About the guide

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Published December 2023. Next review: 2028

Critical bleeding is responsible for over 40% of trauma deaths within the first 24 hours.1

This guide is intended for all healthcare workers who provide clinical care to patients in traumatic haemorrhagic shock. It is particularly designed for clinicians working in regional or rural settings and/or clinicians who do not regularly manage trauma patients.

There are five sections in this resource.

  1. Prepare for the bleeding patient
  2. Assess and locate the bleeding
  3. Stop the bleed
  4. Resuscitate and restore blood volume and function
  5. Transfer to definitive care

These sections are not necessarily linear and can be used concurrently, i.e. restoring blood volume while finding the source of bleeding and arranging transfer to definitive care. This guide provides succinct and practical information in real-time and at the point of care. It also provides more detailed information by linking to other resources, such as guidelines and systematic reviews.

Section structure

Sections 2, 3 and 4 are divided into three sub-sections:

  • Basic measures - essential first steps in managing haemorrhagic shock
  • Advanced measures – high level interventions, requiring specialist skills and/or a specialist centre
  • Special considerations - areas for greater awareness, e.g. specialist patient groups, differential diagnosis, etc.

Definition of haemorrhagic shock and critical bleeding

Haemorrhagic shock occurs when critical bleeding results in organ hypoperfusion and cellular hypoxia.2 Critical bleeding is defined as major bleeding that is deemed by treating clinicians to meet any of theses criteria:3

  • Life threatening and likely to require urgent and rapid transfusion of blood products.3
  • Associated with persistent haemodynamic instability refractory to initial management.4
  • Ongoing and uncontrolled, requiring definitive haemorrhage control management.4

Other forms of shock resulting from trauma can have a similar clinical presentation, especially neurogenic shock. As the treatment of the various causes are different, careful assessment is imperative. Sometimes multiple lines of treatment are necessary.

Method

The guide is based on clinician expertise and high-level evidence. This guide replaces the NSW Institute of Trauma and Injury Management (ITIM) Hypovolemic shock guideline.

Two search methods were used in gaining information for this document: grey literature search and a database search.

Grey literature search

Google was searched using key terms such as trauma guidelines, haemorrhagic shock guidelines, on 10 October 2022. Only the first three pages (or top 20 hits) of the search results were screened. Other resources were added by other contributors from the trauma innovation committee and ITIM.

Database search

A PubMed search was conducted using terms related to haemorrhagic shock, haemorrhagic shock / guideline/s on 10 November 2022. Filters were added with a time range of 2015 –2022 and in English. 497 results were found. Further resources were added by other contributors from the trauma innovation committee and ITIM.

References

  1. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. Journal of Trauma and Acute Care Surgery. 2006;60(6):S3-S11.
  2. Cannon JW. Hemorrhagic shock. New England Journal of Medicine. 2018;378(4):370-9.
  3. Authority NB. Patient Blood Management Guidelines. Module 4, Critical Care: National Blood Authority; 2012.
  4. ITIM. Trauma ‘Code Crimson’ Pathway. ACI: NSW State Government; 2017 2017. Report No.: SHPN (ACI) 170038, ISBN 978-1-76000-595-5.
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