Causes

The causes of hemorrhagic shock are traumatic, vascular, GI, or pregnancy related.

Traumatic causes can result from penetrating and blunt trauma. Common traumatic injuries that can result in hemorrhagic shock include the following: myocardial laceration and rupture, major vessel laceration, solid abdominal organ injury, pelvic and femoral fractures, and scalp lacerations. Vascular disorders that can result in significant blood loss include aneurysms, dissections, and arteriovenous malformations. GI disorders that can result in hemorrhagic shock include the following: bleeding esophageal varices, bleeding peptic ulcers, Mallory-Weiss tears, and aortointestinal fistulas. Pregnancy-related disorders include ruptured ectopic pregnancy, placenta previa, and abruption of the placenta. Hypovolemic shock secondary to an ectopic pregnancy is common. Hypovolemic shock secondary to an ectopic pregnancy in a patient with a negative urine pregnancy test is rare but has been reported.

Symptoms of shock, such as weakness, lightheadedness, and confusion, should be assessed in all patients.

If conscious, the patient may be able to indicate the location of pain. Vital signs, prior to arrival in the ED, should also be noted. Chest, abdominal, or back pain may indicate a vascular disorder. The classic sign of a thoracic aneurysm is a tearing pain radiating to the back. Abdominal aortic aneurysms usually result in abdominal, back pain, or flank pain. In patients with GI bleeding, inquiry about hematemesis, melena, alcohol drinking history, excessive nonsteroidal anti-inflammatory drug use, and coagulopathies (iatrogenic or otherwise) is very important.

The chronology of vomiting and hematemesis should be determined. The patient who presents with hematemesis after multiple episodes of forceful vomiting is more likely to have Boerhaave syndrome or a Mallory-Weiss tear, whereas a patient with a history of hematemesis from the start is more likely to have peptic ulcer disease or esophageal varices.