Part2.

Approach to the assessment and management of hypovolemic/trauma shock as compared to

septic shock. How the differences are evolving.

Dr Kinkunba Michel Makia

JANUARY 21, 2024

 Part2. Approach to the assessment and management of hypovolemic/trauma shock as compared to septic shock. How the

References
 Part2. Approach to the assessment and management of hypovolemic/trauma shock as compared to septic shock. How the

Introduction.
The hypovolemic/trauma shock and the septic shock are both global health problems and
both are life-threatening and time-dependent conditions that require timely management to
reduce mortality. The assessment and management of both conditions have evolved over
the years and improving knowledge of these challenging conditions is crucial to achieve
better patient outcomes.

1.Hypovolemic/trauma shock
Assessment:
The rapid assessment of the patient to determine the cause and severity of hypovolemia as
well as addressing the underlying cause of such significant blood loss due to trauma is part
of the initial assessment.
The physical examination considering the ABCDE (airway, breathing, circulation), the vital
signs, bedside arterial blood gas, and laboratory test will help determine the severity of the
fluid loss.
Administering intravenous fluids for volume resuscitation and closely monitoring vital signs
and perfusion parameters using noninvasive hemodynamic monitoring such as point-of-care
echo sonography when needed.
Management
The goals of fluid resuscitation include controlling the bleeding, restoring the loss of blood
volume, and regaining tissue perfusion and organ function.
- Fluid administration is beneficial only if it increases the stroke volume (SV) and
thereby the cardiac output. Patients are considered fluid responsive if the stroke
volume increases by at least 10% after a fluid challenge of 500 ml of crystalloid
(Marik PE. Fluid Responsiveness and the Six Guidelines Principles of Fluid
Resuscitation, Crit. Care Med.2016:1920-2.
- International guidelines recommend restrictive volume replacement to achieve
target blood pressure until bleeding is controlled (Rossaint R, Bouillon B. The
European guideline on management of major bleeding and coagulopathy following
trauma: fourth edition. Crit Care, 2016).
- Blood products, like packed red blood cells, consider the different target systolic
blood pressure (SBP) values: 60-70 mmHg for blunt penetrating trauma, 80-90 mmHg
for blunt trauma, and 100-110 mmHg for blunt traumatic brain.
- Control of bleeding through surgical intervention and the use of Tranexamic acid
(TXA).
- In patients with life-threatening hypotension, both vasopressors and fluids should be
given to maintain target arterial pressure (Rossain R, Bouillon B. Crit Care,2016).
 Part2. Approach to the assessment and management of hypovolemic/trauma shock as compared to septic shock. How the

2. Septic shock
Assessment:
- Thorough history taking and physical examination identifying the clinical signs and
symptoms of septic shock like tachycardia, bounding peripheral pulses, fast capillary
refill, widening pulse pressure, mottles cool extremities, and decreased urinary
output.
- Laboratory results including serum lactatemia, and blood cultures to identify the
infectious agent.
- An electrocardiogram should be obtained to show evidence of acute coronary
syndrome, arrhythmia, or pulmonary embolism.
- Bedside point of care or focused cardiac ultrasound is also a useful tool for diagnosis.
Management:
- Following the ABCDE (Airway, Breathing, Circulation, Exposure) approach the initial
approach to management should be the stabilization of the airway and breathing
with oxygen and oral mechanical ventilation when needed: oxygen therapy should be
started at 15L/min via a reservoir mask and titrated to aim SPO2 94-98% or SPO2 88-
92% in obese patient or if the patient is at of hypercapnic respiratory failure. If
mechanical ventilation is indicated the tidal volume should be reduced from 10 to 6
ml/kg(O’Driscoll B.R, Howard. L.S. British Thoracic Guideline for Oxygen Use in
Adults, 2017).
- Early empirical antimicrobial therapy based on local epidemiology.
- Immediate treatment with intravenous fluid crystalloid replacement is to be
established according to fluid tolerance and fluid responsiveness: small boluses of
fluids at 2-hour intervals. Balanced crystalloids are preferable because they have an
electrolytic composition close to plasma (Evans L, Rhodes A. Shock 2021. Intensive
care Med.2021PubMed.
- Vasoactive agents: to counteract the loss of vasomotor tone with consequent
vasodilatation and hypotension (Vincent J.L, De Backer D. Circulatory Shock.
PubMed)
- Heparin (Low molecular weight heparin) is administered to prevent venous
thromboembolism (VTE)(Iba T, Levi M, Levy J.H. Sepsis-Induced Coagulopathy and
Disseminated Intravascular Coagulopathy.2020 PubMed.
3. How differences in Care are evolving.
1.Hypovolemic/trauma shock:
- Prehospital trauma care reduces mortality in all settings thus the need to revise prehospital
trauma guidelines.
- There’s a call to empower paramedics to use tranexamic acid (TXA).
 Part2. Approach to the assessment and management of hypovolemic/trauma shock as compared to septic shock. How the

- More and more calls that all trauma hypovolemic patients should be given blood or blood
products.
- Bedside-focused ultrasound is a useful diagnostic tool.

2. Septic shock
- Early recognition of the disease and early management of sepsis and septic shock will
reduce mortality.
- Management of sepsis and septic shock is guided by the Sepsis Six Campaign protocols.
- The use of echocardiography and point-of-care ultrasound is more and more
recommended to assess cardiac load and cardiac response to fluid administration

Conclusion: These two life-threatening conditions both need timely diagnosis and treatment.
Adhering to evidence-based clinical practice guidelines as well as new technology will
improve patient outcomes and reduce mortality.
Part2. Approach to the assessment and management of hypovolemic/trauma shock as compared to septic shock. How the
Part2. Approach to the assessment and management of hypovolemic/trauma shock as compared to septic shock. How the