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hemorrhagic

Symptoms: the presence of low blood pressure should not be a prerequisite of shock diagnosis, and assessment of inadequate tissue perfusion by thorough examination of cutaneous perfusion, urine output and altered mental status should be taken into account (1).

Measurements: laboratory signs of anaerobic metabolism such as serum lactate and metabolic acidosis should be taken into account (1). The parameters of tissue perfusion and oxygen debt, such as central venous oxygen saturation (ScvO2) and a venous-to-arterial CO2 gap, should also be put into context during treatment (1,2).

Treatment: in order of priority (1):
  1. Surgical interventions: compression bandage, pelvic compression, damage control surgery, packing.
  2. Physiological triggers: T >35° C, pH >7.2, Ca(i) >1 mmol/l, Hb 7-9 g/dl.
  3. Anticoagulation:
    1. Aspirin, clopidogrel: platelets 5-10U +/- desmopressin 0.3mcg/kg
    2. Warfarin: PCC 25 IU/kg or FFP 5-20 ml/kg, benefit remains controversial for new direct oral anticoagulants
    3. Heparin: 1 mg Protamin/100 IU Heparin
    4. Dabigatran: hemodialysis can be considered
  4. Hyperfibrinolysis: in severe trauma/schock or EXTEM ML>15% -> TXA 15-20 mg/kg
  5. Fibrinogen: <1.5 g/l or FIBTEM CA10 <7mm -> FC 3-6 g or FFP 15-30 ml/kg
  6. Thrombin generation: INR <1.5 or EXTEM CT >80 s -> PCC 500-2000 IU and/or FFP 15-30 ml/kg
  7. Platelets: <50 G/l or <100 G/l in traumatic brain injury -> platelet concentrate 1U/10 kg +/- desmopressin 0.3 mcg/kg
  8. rFVIIa/FXIII: rFVIIa 100 mcg/kg, FXIII 10-20 IU/kg
References:
  1. Krisztián Tánczos et al. What's new in hemorrhagic shock? Intensive Care Med. 2015;41:712-714: full text | pdf.
  2. Cecconi M et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014;40:1795-1815: full text | pdf.