Hypovolaemic shock

NON-TRAUMA RELATED HYPOVOLAEMIC SHOCK

R57.1

DESCRIPTION

This happens when there is loss of intravascular fluid, e.g. severe diarrhoea and dehydration, haemorrhage or fluid shifts.

GENERAL MEASURES

Control obvious bleeding with direct pressure.

Insert one or two large bore IV catheters; peripheral lines are adequate.

MEDICINE TREATMENT

Non trauma related

  • Sodium chloride 0.9%, IV, 1–2 L.

LoEI [21]

Monitor blood pressure, pulse and clinical response.

TRAUMA-RELATED HYPOVOLAEMIC SHOCK

T79.4 + (R57.1 + Y34.99/Y57.9/Y14.99)

DESCRIPTION

Shock is inadequate perfusion of the vital organs. Clinically this may manifest with hypotension, tachycardia, weak pulses, clammy skin, pallor, altered mental state, poor urine output and elevated lactate.

The presence of shock in a patient with bleeding indicates that a significant volume of blood has already been lost.

The common traumatic sites of blood loss include the chest, abdomen, pelvis, long bone fractures and vascular injuries.

Major non-traumatic bleeds include gastrointestinal haemorrhage, ruptured ectopic pregnancy and obstetric haemorrhage.

GENERAL MEASURES

Control bleeding. Techniques may include:

  • Direct, sustained pressure over the bleeding point.
  • Use of tourniquets in exsanguinating limb haemorrhage, e.g. manual BP cuff or specialized tourniquet while awaiting transfer to theatre. (Do not use for longer than 6 hours).
  • Tamponade techniques e.g. inflated Foley catheter in neck, axilla or femoral wounds.

Obtain large bore IV access, preferably two lines.

Prevent hypothermia.

Send blood sample to blood bank as early as possible for blood type and screening. Notify blood bank of possible massive transfusion.

MEDICINE TREATMENT

  • Oxygen if saturation <94%.

LoEI [22]

Trauma related

  • Sodium chloride 0.9%, IV.

LoEI [23]

Consider blood products If more than 1 litre of fluid is needed, consider blood products:

  • In cases of major bleeding, limit fluid volumes to less than 1.5 litres in total where possible. Replace acute blood loss with blood and blood products.
  • Emergency blood should be used in unstable patients and when there will be significant delay in obtaining cross-matched blood from a blood bank.
  • Rh typing is advised when possible.
    • Type O Rh negative blood should be reserved for women of childbearing age that are Rh negative or Rh status unknown.
    • Type O Rh positive blood may be given to Rh positive women of childbearing age, females >50 years of age or males regardless of Rh status.
  • After 2 units of emergency blood, consider activation of massive transfusion protocol. See Massive transfusion.

MASSIVE TRANSFUSION

Z51.8

DESCRIPTION

A massive transfusion is the replacement of a patient’s blood volume or 10 units over a 24-hour period, or replacement of half of that volume over 4 hours.

GENERAL MEASURES

Actively treat and prevent hypothermia.

When it is anticipated that large volumes of blood will be required, the replacement of platelets and clotting factors in addition to red blood cells is needed to prevent coagulopathy.

MEDICINE TREATMENT

Facilities without access to a blood bank:

  • Lyophilised plasma, IV.
    • 1 unit for each unit of emergency blood transfused. LoEIII

Arrange urgent transfer to a centre with blood bank and specialist services.

Facilities with access to a blood bank:

  • Ensure that the blood bank receives an appropriate specimen as soon as the possible need for transfusion is identified.
  • Notify the blood bank as soon as possible of the need for a massive transfusion and request a massive transfusion pack.

A massive transfusion pack will typically consist of:

  • Red blood cells (RBCs), 6 units.

LoEIII

AND

  • Lyophilised plasma, IV.
    • 1 unit for each unit of emergency blood transfused.

OR

  • FFP, 6 units - thawed when requested.

AND

  • Platelets, 1 mega-unit (normally 6 pooled donor units).
    • Aim to transfuse the above products in a 1:1:1 ratio, or as guided by laboratory parameters.
    • Send specimens for FBC and INR and continue to monitor.

LoEIII [24]

Expedite definitive control of bleeding:

  • Tranexamic acid, IV, 1 g, infused over 10 minutes.

LoEI [25]

If patient responds initially and subsequently deteriorate, there may be an ongoing occult haemorrhage. If no response occurs, consider:

  • Occult exsanguinating haemorrhage: intra-abdominal, retroperitoneal and intrapleural.
  • Non-hypovolaemic shock: tension pneumothorax, myocardial contusion, cardiac tamponade or myocardial infarct.