Hemorrhagic Shock Identified
Signs of hemorrhagic shock in trauma patient
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Trauma SurgeryEmergency
Hemorrhagic Shock & Damage Control Resuscitation
Hemorrhagic Shock & Damage Control Resuscitation: Hemorrhagic Shock Identified → Classify Shock Severity → Class I-II: Crystalloid Trial → Damage Contro...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Decision Classify Shock Severity
Assess hemorrhage class
- Class I: <15% blood loss, HR normal, BP normal
- Class II: 15-30%, HR 100-120, BP normal, RR 20-30
- Class III: 30-40%, HR 120-140, BP decreased, confused
- Class IV: >40%, HR >140, BP very low, lethargic
03Action Class I-II: Crystalloid Trial
Initial fluid resuscitation
- 1-2L warm crystalloid (LR preferred)
- Reassess response
- Type and screen blood
- Monitor for progression
04Action Damage Control Resuscitation
Core DCR principles
- PERMISSIVE HYPOTENSION: SBP 80-90 mmHg until surgical control
- HEMOSTATIC RESUSCITATION: 1:1:1 ratio (or whole blood)
- Limit crystalloid (<2L total)
- Avoid hypothermia and acidosis
- Target: Lethal triad prevention
05Action Tranexamic Acid (TXA)
Give within 3 hours of injury
- 1g IV bolus over 10 minutes
- Then 1g IV infusion over 8 hours
- Most benefit if given <1 hour
- Do NOT give if >3 hours from injury
06Action Prevent Lethal Triad
Target hypothermia, acidosis, coagulopathy
- HYPOTHERMIA: Warm fluids, forced-air warming, target >36°C
- ACIDOSIS: Treat with perfusion, avoid excessive crystalloid
- COAGULOPATHY: Balanced blood products, calcium replacement
- Calcium chloride 1g IV per 4 units blood (counter citrate)
07Decision TEG/ROTEM Available?
Goal-directed coagulation management
08Action TEG/ROTEM-Guided Therapy
Targeted product replacement
- Prolonged R/CT (clot initiation): Give FFP
- Low α-angle/K (fibrinogen): Give cryoprecipitate (10 units)
- Low MA/MCF (platelet function): Give platelets
- Fibrinolysis (LY30 >3%): Consider additional TXA
09Decision Hemorrhage Controlled?
Surgical or procedural hemostasis achieved
10Warning Continue DCR → OR/IR
Hemorrhage not controlled
- Emergent surgical intervention
- Consider IR angioembolization
- REBOA for non-compressible torso hemorrhage
- Damage control surgery (pack and return)
- Path rejoins step 09Shared downstream outcome
11Action Post-DCR Management
Transition to definitive care
- Deactivate MTP when hemorrhage controlled
- Warm patient to normothermia
- Correct residual coagulopathy
- Monitor for abdominal compartment syndrome
- Plan for definitive surgery (24-48h)
12Outcome Hemorrhage Controlled, Resuscitation Complete
Patient stabilized for ICU care
13Action Empiric Lab-Guided
Without viscoelastic testing
- Check CBC, PT/INR, PTT, fibrinogen q30-60min
- Continue 1:1:1 ratio empirically
- Target: Plt >50K, INR <1.5, Fib >1.5 g/L
- Consider cryoprecipitate if fibrinogen <1.5
- Path rejoins step 09Shared downstream outcome
14Action Blood Product Administration
Balanced resuscitation
- Whole blood if available (preferred)
- Or 1:1:1 ratio RBC:FFP:Platelets
- Use rapid infuser/blood warmer
- Target: Hgb >7, Plt >50K, INR <1.5
- Fibrinogen >1.5 g/L
- Path rejoins step 06Shared downstream outcome
15Warning Class III-IV: Activate MTP
Severe hemorrhage - immediate MTP
- Activate massive transfusion protocol
- Call blood bank immediately
- Notify OR/trauma surgery
- Type O blood if uncrossmatched needed
- Path rejoins step 04Shared downstream outcome
Guideline Source
WTA Critical Decisions: Damage Control Resuscitation 2025
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Blood product availability varies by institution
- TEG/ROTEM availability varies
- Does not replace surgical hemorrhage control
- Specific product ratios may vary by protocol
Applicable Regions
USEUGlobal
EU: Component therapy ratios may vary
US: Whole blood increasingly available at level 1 trauma centers
Version 1Next review: 2028-01-01
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Related Resources
Frequently Asked Questions
What is the Hemorrhagic Shock & Damage Control Resuscitation?
The Hemorrhagic Shock & Damage Control Resuscitation is a emergency clinical algorithm for Trauma Surgery. It provides a structured decision tree to guide clinical decision-making, based on WTA Critical Decisions: Damage Control Resuscitation 2025.
What guideline is the Hemorrhagic Shock & Damage Control Resuscitation based on?
This algorithm is based on WTA Critical Decisions: Damage Control Resuscitation 2025 (DOI: 10.1097/TA.0000000000004088).
What are the limitations of the Hemorrhagic Shock & Damage Control Resuscitation?
Known limitations include: Blood product availability varies by institution; TEG/ROTEM availability varies; Does not replace surgical hemorrhage control; Specific product ratios may vary by protocol. Individual patient factors may require deviation from these recommendations.
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