Hemorrhagic Shock & Damage Control Resuscitation

Algorithm Steps

1. ▶

   Start

   Hemorrhagic Shock Identified

   Signs of hemorrhagic shock in trauma patient

   1. ◆

      Decision

      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
      1. ●

         Action

         Class I-II: Crystalloid Trial

         Initial fluid resuscitation

         • 1-2L warm crystalloid (LR preferred)
         • Reassess response
         • Type and screen blood
         • Monitor for progression
         1. ●

            Action

            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
            1. ●

               Action

               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
               1. ●

                  Action

                  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)
                  1. ◆

                     Decision

                     TEG/ROTEM Available?

                     Goal-directed coagulation management

                     1. ●

                        Action

                        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
                        1. ◆

                           Decision

                           Hemorrhage Controlled?

                           Surgical or procedural hemostasis achieved

                           1. ⚠

                              Warning

                              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)
                           2. ●

                              Action

                              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)
                              1. ✓

                                 Outcome

                                 Hemorrhage Controlled, Resuscitation Complete

                                 Patient stabilized for ICU care

                     2. ●

                        Action

                        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
            2. ●

               Action

               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
      2. ⚠

         Warning

         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