Bleeding & Volume Loss: Hypovolemic Shock

• With hemorrhage, controlled or uncontrolled, stop the bleeding FIRST (pressure, tourniquet, surgery, IR); fluids only buy time.
• Trauma resuscitation runs on blood products (1:1:1 plasma:platelets:RBC), minimizing crystalloids, with permissive hypotension until surgical control (except TBI).
• For non-hemorrhagic losses (GI, burns, DKA) give balanced crystalloid 20–30 mL/kg, reassessing after every bolus.
• Resuscitation endpoints: MAP ≥65, urine ≥0.5 mL/kg/h, clearing lactate, improving base deficit.
• TXA 1 g within 3 h of injury saves lives — but given >3 h after injury it may increase mortality, so never give it late. Penetrating torso trauma may warrant a slightly higher pressure target (SBP 90–100) than blunt trauma.

Managing Hypovolemic Shock

• Shock picture: SBP <90 mm Hg · MAP <65 mm Hg · lactate ≥4 mmol/L — act on all fronts simultaneously
• Control the bleeding source: compress visible vascular injury; meticulous exposure and control of internal bleeding vessel/tissue injury; esophageal banding or tamponade for rapid variceal bleeding
• For rapid fluid/blood product delivery, establish vascular access: 8.5-French central vein catheter or two 14-gauge peripheral catheters
• Bleeding source controlled?
• Keep up IV fluid resuscitation
• Keep up IV fluid resuscitation and consider alternative bleeding control (vascular embolization)
• Hemorrhagic shock (bleeding trauma, GI bleed, ruptured aneurysm) vs non-hemorrhagic losses (GI losses, burns, DKA)?
• Balanced blood-product transfusion 1:1:1 plasma:platelets:RBC · minimize crystalloids · correct coagulopathy
• TXA 1 g if within 3 h of trauma · permissive hypotension (SBP 80–90 mm Hg) until surgical/IR control — EXCEPT TBI: hold SBP ≥100 mm Hg
• Dynamic fluid responsiveness (passive leg raise, pulse pressure variation), not CVP, guides balanced crystalloid 20–30 mL/kg — reassess after each bolus
• After bleeding control: restrictive RBC threshold Hgb 7 g/dL (8 g/dL in cardiac disease)
• Endpoints achieved: urine ≥0.5 mL/kg/h · MAP ≥65 mm Hg · capillary refill · lactate clearance?
• Resuscitation complete
• Volume restored but MAP <65 mm Hg → norepinephrine
• Track fluid responsiveness via pulse pressure variability, IVC distension index, or stroke volume index during fluid challenges to avoid excess crystalloid