The management of traumatic haemorrhagic shock: quick reference guide is an education tool and a practical guide for clinicians during the resuscitation of a patient with traumatic haemorrhagic shock.
This quick reference guide is not intended to replace senior clinical decision-making. Any concerns should be escalated early through your local trauma network. It does not represent a systematic review of evidence, however, provides links to various established clinical resources and high-level evidence where relevant.
Not all content mentioned in this resource is necessarily within a clinician’s scope of practice.
All clinicians should work within their scope of practice.
1. Prepare
Goal: Be as prepared as possible before receiving the patient.
Prepare
Don’t delay, call for help early!
- Alert senior and specialist staff of an incoming patient using ISBAR.
- Consider systems alert and/or activation.
Use a structured approach, such as Zero point survey.
- Prepare self. Conduct a rapid physical readiness assessment using I’M SAFE checklist , take action and mentally prepare .
- Optimise your environment .
- Check equipment for patient resuscitation.
- Brief team and delegate roles and responsibilities.
- Apply personal protective equipment (PPE) .
2. Assess and locate the bleed
Goal: Rapid identification of haemorrhagic shock and source of bleeding.
Basic measures
- Follow a CABC approach .
- Once the source of bleeding has been identified the priority is to stop the bleeding.
- Apply continuous monitoring and provide oxygen via non‑rebreather mask.
- Conduct a specific physical examination in patients with potential haemorrhagic shock .
- Look for abnormal vital signs .
- Use pulse pressure and shock index calculators to determine shock severity.
- Consider classes of haemorrhagic shock .
- Perform required x-ray imaging as clinically indicated.
- Take blood tests in resuscitation.
Advanced measures (requires specialist skills and knowledge)
- eFAST Ultrasound .
- Consider a CT scan and when to do it .
Special considerations
- Search and rule out other causes of shock .
- Values indicative of critical physiologic derangement .
- Minimise patient movement .
3. Stop the bleed
Goal: Stop compressible bleeding as early as possible. Transfer to definitive care for non-compressible bleeding without delay.
Basic measures
Uncontrolled and non-compressible bleeding requires urgent transfer to definitive care .
- Apply direct pressure and/or elevate external bleeding.10
- Apply tourniquet for life-threatening limb bleeding.
- Apply haemostatic gauze and pressure bandages.
- Pack wound .
- Suture, clamp, or staple wound (e.g. scalp wounds).
- Apply pelvic binder. See Ambulance NSW immobilisation procedure.
- Splint limbs with long bone fractures.
- Consider reversing anticoagulant .
- Administer tranexamic acid (TXA) if < 3 hours of injury .
- For pregnant patients, consider positioning left lateral 30 degree tilt .
Advanced measures (requires specialist skills and knowledge)
- For bleeding in junctional zones consider using a Foley balloon catheter .
- For maxillo-facial haemorrhage consider epistaxis balloon
- Insert chest drain if indicated . Massive and uncontrolled haemothorax is likely to require a trauma or general surgeon and/or cardiothoracic intervention. Consult your major trauma service early.
- Consider resuscitative thoracotomy if indicated.
Special considerations
Wind
Secure
Time
4. Resuscitate
Goal: Replace blood loss with blood to sustain life until bleeding is stopped. Continue to support patient's physiology.
Basic measures
- Establish vascular access .
- Consider permissive hypotension and minimal volume resuscitation target systolic blood pressure (SBP) .
- Administer intravenous fluids, fresh frozen plasma (FFP) and packed red blood cells are preferable. Limit use of crystalloids .
- Replace calcium
- Prevent hypothermia .
- Measure vital parameters early and frequently .
- Physiological targets to aim for .
Advanced measures (requires specialist skills and knowledge)
- Consider trigger to activate major haemorrhage protocol . Aim for a balanced ratio .
- For centres with limited range of blood supply or nothing, contact the Aeromedical Control Centre.
- Consider 1 pool adult therapeutic platelets if on antiplatelets.
- Consider central vascular access (CVC).
Watch CVC videos
Special considerations
- Consider drug dose adjustments .
- Discuss ceilings of care .
- Communicate well to all teams involved in care.
- Notify transfusion laboratory as soon as possible if bleeding is controlled or blood no longer required.
- Cardiopulmonary resuscitation (CPR) in traumatic cardiac arrest.
5. Transfer to definitive care
Goal: Transfer patient to where bleeding can be stopped in a timely manner.
Non-trauma hospital
Is interhospital transfer required?
- Call Aeromedical Control Centre early 1800 650 004 or your regional retrieval service or critical care advisory service.
- For children under 16 years old call Neonatal and Paediatric Emergency Transport Service (NETS) 1300 362 500.
- If persistently unstable due to ongoing and uncontrolled bleeding, consider damage control surgery prior to transfer where feasible. This should be discussed with critical care supporting services (Aeromedical Control Centre, Critical Care Advisory Service or your regional retrieval service).
- Plan and continue to resuscitate during transfer.
- Use Checklist for retrieval.
Trauma hospital
Consider code crimson , if the patient is:
- persistently haemodynamically unstable despite standard trauma care
- assessed as being secondary to ongoing haemorrhage in blunt or penetrating trauma, and
- is unresponsive to intravenous fluids and/or blood transfusion.
See code crimson pathway.
References
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- National Blood Authority. Patient blood management guidelines: Module 4 critical care. National Blood Authority; 2023 [cited 19 Jan 2024].
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