Use of the equipment and the training does not guarantee that all bleeding will be stopped or that all lives will be saved.
© 2017 American College of Surgeons
from tourniquet ischemia is rare when definitive

care is available in less than 2 hours.14 Some models © 2017 American College of Surgeons. Resources are available at:
of major bleeding show that tourniquet applica- https://www.stopthebleed.org/resources-poster-booklet
tion may be required within 3 to 5 minutes before Reprinted with permission of American College of Surgeons.
Table 1. Traumatic Hemorrhagic Shock Differential

Type of Shock Examples Comment
Hypovolemic • Hemorrhagic Exsanguinating hemorrhage locations: Chest, Abdomen, Retroperitoneum,
• Renal/gastrointestinal losses Thigh, Scalp/Scene (CARTS)
Distributive • Neurogenic (spinal injury) Bradycardia may signify neurogenic or toxin effects
• Anaphylaxis
• Toxin
• Sepsis
Cardiogenic • Myocardial infarction Caution in ground-level falls or single-car motor vehicle crash; cardiac
• Arrhythmia monitoring or electrocardiogram indicated
• Cardiomyopathy
Obstructive • Tension pneumothorax Clinical diagnosis if unstable, but extended focused assessment with
• Cardiac tamponade sonography in trauma (eFAST) assists in differential
• Pulmonary embolism
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November 2020 • www.ebmedicine.net 3 Copyright © 2020 EB Medicine. All rights reserved.

Pitfalls of tourniquet application in the field include Tranexamic Acid
missed proximal injury and failing to verify distal Prehospital tranexamic acid administration for trau-
pulse loss, signifying a venous-only application that matic hemorrhage has been adopted in many EMS
can exacerbate bleeding. systems in light of data from the CRASH-2 trial.29,30
Multiple studies have demonstrated safety and effi-
Hemostatic Dressings cacy of tranexamic acid when given, with indication,
Hemostatic dressings function as factor concen- within a 3-hour window.30,31
trators, mucoadhesive agents, or procoagulants.
Low-quality, mostly animal research shows some Temperature Management
later-generation kaolin- or chitosan-based agents Hypothermia is independently associated with
to be safe and effective prehospital treatments in worse outcomes and mortality in hemorrhagic
hemorrhage.9,16 Chitosan-coated dressings (eg, Celox shock, so temperature management must be ad-
Gauze®), may be more effective in coagulopathy dressed early, removing wet clothing, avoiding cold
versus the CoTCCC-preferred kaolin-based Combat fluid administration, and utilizing either passive or
Gauze®, since they do not rely on patient-derived (potentially more effective) active warming meth-
factors for hemostasis.17 While Combat Gauze® ods.32 Measures for prevention of hypothermia
appears to be the most studied in humans, the only should continue throughout the hospital resuscita-
clinical randomized controlled trial showed Celox tion as well.
Gauze® to achieve hemostasis significantly faster
than standard gauze.18 The XSTAT® device, which Transport
relies on expanding sponges, was effective in he- Time to hemorrhage control is so important in
mostasis compared to Combat Gauze® in an animal trauma that, for gunshot victims, even drop-off
model with long junctional wound tracts, but clinical by private vehicle has been shown to be benefi-
evidence is extremely limited.19,20 Clinicians may ref- cial.33 Though the “golden hour” concept has been
erence the frequently updated CoTCCC guidelines criticized when used for undifferentiated patients,
for expert opinions on newer effective hemostatic Harmsen et al validated its importance in patients
dressings and devices for prehospital care, as this is with neurotrauma and those with hemodynamically
an area of frequent innovation, without high-quality unstable penetrating trauma.34
clinical evidence.9
Emergency Department Preparation
Airway and Breathing Prehospital notification and telemetry helps the
There is no imperative for endotracheal intuba- emergency department (ED) or trauma center pre-
tion over bag-valve mask ventilation in prehospital pare for the incoming patient. Trauma bays should
trauma.21 It should be recognized that changing the be kept warm and supplies readied for the resuscita-
patient to positive pressure ventilation may severely tion. Multidisciplinary team activation protocols en-
alter hemodynamics in patients with shock and sure efficient access to computed tomography (CT)
precipitate arrest.22 and operating room (OR).35 Additionally, proper
utilization of resources and personnel through
Circulation anatomic- and physiologic-based activation criteria
If blood products are not available, prehospital rather than solely on the mechanism of injury can
crystalloid fluid administration should be enough result in better outcomes.36
only to maintain mentation and pulses.23 A 2017
retrospective analysis of patients injured in combat
found that the use of prehospital blood products
Emergency Department Evaluation
in those meeting massive transfusion (MT) criteria
An EMS “time-out” on arrival allows for an uninter-
did have a significant survival benefit.24 Civilian
rupted, structured handoff to the emergency clini-
regional implementation of cold-stored low-titer
cian. The typical ED trauma assessment consists
group O-positive whole blood (LTOWB) for heli-
of primary and secondary surveys, as informed by
copter emergency medical services (EMS) has now
ATLS®. The history should focus on understanding
been demonstrated to be safe and effective.25 Studies
the mechanism and expected injuries as well as iden-
of the use of thawed plasma in air transport have
tifying medical conditions and medications that will
shown lower 30-day mortality, but this benefit was
impact the resuscitation (eg, antihypertensives and
not seen in a similar study of short-transport ground
anticoagulant use). On physical examination, the
EMS.26,27 The use of freeze-dried plasma in prehospi-
patient must be fully exposed, noting areas of injury
tal care is feasible and has shown positive effects on
to the axillae and perineum, which are easily missed.
international normalized ratio (INR) values.28 Addi-
The extended focused assessment with sonography
tional investigation is needed to identify permissive
for trauma (eFAST) extends the normal FAST ultra-
hypotension targets in the less-monitored prehospi-
sound to check for pneumothorax and may identify
tal environment.

important intra-abdominal or intrathoracic bleeding, systolic blood pressure (SBP), and respiratory rate
but eFAST will not identify significant hemorrhage demonstrate poor sensitivity but high specificity
into the pelvis/retroperitoneum. Adjuncts to the sur- for predicting severe injury in trauma patients.37
vey with eFAST, plain films, and/or CT can inform The use of these traditional vital signs to identify a
the trauma team, but they should not delay opera- particular class of shock has little impact on out-
tive intervention if a patient is unstable. Because comes, as > 90% of trauma patients do not match
diagnostic and therapeutic capabilities will vary one of these shock classes.38 The actual evaluation
greatly between ED settings, some of the following of shock severity relies on a combination of vital
discussions will apply only in larger trauma centers. signs, examination findings (such as mental status),
and laboratory assessment.
Assessment and Recognition of the The equations in Table 3 may help with clini-
Hemorrhagic Shock State cal predictions in a setting of hemorrhagic shock
No single empiric test or scoring system has shown without laboratory markers, but they have not been
superiority in predicting outcomes in traumatic adopted uniformly in practice.
hemorrhagic shock patients. ACS COT has updated • Stratification by the degree of shock index is the
its traditional 4 classes of hemorrhage, teaching most cited of these in the literature and guide-
that most adult patients can compensate until about lines and may predict outcomes better than the
15% of their blood has been lost, at which time the traditional ATLS® classification, with values ≥ 1
first noticeable compensatory measure—tachycar- having a 31% likelihood of MT and values > 1.4
dia—appears.6 (See Table 2.) As the patient con- a 57% likelihood of MT.39,40 This index has been
tinues to lose blood, classic signs of shock become found to have less accuracy for predicting MT in
more apparent: anxiety, tachypnea, cool extremi- patients with hypertension, diabetes mellitus, or
ties, pallor, and narrow pulse pressure. Pulse rate, coronary artery disease.41
Table 2. Signs and Symptoms of Hemorrhage, by Class (ATLS®)

Parameter Class I Class II (Mild) Class III (Moderate) Class IV (Severe)
Approximate blood loss < 15% 15%-30% 31%-40% > 40%
Heart rate
 / /
➞
➞
➞
➞
Blood pressure
  /
➞
➞
Pulse pressure

➞
➞
Respiratory rate
  /
➞
➞
Urine output
 
➞
➞
➞
Glasgow Coma Scale score
 
➞
➞
Base deficit* 0 to -2 mEq/L -2 to -6 mEq/L -6 to -10 mEq/L -10 mEq/L or less
Need for blood products Monitor Possible Yes Massive transfusion protocol
*Base excess is the quantity of base (HCO3-, in mEq/L) that is above or below the normal range in the body. A negative number is called a base deficit
and indicates metabolic acidosis.
Data from: Mutschler A, Nienaber U, Brockamp T et al. A critical reappraisal of the ATLS classification of hypovolemic shock: does it really reflect clinical
reality? Resuscitation. 2013,84:309-313.
Henry S. 10th Edition of the Advanced Trauma Life Support (ATLS) Student Course Manual. Chicago (IL): American College of Surgeons. Copyright
2018. Reprinted with permission of American College of Surgeons.
Table 3. Clinical Prediction Calculators for Shock

Clinical Prediction Calculator Equation for Calculation Normal Range
Shock index SI = HR/SBP 0.5-0.7 (≥ 1 likely to need transfusion)
Delta shock index (field SI) – (ED SI) > 0.1 is associated with greater mortality
Respiratory-adjusted shock index HR/SBP × RR/10 Upper limit of normal is 1.33
ABC score +1 penetrating mechanism Scores > 2 may indicate need for MT
+1 SBP < 90 mm Hg
+1 HR > 120 beats/min
+1 positive FAST
Abbreviations: ABC, assessment of blood consumption; ED, emergency department; HR, heart rate; FAST, focused assessment with sonography for
trauma; MT, massive transfusion; RR, respiratory rate; SBP, systolic blood pressure; SI, shock index.
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• A delta shock index value of > 0.1 is linked to metabolic process, and it is unknown how circulat-
greater mortality, blood transfusion, and inten- ing concentrations of lactate, base deficit levels,
sive care unit (ICU) length of stay.42 and systemic pH levels fully quantify cumulative
• A retrospective analysis of 3093 patients found hypoperfusion.47 Low initial hemoglobin (Hb) is
no difference in the shock index among admit- more associated with transfusion than heart rate,
ted versus discharged patients who showed SBP, or base deficit.48 Serial Hb levels may detect
elevated levels of lactic acid; however, for the ongoing bleeding.49 Electrolytes—particularly potas-
same group of patients, there was a significant sium and calcium— are subject to fluctuations with
difference in the respiratory-adjusted shock the administration of blood products, with severe
index (RASI), indicating improved diagnostic calcium abnormalities being particularly associated
accuracy for detecting early occult shock.43 with mortality.50-52 Platelet counts obtained with a
complete blood count (CBC) will inform resuscita-
Online and mobile calculators are available at: tive efforts as well. Platelet function testing is now
www.MDCalc.com available, but its use in guiding therapy is unclear at
• Shock Index this time.
www.mdcalc.com/shock-index Low presenting fibrinogen levels have been
• ABC Score for Massive Transfusion associated with ATC and mortality.53 A 2019 retro-
www.mdcalc.com/abc-score-massive-transfusion spective study of initial platelet count, fibrinogen,
prothrombin time (PT)/INR, and D-dimer in pa-
Multiple technologies have been developed tients with severe trauma demonstrated that fibrino-
to deliver real-time assessments of cardiac output; gen levels < 130 mg/dL and D-dimer ≥ 110 mcg/mL
however, to date, none have been shown to improve were independently associated with 28-day mortal-
patient-oriented outcomes for ED trauma. Pulse pres- ity.54 Relying on standard conventional coagulation
sure waveform variability requires advanced inva- tests to exclude concurrent direct oral anticoagulant
sive monitoring, intubation, and conditions found (DOAC) use is not advised, though specialized vis-
typically only in the OR or ICU. Noninvasive surro- coelastic clot testing (VCT) may be helpful.
gates for cardiac output, such as impedance noninva- European guidelines regarding hemorrhagic
sive cardiac output monitoring (NICOM), end-tidal shock suggest that CBC, PT, VCT, fibrinogen, cal-
capnography, and tissue oxygenation monitors may cium, lactate, base excess, and pH be assessed within
be predictive of outcomes in trauma and correlate 15 minutes of arrival, a goal unlikely to be achiev-
with standard hemodynamic monitoring.44 able in most EDs.49 Additional laboratory tests for
the critically ill may include type and screen/cross,
basic metabolic panel, liver function tests, urinalysis,
Diagnostic Studies and pregnancy testing in women of child-bearing
age. Resuscitation should not be delayed for labora-
Ultrasound and Other Imaging tory results.49
eFAST ultrasound is particularly useful for find-
ing hemodynamically significant thoracic and
Figure 2. Fluid in Morison Pouch on eFAST
abdom-inal bleeding. (See Figure 2.) In practice,
eFAST sensitivities compared to CT for detecting
free fluid have been as low as 38% for unstable
patients and 28% for significant intra-abdominal
injury; therefore, a negative study should not
delay imaging or surgery.45 Dynamic ultrasound
evaluation of the heart and inferior vena cava can
estimate volume status. Imaging can also illustrate
other causes that may be contributing to the shock
state. CT scanning may be indicated for operative
planning in the setting of controlled hypotension,
but may be unwise for unstable patients. Plain
films of extremity injuries should not delay life-
threat identification and stabilization.
Laboratory Testing
Laboratory markers of shock include serum lactate
and base deficit. These have been shown to predict Abbreviation: eFAST, extended focused assessment with sonography
resuscitation requirements and mortality more ac- in trauma.
curately than classic shock classification.46 However, Abnormal fluid collection is seen between liver and right kidney
these are only single-time-point views of the overall (arrows). https://en.wikipedia.org/wiki/File:Morrisons-with-fluid.jpg

Viscoelastic Clot Testing dangerous, and the trauma team leader must priori-
VCT methods such as thromboelastography tize volume resuscitation when airway compromise
(TEG/r-TEG) and rotational thromboelastometry can be temporized noninvasively.
(ROTEM) employ mechanical means to measure
the speed and strength of clot formation, and they Hemorrhage Control With In-Hospital
often result sooner than conventional coagula- Hemostatic Devices
tion tests. Several guidelines, such as United States By the time a patient arrives at the ED, the sites of ini-
military damage control resuscitation (DCR) guide- tial hemorrhage may have ceased bleeding, but ignor-
lines, ACS Trauma Quality Improvement Program ing these areas can lead to an occult loss later in the
Massive Transfusion (TQIP MT) guidelines, and resuscitation, so these should be addressed when life-
pan-European trauma guidelines all recognize the threats are stabilized. At the soonest appropriate time,
increasingly important role of VCT in managing tourniquets should also be assessed for take-down.
traumatic hemorrhage, while acknowledging the While tourniquet use has been found to be associated
currently limited (though quickly growing) avail- with wound infection and neurologic compromise, it
ability. ATC is traditionally defined as prolongation is not associated with limb loss or mortality rates.14
of the PT/INR beyond 1.5, but VCT data can inform Tourniquet duration of 60 minutes or longer was not
the clinician of specific deficiencies in clot formation associated with increased amputations but was as-
and lysis which, in theory, allows a tailored resusci- sociated with more incidences of rhabdomyolysis.14
tation with component therapy and adjuncts rather Estimates for absolute duration of tourniquet applica-
than whole blood transfusions or empiric 1:1:1 tion vary; however, to preserve limb function, 2 hours
(plasma:platelet:packed red blood cell) resuscitation. may be the safest recommended maximum length of
VCT can identify coagulation phenotypes that
cannot be treated with blood products alone, such
as hyperfibrinolysis.55 Hyperfibrinolysis is lethal Figure 3. TEG Waveforms in Various
(53%-76% mortality), found in 2% to 34% of trauma Coagulopathic States Showing Clot
patients, and can be treated with tranexamic acid.56 Firmness Versus Time
To date, only one randomized controlled study (un-
blinded and open label) by Gonzalez et al informs
the use of VCT compared to conventional coagu-
lation tests. This 2016 trial of TEG involving 111
patients found significantly reduced 28-day mortal-
ity (36.4% vs 19.6%, P = .04), fewer blood compo-
nents used, and less time in the ICU. Moreover, VCT
patients began to show higher survivability rates at
6 hours, at which time the conventional coagulation
test patients had actually received more plasma and
platelets.57
A 2016 Cochrane review of VCT-guided therapy
(not including the Gonzalez study) found growing,
but low-level, evidence that VCT-guided therapy
may improve survival and product use, noting that
most studies are based on cardiac surgery data, and
only 2 studies had low risk of bias.58 Because of
this low strength of data, at this time, VCT cannot re-
place conventional coagulation tests in the detection
and management of ATC. Figure 3 shows clinical
interpretations of TEG.
Treatment
The concept of DCR is now ubiquitous in the trauma
literature and defines the approach of balanced re-
suscitation and permissive hypotension. In addition,
prioritizing immediate life-threats first means alter-
ing the traditional strict “ABCDE” primary survey
Abbreviation: TEG, thromboelastography.
advocated by ATLS®. Exsanguinating hemorrhage
David Whiting, James A. DiNardo. TEG and ROTEM: Technology and
should be addressed first. Endotracheal intubation Clinical Applications. American Journal of Hematology. 2014; Volume
in the setting of hemorrhagic shock is particularly 89, Issue 2. Pages 228-232. © 2013 Wiley Periodicals, Inc.

time.14 Nevertheless, these limits should not apply is < 15 minutes. Inflation in Zone III (lowest renal
in hemorrhagic shock, as models suggest the pos- artery to the aortic bifurcation) is indicated for se-
sibility of the loss of limb function if tourniquet time vere pelvic, junctional, or proximal lower extremity
is more than 1 hour.59 Suspected open-book pelvic hemorrhage.61 A 2018 study in swine models found
fractures may be treated initially with pelvic bind- that in cases of impending hemodynamic collapse,
ing to facilitate tamponade prior to surgical packing, Zone I placement may be more efficacious regard-
angioembolization, and/or external fixation.14 less of injury pattern, whereas Zone III should be
Limited data inform the efficacy of hemorrhage reserved for only relatively stable patients with
control at junctional sites with junctional tourni- ongoing distal hemorrhage.62
quets. These devices are rarely found outside of Adverse effects of REBOA include progressive
tactical settings. The 4 main devices for junctional distal ischemia, amputation, kidney injury, arterial
hemorrhage control are: (1) the Abdominal Aortic injury, supraphysiologic pressures, and a related
and Junctional Tourniquet (AAJT™); (2) the Junc-
tional Emergency Treatment Tool™ (JETT®, North
American Rescue, LLC); (3) the SAM® Junctional
Figure 4. ER-REBOA™ PLUS Catheter
Tourniquet (SAM Medical®, Tualatin, OR); and (4)
the CRoC® Combat Ready Clamp (Combat Medi-
cal®). A 2019 meta-analysis examining junctional
tourniquets in healthy volunteers found all appli-
cable studies had a high risk of bias but determined
similarly high rates of successful occlusion with the 4
tourniquets noted except for abdominal application
of the AAJT™. This study also noted significant pain
and failure rates with short transport.60 Successful
use of these devices in trauma patients is limited to
case reports.
Resuscitative Endovascular Balloon

Courtesy of: Prytime Medical Devices, Inc, Boerne, TX
Occlusion of the Aorta
Another much-discussed adjunct for the control of
noncompressible torso injuries is resuscitative en- Figure 5. Zones of Aortic Occlusion in
dovascular balloon occlusion of the aorta (REBOA). Resuscitative Endovascular Balloon
With exsanguinating hemorrhage from abdominal Occlusion of the Aorta
trauma, surgical control of the bleeding by initial
rapid aortic clamping is a lifesaving, but highly
morbid procedure. REBOA attempts to achieve the
same effect by endovascularly occluding blood flow
through the aorta temporarily. (See Figure 4.) The
scope of practice under which REBOA belongs has
been subject to substantial controversy, requiring a
2019 joint statement from ACS COT/ACEP updating
their 2018 joint statement. The 2019 revision recom-
mends that only emergency physicians with specific
training and in direct consultation with the operat-
ing surgeon place REBOA.61
Exact indications for the use of REBOA cannot
be given, due to a paucity of prospective data re-
flecting the latest technique with smaller catheters
and variability in the comparative cohort, whether
resuscitative thoracotomy or case-matched controls.
There are no Class I or II data. Main indications for
REBOA have been life-threatening hemorrhage and
hemorrhagic shock originating solely from a source Adam Stannard, Jonathan L. Eliason, Todd E. Rasmussen.
below the diaphragm, without traumatic arrest. Resuscitative endovascular balloon occlusion of the aorta (REBOA)
Inflation in Zone I (origin of the left subclavian to as an adjunct for hemorrhagic shock. The Journal of Trauma and
the celiac artery) (see Figure 5) for control of severe Acute Care Surgery. 2011; Volume 71, Issue 6. Pages 1869-1872.
intra-abdominal or retroperitoneal hemorrhage is With permission from Wolters Kluwer Health, Inc. Available at:
https://journals.lww.com/jtrauma/Citation/2011/12000/Resuscitative_
indicated only if the anticipated time to operation
Endovascular_Balloon_Occlusion_of.62.aspx

increase in cardiac afterload.63 Time to access is also donors, and this is an early critical decision in many
important, with a 10% increase in mortality for every local algorithms.70 A 5-year retrospective review
additional 10 minutes acquiring cannulation.64 A indicated that resuscitative thoracotomy is futile in
2019 case-control study of data including previous patients aged > 60 years with blunt trauma or any
12 Fr REBOA catheters in the United States found patient aged ≥ 70 years.71
worsened overall mortality, kidney injury, and
amputation.65 More study and understanding of the Airway
place of REBOA in the practice of emergency medi- Airway security is critical in the trauma patient,
cine is indicated prior to widespread adoption. though the approach needs adjustment in a pa-
tient with hemorrhagic shock. Preparation for post
Cardiac Arrest intubation hypotension must be made prior to the
Cardiac arrest in trauma patients is physiologically intubation, as this should be expected to occur
different from medical cardiac arrest. A compro- even with “neutral” induction agents. In one study,
mised rib cage limits recoil-driven venous return 36% of intubated trauma patients had post rapid
and hypovolemia limits stroke volume, all while sequence intubation (RSI) hypotension.72,73 Swine
the repetitive compressions in CPR disrupt low- models show the effective propofol dose is reduced
flow-driven hemostasis. A study of early in-hospi- approximately 50% in hemorrhagic shock and is
tal traumatic arrest patients who underwent CPR associated with significant hypotension.74 Succinyl-
shortly after arrival found that the survival rate choline carries relative contraindications for patients
was influenced greatly by the timing of onset of the with hyperkalemia, burns, globe injury, and severe
arrest (4.3%-36.4%).66 A 2019 retrospective review traumatic brain injury (TBI). These conditions often
of 582 patients in the United States Department of occur with hemorrhagic shock, and succinylcholine
Defense Trauma Registry showed that closed-chest seems to offer a more rapid induction sequence
cardiac massage in combat patients had a 30-day time and better intubation conditions only when
survival rate of 13%. Survival rate was 17% if it was compared to doses < 1.2 mg/kg of rocuronium.75 In
performed in-hospital; there were zero survivors elective surgical patients, higher-dose rocuronium
among those who had open cardiac massage.67 CPR (up to 2 mg/kg) has been associated with better
should not delay definitive measures such as chest intubation conditions without hemodynamic com-
decompression, hemorrhage control, tamponade promise.76 Standard indications, such as severe facial
relief, or transfusion if these measures are aimed trauma causing obstruction and inadequate oxygen-
at the suspected cause of the traumatic arrest. In a ation/ventilation, remain uncontroversial. The data
traumatic swine model of modified CPR, transtho- supporting the widely taught standard intubation
racic echo-marked left ventricular compressions criteria of a Glasgow Coma Scale score < 8 has been
improved 1-hour survival over traditional CPR criticized as being dogmatic, but it has Level 1 sup-
(38% vs 0%, P = .04).68 port in the EAST guidelines, as does intubation for
severe hemorrhagic shock in which RSI may precipi-
Resuscitative Thoracotomy tate arrest.22,77
Indications for resuscitative thoracotomy for sal-
vageable blunt or penetrating trauma victims vary Breathing
among guidelines, but they agree that an appropri- Concurrent pathology, such as tension pneumo-
ate surgeon must be quickly available. The 2012 thorax or hemothorax, should be addressed with
WTA guidelines specify acceptable CPR times in appropriate interventions, particularly when in-
penetrating trauma (15 minutes) or blunt trauma (10 tubating. When mechanically ventilating patients,
minutes) before performing resuscitative thoracoto- normoventilation and normoxia are goals unless
my.8 Based on 10,238 ED resuscitative thoracotomy imminent cerebral herniation is assessed. Titration
procedures, Level III EAST guidelines strongly of the fraction of inspired oxygen (FiO2) is critical,
recommend resuscitative thoracotomy in pulseless, as hyperoxygenation is associated with increased
penetrating thoracic trauma with signs of life (21.3% mortality in the critically ill.78 A low tidal volume
survival); but only conditionally support resuscita- strategy is advised with or without associated acute
tive thoracotomy in pulseless penetrating thoracic respiratory distress syndrome.79
trauma without signs of life (3.9% neurologically
intact survival), or in extrathoracic penetrating
trauma with or without signs of life (15.6% vs 4.6%
survival, respectively). They conditionally recom-
mended resuscitative thoracotomy for blunt trauma
only if signs of life were present in the ED.69 Cardiac
motion on ultrasound was found to be 100% sensi-
tive in identifying survivors and successful organ

Circulation • > 2 regions positive on FAST exam
Hemorrhagic shock in trauma is a hypovolemic • Laboratory findings (pH < 7.25, hematocrit
crisis. Successfully addressing and treating the shock < 32%, lactate > 2.5 mmol/L, INR ≥ 1.2, base
state relies on hemorrhage control and blood prod- deficit > 6 mEq/L)
uct resuscitation.
The ABC score attempts to predict which pa-
Fluid Resuscitation tients will need MT. In validation, the cutoff of
Restoration of intravascular volume in a manner that ≥ 2 to trigger MTP had sensitivity and specificity
halts the progressing coagulopathy and provides oxy- ranging from 75% to 90% and 67% to 88%, respec-
gen and nutrient-carrying capacity is key to revers- tively.84 This score has been found to be more sensi-
ing the shock state in the hemorrhagic shock patient. tive than clinical gestalt and is significantly faster
Normalization of intravascular volume should be to recognize MT need, with previous data showing
delayed in patients until definitive hemostasis has that, for every minute of delay from recognition
been achieved, specifically in patients with penetrat- to implementation of the MTP, mortality increases
ing trauma to the torso and short prehospital trans- 5%.85 MTP can, however, lead to higher fresh frozen
port times.11 Key issues are when to trigger the mas- plasma waste without significant impact on mortal-
sive transfusion protocol (MTP), how to utilize the ity.85 When immediately available, it is preferable
various blood components and adjuncts, and what to reserve O-negative pRBCs for child-bearing-age
ratio to use for blood products. Military guidelines women and O-positive pRBCs for men, due to the
suggest the choice of initial resuscitative fluid should approximately 20% risk of infertility-associated al-
be whole blood, component therapy with a balanced loimmunization.86 Approximately 40% of the donor
1:1:1 ratio, red blood cells (RBCs) and plasma in 1:1 population is type A, with lower titers of anti-B
ratio, then very limited use of crystalloids.80 antibodies, and transfusing this much more readily
available plasma rather than AB is safe for virtually
Massive Transfusion all recipient patients.4
The MTP brings preset universal donor blood prod- Decision-making for stopping the MTP should
ucts to the patient in hemorrhagic shock. These blood include hemorrhage control, meeting hemodynamic
products include packed red blood cells (pRBCs), targets, and discussion with the trauma team. There
plasma, platelets, cryoprecipitate or fibrinogen is limited evidence for restrictive transfusion thresh-
concentrate, and other adjuncts such as calcium, olds in trauma if the patient is still being acutely
tranexamic acid, and possibly prothrombin complex resuscitated but is not actively bleeding. The follow-
concentrate (PCC). The implementation of MTPs ing guides can be used:49
into trauma systems has been linked with faster • Stop pRBC transfusion for Hb > 7-9 g/dL
onset of transfusion, reduced product use and waste, • Stop plasma transfusion for PT or partial
and improved mortality.81,82 The definition of MT thromboplastin time (aPTT) < 1.5 times normal
varies in the medical literature. Definitions include:83 • Stop platelet transfusions for platelet count
• Transfusion of > 10 units of pRBCs in 24 hours > 50,000/mcL or >100,000/mcL in patients
(ACS definition) with TBI
• Replacement of entire blood volume in 24 hours
• Transfusion of > 4 units in 1 hour Whole blood, platelets, plasma, and pRBCs
• Replacement of 50% of total blood volume in are stored with citrate, which functions as an anti-
3 hours coagulant. Citrate is a calcium-binding agent and,
in healthy individuals, is hepatically metabolized.
The ACS guideline criteria for initiating an MTP However, with MT, an overload of citrate could lead
in trauma include 1 or more of the following:4 to a life-threatening hypocalcemia and progressive
• Assessment of blood consumption (ABC) score coagulopathy.50 To address this, empiric calcium
of ≥ 2 (See Table 2, page 5) dosing and frequent reassessment of electrolyte lev-
• Persistent hemodynamic instability els should be conducted during MT.
• Active bleeding requiring operation or angioem-
bolization Crystalloid Therapy
• Blood transfusion in the trauma bay Isotonic crystalloids have been advocated for
decades in the initial resuscitation of trauma pa-
Military guidelines recognize several other fac- tients. They expand the intravascular volume, but
tors predictive of MT or aggressive resuscitation:80 only transiently, due to third-spacing. After this
• Injury patterns (above-the-knee amputation, temporary benefit, crystalloids become maladap-
multiple amputations, clinically obvious pen- tive, contributing to respiratory failure, abdominal
etrating injury to torso) and extremity compartment syndrome, and dilu-
• Vital sign measurements (SBP < 110 mm Hg, tional coagulopathy. The balanced resuscitation
heart rate > 105 beats/min) principle avoids the use of these fluids in favor of

blood products, when possible. Data suggest that Platelets
while coagulation alterations begin in traumatic Platelets are central to achieving and maintaining
hemorrhage before resuscitation, they are worsened hemostasis. The 1:1:1 ratio that DCR principles
by crystalloid use.87 This extends to colloids such reference is the random donor platelet unit. The
as albumin, dextran, and hypertonic saline.11,88,89 more available pooled apheresis platelet unit is
Therefore, limiting crystalloid infusions to approxi- equivalent to 6 random donor platelet units. Each
mately 3 liters in the first 6 hours after arrival in the apheresed unit should increase platelet counts by
hospital is recommended.90 Hydroxyethyl starch approximately 30,000 to 50,000/mcL. Initiating
solutions (such as HEXTEND®) carry a United States platelet therapy early and in a balanced ratio has
Food and Drug Administration (FDA) warning and been linked to hemostasis and better survival ad-
are linked to dose-dependent acute kidney injury, vantage.97 Outside of fixed-ratio resuscitation, trans-
renal replacement therapy, and increased need for fusion endpoints for platelets vary, but 100,000/mcL
blood products.91 When indicated, lactated Ringer’s in trauma is common.49
solution is preferred over 0.9% (normal) saline in
patients without suspected TBI, due to the lower Blood Product Ratios
chance of causing hyperchloremic acidosis, which There is much debate over the most beneficial
has been shown in human studies, and less coagu- ratio of blood products, with some authors (mostly
lopathy, which has been shown in swine models. European) advocating the 1:1:2 ratio. The ideal trans-
However, lactated Ringer’s solution may have inter- fusion ratio cited most often approximates whole
actions with some medications.92 PLASMA-LYTE A blood. This ratio is derived from 2 prospective
is also preferred over saline since it has a neutral pH, studies (PROMMTT and PROPPR).97,98 The PROM-
osmolarity equivalent to blood (295 mOsm/L), and MTT study found that high ratios of plasma and
no calcium, allowing concurrent blood transfusion.93 platelets had mortality benefit at 6 hours but not at
The lack of long-term benefit and possible harm of 24 hours.97 The PROPPR trial found that while 1:1:1
crystalloid infusion may necessitate using small- versus 1:1:2 had no overall mortality benefit, there
bolus increments (eg, 250 mL) just to maintain blood was improved time to hemostasis and a lower rate of
pressure goals until blood is available.23 death due to exsanguination at 24 hours with high-
ratio balanced resuscitation.98
Whole Blood and Red Blood Cells
Warm, fresh whole blood has been independently Permissive Hypotension
associated with improved survival in combat pa- The goal of initial blood transfusion should be to
tients and a reduction in ATC.94 However, its use restore perfusion to the extremities yet allow for
outside of military and tactical settings is imprac- permissive hypotension. Though the largest trial, to
tical, due to the need for adjacent blood collec- date, excluded blunt trauma, this concept is associ-
tion centers, personnel, and a pool of prescreened ated with lower mortality and reduced transfusion
donors. Autologous whole blood transfusion from requirements in both blunt and penetrating trau-
hemothorax has been shown to be safe and to reduce ma.99,100 The exact target of permissive hypotension
cost and the need for transfusion products.95 In is under debate, since studies have used various
the civilian setting, cold-stored LTOWB has been targets of SBP or MAP, but European guidelines
demonstrated to be practical and effective in initial suggest an SBP goal of 80 to 90 mm Hg, higher
uncrossmatched resuscitation, but is not yet widely than most studies in the literature.49 Other authors
adopted or studied in large trials.86 In a retrospec- advocate even higher targets of 100 to 110 mm Hg
tive study of 198 LTOWB transfusions, Williams et in lower-resource conditions.101 Once hemostasis is
al showed improved post ED transfusion require- achieved, a restrictive pRBC transfusion threshold
ments and mortality.96 pRBCs and plasma should is advised, though the data specifically for trauma
be delivered utilizing blood warming capabilities. are limited.102 Permissive hypotension should not
Platelets and cryoprecipitate should not be trans- be applied to patients with TBI, and it is not clear
fused through the blood warmer.4 whether permissive hypotension is applicable in
elderly patients or patients with hypertension or
Plasma cardiac disease.
Plasma contains the blood-clotting factors needed
to maintain hemostasis, whether in fresh-frozen, Hemostatic Products
liquid, or freeze-dried (lyophilized) form. Plasma Tranexamic Acid
transfusion may be guided by balanced resuscitation If not already given by EMS, tranexamic acid,
principles, conventional coagulation tests, or VCT administered as a 1-gram IV bolus over 10 minutes
assessments. Freeze-dried plasma has yet to achieve followed by an infusion dose of 1 gram over 8 hours,
FDA approval for nonmilitary use, though its safety should be given within 3 hours of injury for patients
and efficacy have been shown in multiple countries. at risk for significant hemorrhage or with significant

bleeding (defined as SBP < 90 mm Hg and heart rate Nardi et al introduced a clinical pathway utilizing an
> 110 beats/min). The 20,211-patient randomized empiric dose of fibrinogen concentrate (2 g) for pa-
placebo-controlled CRASH-2 trial showed signifi- tients in hemorrhagic shock and found significantly
cant improvement in mortality with tranexamic reduced need for plasma and platelets.108 Reduced
acid without an increased risk for venous throm- fibrinogen levels on arrival are associated with
boembolism.29,30 Subsequent retrospective studies higher blood loss and mortality. The particularly
evaluating its implementation have had less impres- dangerous hyperfibrinolytic state must be addressed
sive results, with a large 2018 study showing no with supplementation of fibrinogen, in addition to
associated reduction in mortality in the population tranexamic acid.109 The opposite state—fibrinolytic
overall, but showing a mortality reduction in the shutdown—is more common on admission. Thus,
subset of patients who received pRBCs in the ED.103 it is recommended that further fibrinogen supple-
The preponderance of the evidence still supports mentation be guided by laboratory testing.110 The
early tranexamic acid use, and now VCT can detect RETIC study, which evaluated bleeding trauma
the hyperfibrinolysis phenotype.49,104 Of note, the patients with poor fibrin polymerization or clotting
recent CRASH-3 tranexamic acid trial focused on times ended early due the higher need for rescue in
TBI patients, and cannot be generalized for hemor- the FFP arm versus coagulation factor concentrates
rhagic shock. (mostly fibrinogen).111 Conventional coagulation test
cutoffs for supplementation are plasma fibrinogen
Prothrombin Complex Concentrate levels of < 1.5 g/L. Desmopressin is also recom-
For traumatic shock patients with high INR due to mended by European guidelines (Grade 2C) for
warfarin use, using 4-factor PCC and intravenous patients on antiplatelet therapy or patients with von
vitamin K is indicated.49 Data from a retrospective Willebrand disease.49 Recombinant activated factor
analysis of the ACS TQIP database (which specifical- VII is no longer advocated, as its expense is not justi-
ly excluded warfarin users) suggest the combination fied by outcomes.112
of FFP and PCC may lower transfusion requirements
and events of transfusion-associated acute lung Special Circumstances and Populations
injury, acute kidney injury, and mortality compared
to a propensity score-matched cohort not receiving Central Nervous System Injury
PCC.105 Prospective trials are needed to study the Central nervous system injury warrants attention in
relative cost and effectiveness of this strategy. hemorrhagic shock beyond recognizing its increased
mortality. As noted in the section on permissive
Direct Oral Anticoagulant Reversal Agents hypotension (page 11), hypotensive resuscitation has
Specific reversal agents are now available for adverse outcomes in patients with TBI, particularly
dabigatran (idarucizumab) and factor Xa inhibitors elderly patients.113 European guidelines suggest a
(andexanet alfa). Their high cost and unknown effec- MAP ≥ 80 mm Hg for resuscitation in TBI with GCS
tiveness in comparison to standard care has limited score ≤ 8 (Grade 1C).49
their adoption. Dosing will be specific to the target
drug and timing of the last dose taken. Infusions Pediatric Patients
may be necessary, as half-lives can be dissimilar. In
Several pediatric studies have shown no benefit
hemorrhagic shock, waiting to initiate reversal for
to balanced resuscitation, but are consistent with
results of drug levels or specialized clotting tests in
adult findings of harm with high volumes of crys-
known users is not advised, but results may inform
talloid.114 LTOWB has been studied and found to be
later resuscitation. PCC has been ineffective against
safe in pediatric patients aged > 3 years and weigh-
dabigatran, though rFVIIa, aPCC, dialysis, and plas-
ing > 15 kg.115 Permissive hypotension is unstud-
mapheresis have shown some effectiveness.2 Both
ied in the pediatric population. In a retrospective
fresh frozen plasma and PCC may be effective with
analysis of pediatric injuries in a combat theater,
factor Xa inhibitors, making the relative benefit of
tranexamic acid was found to have survival benefit
andexanet alfa unclear.106
without adverse events (such as venous thrombo-
embolism).116 VCT has been studied and found cor-
Fibrinogen
relation with conventional coagulation tests in this
Cryoprecipitate and fibrinogen concentrate have
population, though it is often not used.117
shown positive outcomes for bleeding patients, and
use can be guided by VCT or fibrinogen concentra-
tions. Some literature refers to the appropriate ratio
of cryoprecipitate in MT as 1:1:1:1, recognizing that
a unit of cryoprecipitate contains 0.25 grams of
fibrinogen, approaching the > 0.2 g per RBC ratio
found by Stinger et al to have mortality benefit.107

Controversies and Cutting Edge patients. New techniques, such as variable control
and intermittent REBOA show promising data in
Controversies surrounding the ideal initial resus- animal models.63,119
citative ratio will continue, but the introduction of The use of extracorporeal life support in trau-
whole blood and factor concentrates will fuel active matic shock will likely grow as device circuit length
research for the next few years. The recently com- and complexity improve and heparin-minimized
pleted iTACTIC trial may identify the effectiveness protocols allow for its use in the concurrently coagu-
of VCT-guided algorithms versus empiric therapy lopathic patient.120
utilizing conventional coagulation testing.118 An Vasopressor use in trauma has mixed safety
exact SBP or MAP goal in hypotensive resuscita- data. A retrospective analysis of 3551 hemorrhagic
tion needs more study in the ED setting, though the shock patients by Aoki et al found that vasopressor
principle is supported by the evidence. use in trauma patients was associated with an odds
In addition to the controversy over who may ratio of 2.17 for in-hospital mortality.121 A 2011 study
perform REBOA, there is also controversy over its of low-dose vasopressin bolus (4 units) and infu-
safety. Much of the data reflect use of older, more sion (2.4 units/hr) found reduced fluid use without
complicated models of the catheter. Currently, change in other outcomes.122 The 2019 AVERT Shock
REBOA is a skill practiced frequently in only a few trial supported this finding, but started vasopressin
high-volume centers and military teams, leaving after 6 units of blood product and also found sig-
the potential for bias in the literature. Larger tri- nificant reduced blood product use versus placebo
als such as the UK-REBOA trial are still enrolling without change in mortality.123
Risk Management Pitfalls for Traumatic Hemorrhagic Shock
1. “We put a tourniquet on high and tight, but he 6. “The wound was too high for a tourniquet, so
is still bleeding.” we just gave blood.”
Poor tourniquet placement and technique Achieving hemostasis is your number 1 priority.
will result in a venous tourniquet. Ensure the Use manual pressure, junctional tourniquets, or
tourniquet is functioning by confirming absent hemostatic dressings to temporize until surgical
distal pulse. intervention.
2. “I thought I’d give him 2 liters of normal saline 7. “GCS less than 8, intubate!”
for his tachycardia.” Though it is indicated for patients with severe
Overresuscitation with crystalloids causes head trauma, hasty intubation in shock patients
dilutional coagulopathy and acidosis. The 10th often precipitates hypotension and has higher
edition of ATLS® has reduced this initial bolus risk for cardiac arrest.
recommendation.
8. “I checked everywhere for bleeding in this
3. “I put a blanket on him.” traumatic shock patient.”
Failure to account for hypothermia from blood Failing to consider obstructive and neurogenic
loss and iatrogenesis will contribute to the etiologies will endanger your patient.
“lethal triad.”
9. “We don’t want to have too high of a blood
4. “Let’s get that abdominal CT just to confirm pressure.”
the bullet tract.” Failure to account for different end-goals of
Not moving surgical patients in hemorrhagic treatment with central nervous system trauma
shock to the OR in a timely manner is may result in cerebral hypoxia and injury.
exceptionally dangerous.
10. “I’ll activate the team after CT.”
5. “The FAST was negative, so he couldn’t be Failure to involve surgery or interventional
bleeding too much.” radiology early in the presentation may delay
Failure to account for occult or easily missed preparation of the OR, calling in backups,
areas of hemorrhage, such as in the thigh or and eventual delay in care. Utilize activation
retroperitoneum, and external loss, can lead to a protocols.
delay in hemostasis.

Clinical Pathway for Management of Traumatic Hemorrhagic Shock
in the Emergency Department
Primary/secondary
survey with eFAST
identifies patient with
hemorrhagic shock
• Transport to OR (Class I)
• If qualified/meets strict
indications:
• Initiate immediate bleeding control Surgical pathology +
YES l
Resuscitative thoracotomy
with direct pressure, tourniquets, surgeon/IR/OR available?
(Class II)
hemostatic dressing or pelvic binder,
l
REBOA (Class
if appropriate (Class I)
Undetermined)
• Confirm trauma team alert/transfer
planning (Class I)
• Initiate tranexamic acid protocol if • Antiplatelet: desmopressin

Is the patient on an oral antiplatelet
< 3 hours (Class II) YES (Class III)
agent or anticoagulant?
• Anticoagulant: PCC, antidote,
• Follow damage control resuscitation
or dialysis (Class II)
principles* (Class II)
• Initiate MTP if local criteria met

(Class II)
Minimal balanced crystalloid until
• Without delaying interventions, SBP < 80-90 mm Hg or blood is available for transfusion
perform laboratory testing (Class II): MAP < 80 mm Hg in TBI? YES prior to definitive hemostasis
l
CBC, PT, fibrinogen +/- VCT, pH, (Class III)
base excess, lactate, ionized
calcium, metabolic panel
l
Type and screen/cross
l
If indicated: LFT, +/- hCG, UA • Follow instrument-specific
Coagulopathy? YES algorithm for VCT or follow
traditional goals (Class II)
• Platelets if < 100k/mcL
• Plasma if > 1.5 INR
• Fibrinogen if < 1.5 g/L
• Reassess laboratory results every
1-2 hrs
• Hb: 7-9 g/dL if hemostatic (Class II)
• Continue resuscitation
• Transfer/admit to ICU
*Damage Control Resuscitation Principles:

1. Balanced resuscitation (1:1:1)
2. Permissive hypotension
3. Early hemorrhage control
4. Avoid hypothermia
5. Minimal crystalloid
6. Functional coagulopathy correction
7. Tranexamic acid, if indicated
Abbreviations: CBC, complete blood (cell) count; eFAST, extended focused assessment with sonography in trauma; hCG, human chorionic gonadotropin;
Hb: hemoglobin; ICU, intensive care unit; INR, international normalized ratio; IR, interventional radiology; LFT, liver function tests; MAP, mean arterial
pressure; MTP, massive transfusion protocol; OR, operating room; PCC, prothrombin complex concentrate; PT, prothrombin time; REBOA, resuscitative
endovascular balloon occlusion of the aorta; SBP, systolic blood pressure; UA, urinalysis; TBI, traumatic brain injury; VCT, viscoelastic clot testing.
For Class of Evidence Definitions, see page 15.

Disposition • Staged complete operations may not occur until
after the patient’s hypothermia, acidosis, and
Field activation criteria will direct most patients coagulopathy are corrected in the ICU setting.
with hemorrhagic shock to a trauma center, where
the patient’s disposition will most certainly be to the Summary
operating room for surgery or angiographic embo-
lization and afterwards to the trauma ICU. For non- Hemorrhagic shock remains a leading cause of pre-
trauma centers, local protocols for transfer should ventable death in trauma. Primary goals during re-
be activated immediately and transfer-delaying tests suscitation include identifying the source of hemor-
should be avoided while resuscitation continues. In rhage and temporizing it while excluding alternative
areas without trauma center access, general surgery causes of the shock state. Traumatic hemorrhagic
should be consulted, as the principles of damage shock should be managed in consultation with a
control surgery are within their skill set. trauma service early, while utilizing preset activation
criteria. Though definitive data from randomized
Key Points controlled trials are few, the preponderance supports
DCR principles: permissive hypotension, balanced
• Definitive hemostasis is the first requirement resuscitation, early tranexamic acid administra-
and is prioritized in the concept of DCR. tion, and pre-established MTPs. Adjuncts such as
• The principle of permissive hypotension is uti- fibrinogen concentrates and PCC have been shown
lized until hemostasis is achieved, then normal- to improve transfusion requirements. Electrolyte
ization of perfusion will become the new goal. abnormalities such as hypocalcemia in trauma are
• Assessing adequate resuscitation will require linked to mortality. Laboratory tests, such as lactic
continuous vital sign and urine output moni- acid levels and base excess, may help identify the
toring as well as reassessment for rebleeding, shock state better than traditionally taught classes of
hypoxia, anemia, coagulopathy, electrolyte hemorrhage, and VCT assays are increasingly being
derangements, and blood gas abnormalities. used to inform resuscitation. Prospective trials are
• Normalization of lactate and base excess is needed to guide the implementation of DCR in pedi-
correlated with resolution of the shock state atric trauma as well as REBOA, VCT, and vasopres-
and improved mortality, but they may not be sors in adult trauma.
informative, by themselves, to guide transfusion
therapy.124 Time- and Cost-Effective Strategies
• When crossmatching is complete, type-specific
transfusions should be used and, if available, • Activate the trauma team early, based on preset
guided by goal-directed strategies that can in- criteria.
clude conventional coagulation tests or VCT.49 • Minimize delays and unnecessary imaging
• ACS has published suggested VCT thresholds when transferring for definitive management.
for goal-directed therapy based on the specific • Preset MTPs are linked with faster time to trans-
instrument.4 fusion, less waste, and improved mortality
• The end-point of resuscitation in traumatic hem- • The use of VCT to guide therapy may reduce
orrhagic shock typically occurs outside of the component product use and waste.
ED, as these patients often require treatment in • Use the initial eFAST examination to exclude
the operating suite. obstructive causes of traumatic shock.
Class of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II Class III Indeterminate
• Always acceptable, safe • Safe, acceptable • May be acceptable • Continuing area of research
• Definitely useful • Probably useful • Possibly useful • No recommendations until further
• Proven in both efficacy and effectiveness • Considered optional or alternative treat- research
Level of Evidence: ments
Level of Evidence: • Generally higher levels of evidence Level of Evidence:
• One or more large prospective studies • Nonrandomized or retrospective studies: Level of Evidence: • Evidence not available
are present (with rare exceptions) historic, cohort, or case control studies • Generally lower or intermediate levels of • Higher studies in progress
• High-quality meta-analyses • Less robust randomized controlled trials evidence • Results inconsistent, contradictory
• Study results consistently positive and • Results consistently positive • Case series, animal studies, • Results not compelling
compelling consensus panels
• Occasionally positive results
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2020 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Case Conclusions but the trauma team was finishing in the OR. The patient
already had multiple risk factors for need of MT (amputa-
After an EMS time-out, the primary survey for this previ- tion, high shock index), so you had blood ready on arrival
ously healthy 45-year-old man in the motorcycle crash and prioritized IV access in the upper extremities. Since
found him maintaining his airway but having intense you had the specific training, you prepared for REBOA
pain with breathing, intact pulses, and clammy skin. He and cleared its use with your surgeon. On arrival, your
was quickly exposed, revealing a diffusely ecchymotic tor- survey confirmed the injury pattern, but vitals were
so. The secondary survey revealed crepitus along his lower 60/palp with 150 HR and negative FAST. In addition
ribs and an unstable pelvis. Because your first priority to the 1:1:1:1 MTP, you secured REBOA and kept a
was hemorrhage control, you applied a pelvic binder. Your goal systolic of 80-90 mm Hg. Nice work, this patient
eFAST exam revealed free fluid in the Morison pouch, the wouldn’t have made it without you!
splenorenal space, and behind the bladder, but no pneu-
mothorax or tamponade. His shock index of 1.3 and his References
ABC score ≥ 2 indicated a high likelihood for needing ≥ 10
units of pRBCs, so you called for the first cooler of your Evidence-based medicine requires a critical ap-
hospital's MTP, which followed 1:1:1 ratios of plasma, praisal of the literature based upon study methodol-
platelets, and pRBCs, supplemented with calcium and ogy and number of subjects. Not all references are
cryoprecipitate. Because your patient was now maintain- equally robust. The findings of a large, prospective,
ing his SBP > 80 mm Hg and you did not suspect TBI, randomized, and blinded trial should carry more
you did not bolus any crystalloid while the MTP was weight than a case report.
mobilized. Tranexamic acid 1 g was administered by To help the reader judge the strength of each
EMS, and his tranexamic acid infusion was initiated in reference, pertinent information about the study, such
the ED. Initial labs drawn included type and cross, VCT, as the type of study and the number of patients in the
CBC, PT/INR, fibrinogen, VBG with lactate, and ionized study is included in bold type following the references,
calcium, but the patient was taken swiftly to the OR by where available. The most informative references cited
your activated trauma team for exploratory laparotomy. A in this paper, as determined by the authors, are noted
splenectomy was performed and external fixator applied, by an asterisk (*) next to the number of the reference.
in addition to pelvic packing. He recovered in the trauma
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79. Wolthuis EK, Choi G, Dessing MC, et al. Mechanical ventila- tive; 350 patients)
tion with lower tidal volumes and positive end-expiratory 97. Holcomb JB, del Junco DJ, Fox EE, et al. The prospective, ob-
pressure prevents pulmonary inflammation in patients with- servational, multicenter, major trauma transfusion (PROM-
out preexisting lung injury. Anesthesiology. 2008;108(1):46-54. MTT) study: comparative effectiveness of a time-varying
(Randomized trial; 40 patients) treatment with competing risks. JAMA Surg. 2013;148(2):127-
80.* Cap AP, Pidcoke HF, Spinella P, et al. Damage control resus- 136. (Prospective; 1245 patients)
citation. Mil Med. 2018;183(suppl_2):36-43. (Guideline) 98. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of
DOI: 10.1093/milmed/usy112 plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio
81. Riskin DJ, Tsai TC, Riskin L, et al. Massive transfusion proto- and mortality in patients with severe trauma: the PROPPR
cols: the role of aggressive resuscitation versus product ratio randomized clinical trial. JAMA. 2015;313(5):471-482. (Pro-
in mortality reduction. J Am Coll Surg. 2009;209(2):198-205. spective; 680 patients)
(Prospective; 77 patients) 99. Owattanapanich N, Chittawatanarat K, Benyakorn T, et al.
82. Khan S, Allard S, Weaver A, et al. A major haemorrhage Risks and benefits of hypotensive resuscitation in patients
protocol improves the delivery of blood component therapy with traumatic hemorrhagic shock: a meta-analysis. Scand J
and reduces waste in trauma massive transfusion. Injury. Trauma Resusc Emerg Med. 2018;26(1):107. (Meta-analysis; 30
2013;44(5):587-592. (Retrospective; 2986 patients) studies)
83. Patil V, Shetmahajan M. Massive transfusion and massive 100.* Tran A, Yates J, Lau A, et al. Permissive hypotension versus
transfusion protocol. Indian J Anaesth. 2014;58(5):590-595. conventional resuscitation strategies in adult trauma patients
(Review) with hemorrhagic shock: a systematic review and meta-
84. Cotton BA, Dossett LA, Haut ER, et al. Multicenter valida- analysis of randomized controlled trials. J Trauma Acute Care
tion of a simplified score to predict massive transfusion in Surg. 2018;84(5):802-808. (Meta-analysis; 5 randomized
trauma. J Trauma. 2010;69 Suppl 1:S33-S39. (Prospective; 586 trials, 1158 patients) DOI: 10.1097/TA.0000000000001816
patients) 101. Woolley T, Thompson P, Kirkman E, et al. Trauma Hemo-
85. Motameni AT, Hodge RA, McKinley WI, et al. The use of stasis and Oxygenation Research Network position paper
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the yang. J Trauma Acute Care Surg. 2018;85(2):298-302. (Ret- damage control resuscitation. J Trauma Acute Care Surg.
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86. Seheult JN, Anto V, Alarcon LH, et al. Clinical outcomes 102. McIntyre L, Hebert PC, Wells G, et al. Is a restrictive transfu-
among low-titer group O whole blood recipients compared sion strategy safe for resuscitated and critically ill trauma
to recipients of conventional components in civilian trauma patients? J Trauma. 2004;57(3):563-568. (Retrospective; 203
resuscitation. Transfusion. 2018;58(8):1838-1845. (Retrospec- patients)
tive; 124 patients) 103. Boutonnet M, Abback P, Le Sache F, et al. Tranexamic acid
87. Maegele M, Lefering R, Yucel N, et al. Early coagulopathy in in severe trauma patients managed in a mature trauma care
multiple injury: an analysis from the German Trauma Regis- system. J Trauma Acute Care Surg. 2018;84(6S Suppl 1):S54-
try on 8724 patients. Injury. 2007;38(3):298-304. (Retrospec- S62. (Retrospective; 684 patients)
tive; 8724 patients) 104. Moore HB, Moore EE, Chapman MP, et al. Does tranexamic
88. Bulger EM, May S, Kerby JD, et al. Out-of-hospital hyper- acid improve clot strength in severely injured patients who
tonic resuscitation after traumatic hypovolemic shock: a ran- have elevated fibrin degradation products and low fibrino-
domized, placebo controlled trial. Ann Surg. 2011;253(3):431- lytic activity, measured by thrombelastography? J Am Coll
441. (Prospective; 853 patients) Surg. 2019;229(1):92-101. (Prospective; 630 patients)
89. Roberts I, Blackhall K, Alderson P, et al. Human albumin 105. Zeeshan M, Hamidi M, Feinstein AJ, et al. Four-factor pro-
solution for resuscitation and volume expansion in critically thrombin complex concentrate is associated with improved
ill patients. Cochrane Database Syst Rev. 2011(11):CD001208. survival in trauma-related hemorrhage: a nationwide

propensity-matched analysis. J Trauma Acute Care Surg. safely administered to pediatric trauma patients. Transfusion.
2019;87(2):274-281. (Retrospective; 468 patients) 2017;57(S3):24A. (Case series; 18 patients)
106. Smith MN, Deloney L, Carter C, et al. Safety, efficacy, and 116. Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid
cost of four-factor prothrombin complex concentrate (4F- administration to pediatric trauma patients in a combat
PCC) in patients with factor Xa inhibitor-related bleeding: setting: the pediatric trauma and tranexamic acid study
a retrospective study. J Thromb Thrombolysis. 2019;48(2):250- (PED-TRAX). J Trauma Acute Care Surg. 2014;77(6):852-858.
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107. Stinger HK, Spinella PC, Perkins JG, et al. The ratio of fi- 117. Russell RT, Maizlin, II, Vogel AM. Viscoelastic monitoring
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109. Rourke C, Curry N, Khan S, et al. Fibrinogen levels dur- variable aortic control (EVAC) versus resuscitative endo-
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2012;10(7):1342-1351. (Prospective; 517 patients) Trauma Acute Care Surg. 2018;85(3):519-526. (Animal study;
110. Cardenas JC, Wade CE, Cotton BA, et al. TEG lysis shut- 12 subjects)
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(Retrospective; 1096 patients) J Emerg Surg. 2020;15(1):51. (Systematic review; 58 articles,
111. Innerhofer P, Fries D, Mittermayr M, et al. Reversal of 548 patients)
trauma-induced coagulopathy using first-line coagulation 121. Aoki M, Abe T, Saitoh D, et al. Use of vasopressor in-
factor concentrates or fresh frozen plasma (RETIC): a single- creases the risk of mortality in traumatic hemorrhagic
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World Neurosurg. 2018;120:e667-e674. (Retrospective; 12,537 transfusions in patients with trauma and hemorrhagic shock:
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plasma resuscitation does not improve survival in pediatric 124. Dezman ZD, Comer AC, Smith GS, et al. Failure to clear el-
trauma patients. J Trauma Acute Care Surg. 2017;83(2):211-217. evated lactate predicts 24-hour mortality in trauma patients.
(Retrospective; 364 patients) J Trauma Acute Care Surg. 2015;79(4):580-585. (Retrospective;
115. Leeper C. Cold stored uncrossmatched whole blood can be 3887 patients)
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CME Questions 5. Regarding resuscitative endovascular balloon
occlusion of the aorta (REBOA) for hemorrhag-
ic shock:
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www.ebmedicine.net/E1120.
a. pRBC
b. FFP
c. Factor VIIa
d. Cryoprecipitate
e. Platelets
7. When comparing the assessment of blood

consumption (ABC) score to physician gestalt
in predicting massive transfusion, physician
1. Which of the following is not considered one
gestalt:
of the “lethal triad?”
a. Activates massive transfusion more often
a. Coagulopathy
b. Utilizes more blood products
b. Hypoxia
c. Has a higher mortality
c. Acidosis
d. Has a longer time to first transfusion
d. Hypothermia
8. During resuscitative infusions of packed red
2. What iatrogenic factors contribute to acute
blood cells, which electrolyte abnormality is
traumatic coagulopathy?
commonly associated with precipitous hypo-
a. Resuscitation with crystalloid
tension and mortality?
b. Resuscitation with room temperature fluid
a. Hypokalemia
c. Leaving the patient exposed after
b. Hypophosphatemia
completing the physical examination
c. Hypocalcemia
d. All of the above
d. Hypernatremia
3. Compared to balanced transfusion, viscoelastic
9. For trauma patients, the concept of hypoten-
clot testing-guided therapy:
sive resuscitation:
a. May use less blood products
a. Has no evidence of reduced bleeding and
b. Can identify hyperfibrinolysis
transfusion requirements
c. Is more likely to utilize platelet and
b. Is contraindicated for patients with severe
cryoprecipitate
traumatic brain injury
d. All of the above
c. Utilizes only mental status changes as the
lowest tolerable blood pressure
4. Appropriate tourniquet application is associ-
d. Has no evidence of improved mortality
ated with:
a. Higher rates of limb loss
10. Which fibrinolytic state requires supplementa-
b. Higher mortality
tion of fibrinogen?
c. Higher likelihood of neurologic compromise
a. Hyperfibrinolysis
d. Reduced likelihood of rhabdomyolysis
b. Physiologic fibrinolysis
c. Fibrinolytic shutdown
d. None of the above

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CME Information
Date of Original Release: November 1, 2020. Date of most recent review: October 10, 2020.
Termination date: November 1, 2023.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical
Education (ACCME) to provide continuing medical education for physicians. This activity has been
0
August 202ber 8
planned and implemented in accordance with the accreditation requirements and policies of the
ACCME.
Num
Volume 22,
cular
Supraventri
Authors al
FAAEM
e
Naval Hospit
ythmias in th
Clark, DO, Medicine Depar tment,
Delbert D. ency
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA
ian, Emerg
side, CA
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Staff Physic
ton, Ocean
Camp Pendle Naval Medic
al
ire, MD
partment
Depar tment,
Morgan McGuEmergency Medicine
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Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their
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Center San al
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Naval Medic
s, MD Depar tment,
Mary Jone Emergency Medicine
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participation in the activity.

Diego, San
Center San FAAE M Univer sity of
er, MD, ive Medic ine,
Heather Brun l Professor of Palliat
Abstract tachycardias
is rou- Assistant Clinica San Diego, CA
tricular San Diego,
ing supraven can improve California
er, MD, FAAE
M ine, Scripp
s
g and treat new strategies overview of
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME
ency Medic
Diagnosin David Brun Depar tment of Emerg
icine, and an
gency med w provides
ian,
Staff Physic CA
tine in emer outcomes. This revie differ- al, San Diego,
ophysiology, Mercy Hospit
efficiency and ias, their path features. Clinical
lar tachycard
credits..
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raphic ly Peer Review i-
supraventricu , and electrocardiog rmined large MPH Clinical Assoc
Morris, MD,ency Medicine Residency;Emergency Medi-
l diagnosis prac tice is dete ed James E. n of
entia orary r, Emerg
few randomiz
ry, Divisio TX
ing contemp Program Directo tment of Surge , Lubbock,
evidence guid rvational studies, with emergency depart- ate Profes
sor, Depar
Tech Univer
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Sciences Center
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency
obse al and
by multiple ent prehospit the use of adenosine
cine, Texas
, MD al Director,
Assistant
trials. Curr beyond ifer White iate Medic s
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Clinical Assoc r, Sidney Kimmel Colleg , PA
ment managem nel blockers are addr ided, based on the best Program Directo sity Hospital, Philad
elphia
and calcium
therapeutic
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recommen
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dations are
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back page.
Jefferson Univer
Internation
al Editors
on, MD
Physicians for 48 hours of ACEP Category I credit per annual subscription.
available evid
r, MD e, Peter Camer
“CME Inform Robert Schille ent of Family Medicin Alfred
Director, The Centre,
activity, see Chair, Departm Senior Academic
AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been
ing this e, MD Medical Center; and Trauma
Eric Legom e, Mount Emergency rne,
Prior to beginn , ncy Medicin Luke's; Beth Israel Medicine and ity, Melbou
s, MD, MS, FACEP Chair, Emerge St. Faculty, Family School of Monash Univers
Deborah Dierck & Mount Sinai Health, Icahn
Sinai West Affairs for Community New York,
NY Australia
Department
of Academic Mount Sinai,
hief FACC Vice Chair, Mount Sinai Medicine at MD
Editor-In-C, MD, FACEP Professor
and Chair,
University
of Medicine, Andrea Duca, Physician,
Emergency of FACEP Emergency
reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of
Medicine, , Icahn School York, NY Scott Silvers, MD, ncy Attending
Andy Jagoda Chair Emeritus, Emergency estern Medical Center, Health System Sinai, New Profess or of Emerge Papa Giovanni XXIII,
and e; Southw Mount te and le
Professor ncy Medicin Texas Medicine at Associa of Facilities FL
Ospeda
Italy
Department
of Emerge ncy Dallas, TX MD, MS Medicine, Chair Clinic, Jacksonville, Bergamo,
for Emerge Keith A. Marill, Department g, Mayo Peeters, MD
Director, Center ion and Research, MD Profess or, Plannin e Y.G. Physician,
Daniel J. Egan, Vice Chair
of Associate e, Harvard FACP, FACEP Suzann
Emergency
Medicine Educat
approval begins 07/01/2019. Term of approval is for one year from this date. Physicians should
e at Mount Professor, ncy Medicin husetts Slovis, MD, Attending Almere,
Icahn School
of Medicin Associate of Emerge
ncy of Emerge Corey M. Chair, Departm
ent g Hospital,
York, NY Department , Massac
Medical School l, Boston, MA Professor and Medicine, Vanderbilt Flevo Teachin
Sinai, New Education, University ands
Columbia General Hospita of Emergency e, TN The Netherl
hief Medicine, of Physicians
and l Center, Nashvill dez, MD,
FIFEM
Editor-In-C Vagelos College York, NY Mills, MD,
FACEP University Medica Edgardo Menen
ncy
Associate MD, FACEP New Angela M. Department MD Professor
in Medicin
e and Emergea
claim only the credit commensurate with the extent of their participation in the activity. Approved for
Surgeons, Professor
and Chair, Columbia Ron M. Walls, COO, Department
of
of EM, Churrucity,
Kaushal Shah, Vice Chair Medicine, e; Director
Professor, lle Elie, MD Emergency Professor
and
Brigham and l Medicin l of Buenos Aires Univers
Associate ent of
Marie- Carme Departm ent of College of
Medici ne,
ion, Departm Professor, University
Vagelos New York, Emergency Harvard Medica Hospita Argentina
for Educat Weill Cornell Associate Critical & Surgeons, Hospital,
Medicine, NY Medicine & Physicians Women's Buenos Aires,
Emergency e, New York, of Emergency University of Florida , Boston , MA sarntik ul, MD
Medicin e, Rojana
School of FL NY School Dhanadol Emergency
4 AAFP Prescribed credits.

Care Medicin Gainesville, MA, MD, Physician,
Medicine, Pollack Jr., rs Attending
rial Board College of Charles V. , FAHA, FACC,
Critic al Care Edito e, King Chulalo
ngkorn
of
Edito MD, FACEP ent of Genes, MD,
PhD
of FACEP, FAAEM MD, FACEP
, Medicin
Hospital; FacultyUniversity,
Saadia Akhtar, Nicholas Department ent of Knight IV, Memorial
Professor,
Departm Professor, FESC tist, Departm ity William A. Chulalongkorn
Associate Associate
Dean Associate Icahn School ncy Medicine,
Medicine, Medicine, Clinician-Scien Univers FNCS of Emerge
Emergency Education, Emergency Sinai, New Medicine, Professor Medical Thailand
te Medical e at Mount Emergency School of Medicine, Associate Neurosurgery, MPH
Thomas, MD,
AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit hours
for Gradua of Medicin ippi Medicine and
r, Emergency of Mississ Advanced
Practice Stephen H. Chair, Emergency
Program Directo cy, Mount Sinai York, NY Jackson MS Director, EM Medical &
FACEP ; Associate Professor l Corp.,
Medicine ResidenYork, NY Gibbs, MD, MPH
Provider Program University Hamad Medica
Michael A. Department Ali S. Raja,
MD, MBA,
Emergency cience ICU, Medicine, , Qatar;
Beth Israel,
New and Chair, Director, Neuros Medical College
Professor e, Carolinas Executive
Vice Chair, General ati, Cincinn
ati, OH Weill Cornell hief,
Brady, MD ncy Medicin ity of North Massachusetts or of of Cincinn Physician-in-C
e of Emerge Medicine, Emergency l Hospital,
per issue by the American Osteopathic Association.

William J. ncy Medicin l Center, Univers Chapel te Profess rt, MD, FCCM e; Genera
or of Emerge Director, Medica of Medicin
e,
Hospita l; Associa Radiolo gy,
Scott D. Weinga Medicin Hamad
Profess
e; Medical Carolina School Medicine and Boston, MA Emergency Doha, Qatar
and Medicin UVA Emergency , Professor of Care, Stony
Brook
Management, Medical Hill, NC Medical School EM Critical
Emergency onal FACEP Harvard , Chief, NY
Edin Zelihic,
MD ncy
Operati Godwin, MD, FACEP Stony Brook, ent of Emerge l,
Medical Center; rle County Fire Steven A. Department Rogers, MD, Medicine,
and Chair, Robert L. Head, Departm ina Hospita
Director, Albematesville, VA Professor e, Assistant , FACP ncy Edito rs Medicin e, Leopold
Medicin FAAEM Emerge
Research y
Needs Assessment: The need for this educational activity was determined by a survey of medical
Rescue, Charlot ncy of
of Emerge ion, Professor Schweinfurt,
German
MD ion Educat Assistant ity of r, PharmD,
BCPS
Brown III, Dean, SimulatFlorida COM- Medicine,
The Univers Aimee MishleMedicine Pharmacist,
Calvin A. Compliance, of Medicine,
Physician University FL School of Emergency
Director of Care Jacksonville, Maryland r, PGY2 EM
and Urgent ncy Jacksonville, Baltimore,
MD Program Directo cy, Valleywise
Credentialing ent of Emerge ushe, MD
MBA
FACEP cy Residen
Departm 's Habbo ncy MD,
staff, including the editorial board of this publication; review of morbidity and mortality data from the
s, tti, Pharma
Service
Brigham and
Women Joseph or of Emerge Alfred Sacche Professor,
, AZ
Medicine, Assistant Profess ngone and e, Health, Phoenix
, MA Assistant Clinical ncy Medicin MD
Hospital, Boston Medicine,
NYU/La New York, of Emerge Toscano,
l Centers, Department n University, Joseph D. ent of Emerge
ncy
ux, MD Bellevue Medica LLC Thomas Jefferso Chief, DepartmRamon Regional
Peter DeBlie Clinical Medicine, MD Aware PA San
of of NY; CEO, Philadelphia, Medicine, , CA
San Ramon
CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Professor ity School
State Univers nce Officer, Medical Center,
Louisiana
Chief Experie New
Medicine;
Medical Center,
University
Orleans, LA
Management of October 2020 Target Audience: This enduring material is designed for emergency medicine physicians, physician
Deep Vein Thrombosis in the Authors
Volume 22, Number 10
assistants, nurse practitioners, and residents.
Emergency Department Shane R. Sergent, DO, FAAEM,
Michigan State University FACOEP, FAWM, RDMS
College of Osteopathic Medicine,
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-
Director of Global Health and Medical
Research, East Lansing, MI;
Medicine Associate Program Emergency
Director, Ultrasound Course
Abstract Faculty, Kingman Regional
Medical Center, Kingman,
AZ
Director, Core
Michael Galuska, MD, FACEP,
making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most
Associate Program Director,
FAAEM
Deep vein thrombosis (DVT) Conemaugh Memorial Medical
Emergency Medicine Residency,
DLP
can present with a variety Center, Johnstown, PA
nonspecific signs and symptoms, of John Ashurst, DO, MSc, FACEP,
and
per or lower extremities. Manageme can involve the up- FACOEP
critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Director of Graduate Medical
Education, Kingman Regional
nt of patients with DVT Center, Kingman, AZ; Clinical Medical
has changed markedly over Assistant Professor, Arizona
the last 10 years, moving from Osteopathic Medicine, Glendale,
AZ
College of
hospital admission for initiation
of anticoagulation to out- Peer Reviewers
patient management. Diagnosis
Objectives: Upon completion of this activity, you should be able to: (1) Identify the clinical and
requires a risk stratificatio Jennifer Maccagnano, DO,
process involving clinical decision n Assistant Professor, New York
FACEP, FACOEP
rules, D-dimer testing, and Institute of Technology College
ultrasonography. Once the Osteopathic Medicine, Old of
diagnosis is confirmed, the Westbury, NY; Emergency
Medicine Attending
tient should be engaged in pa- Physician, Maimonides Medical
laboratory signs identifying hemorrhagic shock and predicting massive transfusion; (2) choose
Center, Brooklyn, NY
shared decision-making regarding Laura Melville, MD, MS
treatment options. Recurrent
DVT, as well as managing Assistant Professor of Emergency
in pregnant women, the elderly DVT College, New York, NY; Resident
Medicine, Weill Cornell Medical
population, and patients with Research Director, Department
appropriate endpoints of preoperative resuscitation for blood pressure and coagulopathy in the
malignancies are also discussed. Emergency Medicine, New
York Presbyterian Brooklyn of
Brooklyn, NY Methodist Hospital,
Prior to beginning this activity,
setting of hemorrhagic shock; and (3) identify and deploy appropriate adjunctive therapy to improve
see “CME Information”
on the back page.
Editor-In-Chi ef Deborah Diercks, MD, MS,
Andy Jagoda, MD, FACEP FACEP, Eric Legome, MD
FACC
morbidity and mortality in hemorrhagic shock patients.

Professor and Chair Emeritus, Chair, Emergency Medicine, Robert Schiller, MD
Department of Emergency
Professor and Chair, Department
of Sinai West & Mount Sinai St.
Mount Chair, Department of Family International Editors
Medicine; Emergency Medicine, University Luke's; Medicine,
Director, Center for Emergency of Vice Chair, Academic Affairs Beth Israel Medical Center; Peter Cameron, MD
Texas Southwestern Medical for Senior
Medicine Education and Research, Center, Emergency Medicine, Mount Faculty, Family Medicine and Academic Director, The Alfred
Dallas, TX Sinai Community Health, Icahn School
Icahn School of Medicine Health System, Icahn School of Emergency and Trauma Centre,
at Mount of Medicine at Mount Sinai, New
Sinai, New York, NY Daniel J. Egan, MD Medicine at Mount Sinai, New York, NY Monash University, Melbourne,
Discussion of Investigational Information: As part of the journal, faculty may be presenting inves-
York, NY Australia
Associate Professor, Vice Keith A. Marill, MD, MS Scott Silvers, MD, FACEP
Chair of
Associate Editor-In-Chief Education, Department of
Emergency Associate Professor, Department Associate Professor of Emergency Andrea Duca, MD
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Traumatic Hemorrhagic Shock

Uploaded by

Traumatic Hemorrhagic Shock

Uploaded by

An Evidence-Based Approach November 2020

Volume 22, Number 11

Christopher Pitotti, MD, FACEP

in the Emergency Department

The management of traumatic hemorrhagic shock has Ryan M. Knight, MD

Introduction The Lethal Triad

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Prehospital stabilization begins with addressing ex-

through standard ATLS® or Prehospital Trauma Life

Tourniquet Use WRAP WIND SECURE TIME

be delayed. Amputation and extremity dysfunction

© 2017 American College of Surgeons

from tourniquet ischemia is rare when definitive

Table 1. Traumatic Hemorrhagic Shock Differential

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Table 2. Signs and Symptoms of Hemorrhage, by Class (ATLS®)

Table 3. Clinical Prediction Calculators for Shock

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Resuscitative Endovascular Balloon

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Risk Management Pitfalls for Traumatic Hemorrhagic Shock

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• Initiate tranexamic acid protocol if • Antiplatelet: desmopressin

• Initiate MTP if local criteria met

*Damage Control Resuscitation Principles:

For Class of Evidence Definitions, see page 15.

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Class of Evidence Definitions

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Stay up-to-date on the most relevant

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7. When comparing the assessment of blood

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Calculated Decisions gives you 1-click access to

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SIMPLIFIED SUBSCRIPTION ACCESS

START ACCESSING YOUR CONTENT TODAY

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participation in the activity.

4 AAFP Prescribed credits.

per issue by the American Osteopathic Association.

Prior to beginning this activity,

morbidity and mortality in hemorrhagic shock patients.

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Emergency Medicine Practice.... support.

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