No. 115-Hemorrhagic Shock



      To review the clinical aspects of hemorrhagic shock and provide recommendations for therapy.


      Early recognition of hemorrhagic shock and prompt systematic intervention will help avoid poor outcomes.


      Establish guidelines to assist in early recognition of hemorrhagic shock and to conduct resuscitation in an organized and evidence-based manner.


      Medline references were sought using the MeSH term “hemorrhagic shock.” All articles published in the disciplines of obstetrics and gynaecology, surgery, trauma, critical care, anesthesia, pharmacology, and hemotology between 1 January 1990 and 31 August 2000 were reviewed, as well as core textbooks from these fields. Selected references from these articles and book chapters were also obtained and reviewed. The level of evidence has been determined using the criteria described by the Canadian Task Force on Preventive Health Care.


      These guidelines have been reviewed by the Clinical Practice Obstetrics Committee and approved by Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.


      The Society of Obstetricians and Gynaecologists of Canada.


      • 1
        Clinicians should be familiar with the clinical signs of hemorrhagic shock (III-B).
      • 2
        Clinicians should be familiar with the stages of hemorrhagic shock (III-B).
      • 3
        Clinicians should assess each woman's risk for hemorrhagic shock and prepare for the procedure accordingly (III-B).
      • 4
        Resuscitation from hemorrhagic shock should include adequate oxygenation (II-3A).
      • 5
        Resuscitation from hemorrhagic shock should include restoration of circulating volume by placement of two large­bore IVs, and rapid infusion of a balanced crystalloid solution (I-A).
      • 6
        Isotonic crystalloid or colloid solutions can be used for volume replacement in hemorrhagic shock (I-B). There is no place for hypotonic dextrose solutions in the management of hemorrhagic shock (I-E).
      • 7
        Blood component transfusion is indicated when deficiencies have been documented by clinical assessment or hematological investigations (II-2B).They should be warmed and infused through filtered lines with normal saline, free of additives and drugs (II-3B).
      • 8
        Vasoactive agents are rarely indicated in the management of hemorrhagic shock and should be considered only when volume replacement is complete, hemorrhage is arrested, and hypotension continues. They should be administered in a critical care setting with the assistance of a multidisciplinary team (III-B).
      • 9
        Appropriate resuscitation requires ongoing evaluation of response to therapy, including clinical evaluation, and hematological, biochemical, and metabolic assessments (III-B).
      • 10
        In hemorrhagic shock, prompt recognition and arrest of the source of hemorrhage, while implementing resuscitative measures, is recommended (III-B).
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Obstetrics and Gynaecology Canada
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Smith HO
        Shock in the gynecologic patient.
        (editors)in: Rock JA Thomson JD Te Linde's operative gynecology. 8th ed. Lippincott-Raven, 1997: 245-261
        • Woolf SH
        • Battista RN
        • Angerson GM
        • et al.
        Canadian Task Force on the Periodic Health Exam.
        Canada Communication Group, Ottawa1994: xxxvii
        • SOGC Clinical Practice Guidelines
        Prevention and management of postpartum hemorrhage.
        J Soc Obstet Gynaecol Can. 2000; 22: 271-281
        • Barber A
        • Shires GT
        (editor)in: Schwartz SI Principles of surgery. 7th ed. McGraw-Hill, 1999: l01-l22
        • Falk JL
        • O'Brien JF
        • Kerr R
        Fluid resuscitation in traumatic hemorrhagic shock.
        Crit Care Clin. 1992; 8: 323-340
        • Shires GT
        • Barber AE
        • Illner HP
        Current status of resuscitation: solutions including hypertonic saline.
        Adv Surg. 1995; 28: 133-170
        • Demsky MF
        • Wilson RF
        Hemodynamic resuscitation.
        Crit Care Clin. 1993; 10: 715-726
        • Croce MA
        • Fabian TC
        • Davis KA
        • Gavin TJ
        Early and late acute respiratory distress syndrome: two distinct clinical entities.
        J Trauma. 1999; 46: 361-368
        • Ludwig KA
        • Quebbeman EJ
        • Bergstein JM
        • et al.
        Shock-associated right colon ischemia and necrosis.
        J Trauma. 1995; 39: 1171-1174
        • Kale IT
        • Kuzu MA
        • Berkem H
        • et al.
        The presence of hemorrhagic shock increases the rate of bacterial translocation in blunt abdominal trauma.
        J Trauma. 1998; 44: 171-174
        • Marzi I.
        Hemorrhagic shock: update in pathophysiology and therapy.
        Acta Anaesthesiol Scand Suppl. 1997; 111: 42-44
        • Heckbert SR
        • Vedder NB
        • Hoffman W
        • et al.
        Outcome after hemorrhagic shock in trauma patients.
        J Trauma. 1998; 45: 545-549
        • Seekamp A
        • Jochum M
        • Ziegler M
        • et al.
        Cytokines and adhesion molecules in elective and accidental traumarelated ischemia/reperfusion.
        J Trauma. 1998; 44: 874-882
        • ACOG Educational Bulletin
        Hemorrhagic shock. Number 235. April 1997 (replaces no. 82, December 1984). American College of Obstetricians and Gynecologists.
        Int J Gynaecol Obstet. 1997; 57: 219-226
        • Shoemaker WC
        • Peitzman AB
        • Bellamy R
        • et al.
        Resuscitation from severe hemorrhage.
        Crit Care Med. 1996; 24: S12-S23
        • The American College of Surgeons
        In: The American College of Surgeons, editor. Advanced trauma life support. 1990: 59-73 (editorAdvanced trauma life support)
        • Thompson JD
        • Rock WA
        Control of pelvic hemorrhage.
        (editors)in: Rock JA Thomson JD Te Linde's operative gynecology. 8th ed. Lippincott-Raven Publishers, 1997: 197-232
        • Rebarber A
        • Lonser R
        • Jackson S
        • et al.
        The safety of intraoperative autologous blood collection and autotransfusion during Cesarean section.
        Am J Obstet Gynecol. 1998; 179: 715-720
        • Culkin Mann M
        • Votto J
        • Kambe J
        • et al.
        Management of the severely anemic patient who refuses transfusion: lessons learned during the care of a Jehovah's Witness.
        Ann Intern Med. 1992; 117: 1042-1048
        • Gould SA
        • Sehgal LR
        • Sehgal HL
        • et al.
        Hypovolemic shock.
        Crit Care Clin. 1993; 9: 239-259
        • Lucas CE
        Update on trauma care in Canada. 4. Resuscitation through the three phases of hemorrhagic shock after trauma.
        Can J Surg. 1990; 33: 451-456
        • Davies MJ.
        Crystalloid or colloid: does it matter?.
        J Clin Anesth. 1989; 1: 464-471
        • Dubick MA
        • Wade CE
        A review of the efficacy and safety of 7.5% NaCI/6% dextran 70 in experimental animals and in humans.
        J Trauma. 1994; 36: 323-330
        • Vassar MJ
        • Perry CA
        • Holcroft JW
        Prehospital resuscitation of hypotensive trauma patients with 7.5% NaCI versus 7.5% NaCI with added dextran: a controlled trial.
        J Trauma. 1993; 34: 622-632
        • Deakin CD
        Early fluid resuscitation in haemorrhagic shock.
        Eur J Emerg Med. 1994; 1: 83-85
        • Sillett HK
        • Whicher JT
        • Trejdosiewicz LK
        Effects of resuscitation fluids on nonadaptive immune responses.
        Transfusion. 1997; 37: 953-959
        • Napolitano LM.
        Resuscitation following trauma and hemorrhagic shock: is hydroxyethyl starch safe? [editorial; comment].
        Crit Care Med. 1995; 23: 795-797
        • Poole GV
        • Meredith JW
        • Pennell T
        • et al.
        Comparison of colloids and crystalloids in resuscitation from hemorrhagic shock.
        Surg Gynecol Obstet. 1982; 154: 577-586
        • Bunn F
        • Lefebvre C
        • Li-Wan-Po A
        • et al.
        Human albumin solution for resuscitation and volume expansion in critically ill patients.
        Cochrane Database Syst Rev. 2000; 2CD001208
      1. Guidelines for red blood cell and plasma transfusion for adults and children.
        Can Med Assoc J. 1997; 156: S1-S54
        • Schwartz SI
        Hemostasis, surgical bleeding and transfusion.
        (editor)in: Schwartz SI Principles of surgery. 7th ed. McGraw-Hill, 1999: 77-100
        • Hocker P
        • Hartmann T
        Management of massive transfusion.
        Acta Anaesthesiol Scand Suppl. 1997; 111: 205-207
        • Harrigan C
        • Lucas CE
        • Ledgerwood AM
        The effect of hemorrhagic shock on the clotting cascade in injured patients.
        J Trauma. 1989; 29: 1416-1421
        • Martin DJ
        • Lucas CE
        • Ledgerwood AM
        • et al.
        Fresh frozen plasma supplement to massive red blood cell transfusion.
        Ann Surg. 1985; 202: 505-511
        • ACOG technical bulletin
        Blood component therapy. Number 199- November 1994 (replaces no. 78, July 1984). Committee on Technical Bulletins of the American College of Obstetricians and Gynecologists.
        Int J Gynaecol Obstet. 1995; 48: 233-238
        • Ogden JE
        • Parry ES
        The development of hemoglobin solutions as red cell substitutes.
        Int Anesthesiol Clin. 1995; 33: 115-129
        • Rabinovici R
        • Neville LF
        • Rudolph AS
        • et al.
        Hemoglobin-based oxygen-carrying resuscitation fluids [editorial; comment].
        Crit Care Med. 1995; 23: 801-804
        • Assalia A
        • Schein M
        Resuscitation for haemorrhagic shock.
        Br J Surg. 1993; 80: 213
        • Bickell WH
        Are victims of injury sometimes victimized by attempts at fluid resuscitation? [editorial; comment].
        Ann Emerg Med. 1993; 22: 225-226
        • Dries DJ
        Hypotensive resuscitation.
        Shock. 1996; 6: 311-316