Hemorrhagic shock

Meeting the challenges

Hemorrhagic shock is a leading cause of death in people with traumatic injuries. But according to Carol Immermann, R.N., it shouldn't be. Immermann, trauma program manager at Saint Marys, one of Mayo Clinic's hospitals in Rochester, Minn., says that with timely and appropriate care, most patients who experience severe hemorrhagic shock can be saved.

Managing shock, though, is uniquely challenging. "In the early stages, shock is difficult to recognize but easy to treat," Immermann points out. "In the latter stages, it's easy to recognize but difficult to treat."

Difficult to recognize

A large part of the problem is that shock can fool even the most experienced medical providers. The American College of Surgeons (ACS) describes physiological responses to blood loss in a four-stage classification system, but not all hemorrhagic shock is as obvious as this system suggests. What's more, infants, children and many older adults fall outside ACS parameters, which are based on the responses of a 154-pound (70 kilogram) adult male.

"We have an idea of how a person in shock should look, but not all severely injured patients fit this picture," Immermann says. "For example, children handle trauma better than adults do and compensate well. They can be awake, alert, talking and behaving completely appropriately. Then suddenly we lose them."

Administering large volumes of crystalloid also can cause providers to misread a patient's status because the fluids temporarily raise blood pressure. Immermann cautions that blood pressure drops again as hemorrhage continues.

"When we get a report from a referring hospital or EMS provider, we always want to know the lowest blood pressure and highest heart rate the patient has experienced since the injury because IV fluids can fool you. If fluids are needed to treat hemorrhage, we strongly recommend administering packed blood cells rather than large volumes of crystalloid." She adds that patients should also receive plasma, but only if it doesn't delay transport to definitive care.

Finally, Immermann points to a more subtle, seldom-recognized problem: Medical providers sometimes unconsciously will patients to be better than they are.

"We see a person with a rapid heart rate — typically the first sign of shock — and find other reasons to explain it, such as anxiety or pain," Immermann says. "Too often, the tendency is to want to see shock as something other than shock."

Putting shock front and center

The solution to these problems, Immermann says, is to assume that an injured person is in shock until proved otherwise. "No one wants to have a reputation for overreacting, but at Saint Marys, shock is the first thing we think of with seriously injured people and the first thing we rule out. Based on our experience with thousands of trauma patients, we encourage small hospitals to do the same."

Mayo Clinic also encourages referring hospitals to immediately transfer suspected shock patients to the nearest Level I trauma center.

"The best treatment for people who are actively bleeding is surgery," Immermann says. "Our goal is to be out of the trauma bay within 20 minutes. If a person's vital signs are acceptably stable at that point, the next stop is the CT scanner. If not, the patient goes directly to the operating room. We know that saves lives."