**3. Diagnosis**

The early recognition of hemorrhagic shock and stopping hemorrhage is lifesaving as it takes only 2 hours from its start until death [50]. In order to limit the severity level and duration of shock and to replace mounted oxygen debt, a prompt control of the origin of hemorrhage and the restoration of the intravascular volume and oxygen transfer capacity is essential [51].

Traumatic injuries are the fourth and are the first reason for deaths under the age of 45 in the United States. About 80% of traumatic injuries are blunt and the majority of the deaths progress as secondary following the hypovolemic shock. Intraperitoneal bleeding occurs in 12% of blunt traumas, and it is essential to be promptly detected. The optimal test should be rapid, accurate, and noninvasive. Diagnostic peritoneal lavage (DPL) was historically conducted in the diagnosis of hemoperitoneum. While DPL is extremely sensitive (96–99%) and specific (98%), it is an invasive procedure with a complication rate more than 1%. However, it is quite confusing to assess hemodynamically unstable patients for whom it is late and who are brought out of the emergency service [52].

In an emergency situation, ultrasonography can provide guiding insights into a patient's condition or injury pattern and is considered to be a highest priority technological tool that deserves evaluation. The ultrasound protocols used comprised focused assessment with sonography for trauma (FAST), prehospital lung ultrasound (PLUS), and focused echocardiography in emergency life support (FEEL). By combining the standard examination according to the FAST protocol (detection of internal bleeding) with pleural and lung ultrasound (PLUS) and echocardiography (FEEL), important life-threatening conditions, such as pneumothorax and cardiac tamponade, can be ruled out [53].

In irreversible shock, sodium accumulates within the cell due to the inhibition of Na/K ATPase pump. The direction of exchange of sodium and calcium is reversed, and calcium starts accumulating within the cells. Increasing levels of intracellular calcium causes proteolytic enzyme activation leading to degradation of the organelles of cells and at end cell death [54]. This definitely irreversible condition was first observed by Holden et al. under the electron microscope [55].

#### **3.1 Assessment of hemorrhagic shock**

The recently introduced physiological or therapeutic classification of hemorrhagic shock is based on basic physiological principles. It takes the fluid-blood replacement

**47**

*Hemorrhagic Shock*

*DOI: http://dx.doi.org/10.5772/intechopen.82358*

combat to prevent mortality [57].

**3.2 Signs and symptoms**

resistant hypotension and natural hemostatic mechanisms of the body into account as

In critical shock conditions, the circulating blood volume is insufficient, and brain and heart internal circulations are merely holding as a result of the systemic vasoconstriction from chemoreceptor and central nervous system receptor stimulation. Although the endogenous vasomotor/vasoconstrictor compensatory mechanisms are impaired in severe shock, blood volume sufficient to maintain the perfusion exists. In moderate shock, the compensatory mechanism is ongoing,

The total blood volume in relation to body weight is determined to be 70 ml/kg in adults, 80 ml/kg in infants, and between 80 and 90 ml/kg in newborns. Transfusion blood or erythrocyte suspension of 10 U or more in volume is defined as a massive blood transfusion, receiving more attention how to determine the required amount. Cancio et al. pointed out the need for identifying logistic requirements during

To measure the efficacy of fluid replacement, it was attempted to measure the diameter of the vena cava by ultrasound before and after the fluid resuscitation. A failure of an increase in the diameter suggested an inadequate treatment [58]. Ferrada et al. examined the inferior vena cava in echocardiography in order to quantify the volume status in severely injured patients. They used this technique to determine pharmacological interventions and monitor the fluid treatment [59].

It is difficult to identify the signs and symptoms of hemorrhagic shock, especially if hemorrhage is originated from occult source. The presence of hypotension is an insensitive marker due to compensatory mechanisms until the blood volume loss reaches up to 30% of the total blood volume. Early posttrauma hypotension is associated with multiple organ failure (MOF) and development of infectious complications [60]. Nonspecific clinical symptoms including anxiety, tachypnea, and weakened peripheral pulses and mottled, pale, and cold extremities can be more indicative for diagnosis of shock. In regard to classification for severity of shock, for a 70-kg male patient in Class I shock, the blood volume loss is less than 750 ml, which accounts for 15% of the total blood volume, and the only clinical symptom may be a mild form of anxiety. Class II hemorrhage involves blood volume loss to 1500 ml, accounting for 30% of total blood volume. Patients look moderately anxious with a narrow pulse around 120 beats per minute. The respiratory rate is increased and reached over 20 breaths per minute. In Class III hemorrhage, blood volume loss is up to 2000 cc, accounting for 40% of total blood volume. The patient has tachycardia with a heart rate up to 140 beats/min, while the blood pressure is reduced. The patient is observed to be severely anxious, and the loss of consciousness may occur. Class IV patients are lethargic with severe hypotension and tachycardia. The respiration rate is over 35/min. Promising technologies, such as portable incident darkfield microscopy allowing for a simultaneous assessment of the compensatory reserve index and the microvascular bed, may help clinicians to promptly diagnose the patients in shock [2, 61, 62]. Potential bleeding source, such as hematemesis or hematochezia, significant vaginal bleeding, or bleeding from an aneurysm of the abdominal aorta should be identified. Bleeding from the extremities can easily be observed after trauma; however, the intensity of bleeding may not be severe in shock states. The body regions including the proximal thigh and retroperitoneal region can accumulate large amounts of blood, and this volume loss can easily be missed unless it is examined during the initial assessments. The intracavitary spaces in the body like the chest, abdomen, and the pelvis should immediately be examined after trauma by

well as considering the role of the I-R and SIR triggered by ischemia [56].

while a mild shock state means only a little blood loss [56].

#### *Hemorrhagic Shock DOI: http://dx.doi.org/10.5772/intechopen.82358*

*Clinical Management of Shock - The Science and Art of Physiological Restoration*

three types of circulatory shock.

and oxygen transfer capacity is essential [51].

who are brought out of the emergency service [52].

cardiac tamponade, can be ruled out [53].

**3.1 Assessment of hemorrhagic shock**

**3. Diagnosis**

Evans et al. have reported a protein, which occurs in the first 20 minutes of serious hemorrhage in the rats, depolarizing several cells in a number of species [45]. Boulanger et al. have confirmed this finding in dogs with serious hemorrhage [46]. Jones et al. noted that this substance reduced both the contractility and velocity in the isolated and perfused rat hearts, reporting that this depolarizing protein was potentially effective in the development of cardiogenic shock [47]. This led to the conclusion that this hypothetical protein should be the similar underlying cause for

The experiments testing this hypothesis and looking for the significant consequences of cell depolarization isolated adenosine as the stimulating factor [48]. It was demonstrated that adenosine enhanced the ATPase activity and provided survival for hours during the experimental hemorrhagic shock in rats. Following these results, the stimulation of the Na/K ATPase pump showed the significance of inhibition in shock states. The

inhibition of the pump should have a critical effect on mortality [49] (**Figure 1**).

The early recognition of hemorrhagic shock and stopping hemorrhage is lifesaving as it takes only 2 hours from its start until death [50]. In order to limit the severity level and duration of shock and to replace mounted oxygen debt, a prompt control of the origin of hemorrhage and the restoration of the intravascular volume

Traumatic injuries are the fourth and are the first reason for deaths under the age of 45 in the United States. About 80% of traumatic injuries are blunt and the majority of the deaths progress as secondary following the hypovolemic shock. Intraperitoneal bleeding occurs in 12% of blunt traumas, and it is essential to be promptly detected. The optimal test should be rapid, accurate, and noninvasive. Diagnostic peritoneal lavage (DPL) was historically conducted in the diagnosis of hemoperitoneum. While DPL is extremely sensitive (96–99%) and specific (98%), it is an invasive procedure with a complication rate more than 1%. However, it is quite confusing to assess hemodynamically unstable patients for whom it is late and

In an emergency situation, ultrasonography can provide guiding insights into a patient's condition or injury pattern and is considered to be a highest priority technological tool that deserves evaluation. The ultrasound protocols used comprised focused assessment with sonography for trauma (FAST), prehospital lung ultrasound (PLUS), and focused echocardiography in emergency life support (FEEL). By combining the standard examination according to the FAST protocol (detection of internal bleeding) with pleural and lung ultrasound (PLUS) and echocardiography (FEEL), important life-threatening conditions, such as pneumothorax and

In irreversible shock, sodium accumulates within the cell due to the inhibition of Na/K ATPase pump. The direction of exchange of sodium and calcium is reversed, and calcium starts accumulating within the cells. Increasing levels of intracellular calcium causes proteolytic enzyme activation leading to degradation of the organelles of cells and at end cell death [54]. This definitely irreversible condition was

The recently introduced physiological or therapeutic classification of hemorrhagic shock is based on basic physiological principles. It takes the fluid-blood replacement

first observed by Holden et al. under the electron microscope [55].

**46**

resistant hypotension and natural hemostatic mechanisms of the body into account as well as considering the role of the I-R and SIR triggered by ischemia [56].

In critical shock conditions, the circulating blood volume is insufficient, and brain and heart internal circulations are merely holding as a result of the systemic vasoconstriction from chemoreceptor and central nervous system receptor stimulation. Although the endogenous vasomotor/vasoconstrictor compensatory mechanisms are impaired in severe shock, blood volume sufficient to maintain the perfusion exists. In moderate shock, the compensatory mechanism is ongoing, while a mild shock state means only a little blood loss [56].

The total blood volume in relation to body weight is determined to be 70 ml/kg in adults, 80 ml/kg in infants, and between 80 and 90 ml/kg in newborns. Transfusion blood or erythrocyte suspension of 10 U or more in volume is defined as a massive blood transfusion, receiving more attention how to determine the required amount. Cancio et al. pointed out the need for identifying logistic requirements during combat to prevent mortality [57].

To measure the efficacy of fluid replacement, it was attempted to measure the diameter of the vena cava by ultrasound before and after the fluid resuscitation. A failure of an increase in the diameter suggested an inadequate treatment [58]. Ferrada et al. examined the inferior vena cava in echocardiography in order to quantify the volume status in severely injured patients. They used this technique to determine pharmacological interventions and monitor the fluid treatment [59].

#### **3.2 Signs and symptoms**

It is difficult to identify the signs and symptoms of hemorrhagic shock, especially if hemorrhage is originated from occult source. The presence of hypotension is an insensitive marker due to compensatory mechanisms until the blood volume loss reaches up to 30% of the total blood volume. Early posttrauma hypotension is associated with multiple organ failure (MOF) and development of infectious complications [60]. Nonspecific clinical symptoms including anxiety, tachypnea, and weakened peripheral pulses and mottled, pale, and cold extremities can be more indicative for diagnosis of shock. In regard to classification for severity of shock, for a 70-kg male patient in Class I shock, the blood volume loss is less than 750 ml, which accounts for 15% of the total blood volume, and the only clinical symptom may be a mild form of anxiety. Class II hemorrhage involves blood volume loss to 1500 ml, accounting for 30% of total blood volume. Patients look moderately anxious with a narrow pulse around 120 beats per minute. The respiratory rate is increased and reached over 20 breaths per minute. In Class III hemorrhage, blood volume loss is up to 2000 cc, accounting for 40% of total blood volume. The patient has tachycardia with a heart rate up to 140 beats/min, while the blood pressure is reduced. The patient is observed to be severely anxious, and the loss of consciousness may occur. Class IV patients are lethargic with severe hypotension and tachycardia. The respiration rate is over 35/min. Promising technologies, such as portable incident darkfield microscopy allowing for a simultaneous assessment of the compensatory reserve index and the microvascular bed, may help clinicians to promptly diagnose the patients in shock [2, 61, 62].

Potential bleeding source, such as hematemesis or hematochezia, significant vaginal bleeding, or bleeding from an aneurysm of the abdominal aorta should be identified. Bleeding from the extremities can easily be observed after trauma; however, the intensity of bleeding may not be severe in shock states. The body regions including the proximal thigh and retroperitoneal region can accumulate large amounts of blood, and this volume loss can easily be missed unless it is examined during the initial assessments. The intracavitary spaces in the body like the chest, abdomen, and the pelvis should immediately be examined after trauma by

radiologic imaging [2]. An immediate examination of these cavities with chest and pelvic radiograms and focused assessment with sonography for trauma (FAST) can help diagnose the potential sites of bleeding [63]. Ultrasound is also used in the diagnostic evaluation of ectopic pregnancies, abdominal aortic aneurysm ruptures, and uterine hemorrhages, which may remain hidden as bleeding foci. Echocardiography is used for assessing cardiac filling and contractility [64] (**Table 1**).

### **3.3 Laboratory measures**

Blood gas analysis and the markers of hypoperfusion may help quantify the base deficit and the lactate levels. The ratio of heart rate to systolic arterial pressure termed as shock index and better predicts massive transfusion compared with traditional vital signs in trauma patients. In a retrospective study including 302 primary postpartum hemorrhage patients, Sohn et al. confirmed that an increased initial shock index is associated with the need for massive transfusion, and also lactate is a better predictor for blood requirements in trauma patients. Also, it is a robust predictor of requirement for massive transfusion in hemodynamically stable shock patients [65].

In a study, Lee et al. lactate has a prognostic role in patients with nonvariceal upper gastrointestinal bleeding higher lactate clearance rate (%/hr) within 24 hours after admission was associated with lower 30-day rebleeding rate. Higher initial, maximal, and average lactate levels within 24 hour after admission were associated with higher 30-day mortality rate and a more frequent admission over 7 days [66].

Hemoglobin and international normalized ratio (INR) values are used to determine the need for a massive blood transfusion in patients with severe hemorrhage [67]. Thrombocyte count and fibrinogen levels should be examined and treated to return to normal levels. Electrolyte levels, especially the levels of calcium and potassium, should be monitored at frequent intervals because fluctuations may occur during resuscitation with blood or blood products [33, 68]. Finally, any presence of coagulopathies should be diagnosed and resuscitation with blood products should be monitored by evaluating the clot-formation kinetics by means of viscoelastic testing such as thromboelastography or rotational thromboelastometry [69]. All these tests allow for determining the severity of shock, the extent to which the blood bank resources will be used, and will identify the type of coagulopathy.

#### **3.4 Radiology**

A computed tomography scan, which is commonly used for diagnostic means, should be immediately performed in critical patients for whom the origin of the


**49**

and coagulopathies [16].

*Hemorrhagic Shock*

and pneumothoraces [52].

**4. Resuscitation**

**4.1 Prehospital care**

*DOI: http://dx.doi.org/10.5772/intechopen.82358*

better diagnostic and treatment outcomes [2].

bleeding cannot be identified once the clinical picture is stable. CT remains the gold standard for diagnosing intra-abdominal injuries detecting as little as 100 cc of intraperitoneal fluid [52]. CT prompt approaches with intraoperative exploration, angiography, embolization, or gastrointestinal endoscopy may help in achieving

Ultrasound has severe benefits on evolution and treatment of trauma patients. Bedside examination, easy way and cheap, never needs contrast and radiation source, reproducibility are advantages of it. In Europe, during the 1970s, the use of ultrasound to detect intraperitoneal fluid was first described. FAST is an ultrasound protocol for assessing hemoperitoneum and hemopericardium. Sensitivity of this protocol is 85–96% and specificity is over 98%. In the subset of hypotensive trauma patients, the sensitivity of the FAST exam approaches 100%. Experienced physicians perform the FAST exam less than 5 minutes, and its use decreases time to surgical intervention, patient length of stay, and rates of CT and DPL. Recently, many institutions have introduced the Extended FAST (eFAST) protocol into their trauma algorithms. The eFAST examines each hemithorax for the presence of hemothoraces

Time is everything. Causa prima: optimization should be performed in cardiogenic shock, and treatment should be aimed at the underlying cause in hemorrhagic and septic shock. Survival of the patients with time-sensitive disorders like myocardial infarction or stroke can be made possible with prehospital arrangements, which should be performed in the patients with severe hemorrhage as well [70]. Minimizing the bleeding and limiting fluid resuscitation with large peripheral vascular access and immediate transfer to a center for ultimate treatment are limited options for prehospital care. Recent findings have demonstrated that when the patient can immediately be transported to the healthcare center for treatment, applying tourniquets to the proximal extremities to the origin of bleeding is lifesaving without leading to dysfunction or amputation of the extremities [71, 72]. Recent guidelines accept application of tourniquets in patients in whom direct compression cannot be performed during the first-aid procedures or during the prehospital interventions [73, 74]. In large injuries or injuries in joints such as groin and axilla, where tourniquets cannot be applied, a group of newly introduced homeostatic dressings have been demonstrated to be of benefit [75]. Canon demonstrated that, in a patient with a penetrating injury in the torso, delaying the intravenous fluid treatment starting from the urban treatment center until admission to the hospital for final treatment contributes to survival probably by preventing the development of dilutional coagulopathy [76]. Bickell et al. compared the outcomes of immediate and delayed fluid therapies in hypotensive patients with penetrating injuries and found out that survival rates at 62 and 70% were higher and serious complication rates from 30 to 23% were lower in delayed fluid treatment. In contrast to the predictions, the delayed fluid treatment was not disadvantageous but timesaving. The principal motivation of the treatment is to ensure a fast recovery in the patient with an acute injury favoring the transport of the patient compared to primary stabilization [77]. A number of experimental studies on animals' standard resuscitation associated with decreased oxygen delivery, increased rates of hemorrhage, reperfusion injuries, organ failures,

Duton et al. challenged the findings reported by Bickel et al. and suggested to limit the fluid therapy maintain systolic blood pressure around 70 mmHg using an

**Table 1.** *Summary of hemorrhage/hemorrhagic shock and treatment modalities.*

#### *Hemorrhagic Shock DOI: http://dx.doi.org/10.5772/intechopen.82358*

*Clinical Management of Shock - The Science and Art of Physiological Restoration*

is used for assessing cardiac filling and contractility [64] (**Table 1**).

**3.3 Laboratory measures**

radiologic imaging [2]. An immediate examination of these cavities with chest and pelvic radiograms and focused assessment with sonography for trauma (FAST) can help diagnose the potential sites of bleeding [63]. Ultrasound is also used in the diagnostic evaluation of ectopic pregnancies, abdominal aortic aneurysm ruptures, and uterine hemorrhages, which may remain hidden as bleeding foci. Echocardiography

Blood gas analysis and the markers of hypoperfusion may help quantify the base deficit and the lactate levels. The ratio of heart rate to systolic arterial pressure termed as shock index and better predicts massive transfusion compared with traditional vital signs in trauma patients. In a retrospective study including 302 primary postpartum hemorrhage patients, Sohn et al. confirmed that an increased initial shock index is associated with the need for massive transfusion, and also lactate is a better predictor for blood requirements in trauma patients. Also, it is a robust predictor of requirement for massive transfusion in hemodynamically stable shock patients [65]. In a study, Lee et al. lactate has a prognostic role in patients with nonvariceal upper gastrointestinal bleeding higher lactate clearance rate (%/hr) within 24 hours after admission was associated with lower 30-day rebleeding rate. Higher initial, maximal, and average lactate levels within 24 hour after admission were associated with higher 30-day mortality rate and a more frequent admission over 7 days [66]. Hemoglobin and international normalized ratio (INR) values are used to determine the need for a massive blood transfusion in patients with severe hemorrhage [67]. Thrombocyte count and fibrinogen levels should be examined and treated to return to normal levels. Electrolyte levels, especially the levels of calcium and potassium, should be monitored at frequent intervals because fluctuations may occur during resuscitation with blood or blood products [33, 68]. Finally, any presence of coagulopathies should be diagnosed and resuscitation with blood products should be monitored by evaluating the clot-formation kinetics by means of viscoelastic testing such as thromboelastography or rotational thromboelastometry [69]. All these tests allow for determining the severity of shock, the extent to which the blood bank resources will be used, and will identify the type of coagulopathy.

A computed tomography scan, which is commonly used for diagnostic means, should be immediately performed in critical patients for whom the origin of the

**48**

**Table 1.**

*Summary of hemorrhage/hemorrhagic shock and treatment modalities.*

**3.4 Radiology**

bleeding cannot be identified once the clinical picture is stable. CT remains the gold standard for diagnosing intra-abdominal injuries detecting as little as 100 cc of intraperitoneal fluid [52]. CT prompt approaches with intraoperative exploration, angiography, embolization, or gastrointestinal endoscopy may help in achieving better diagnostic and treatment outcomes [2].

Ultrasound has severe benefits on evolution and treatment of trauma patients. Bedside examination, easy way and cheap, never needs contrast and radiation source, reproducibility are advantages of it. In Europe, during the 1970s, the use of ultrasound to detect intraperitoneal fluid was first described. FAST is an ultrasound protocol for assessing hemoperitoneum and hemopericardium. Sensitivity of this protocol is 85–96% and specificity is over 98%. In the subset of hypotensive trauma patients, the sensitivity of the FAST exam approaches 100%. Experienced physicians perform the FAST exam less than 5 minutes, and its use decreases time to surgical intervention, patient length of stay, and rates of CT and DPL. Recently, many institutions have introduced the Extended FAST (eFAST) protocol into their trauma algorithms. The eFAST examines each hemithorax for the presence of hemothoraces and pneumothoraces [52].
