5-16 HEMORRHAGIC SHOCK

Purpose:

·       To provide treatment for patients who are displaying the signs and symptoms of shock suspected to be attributed to hemorrhage from causes such as trauma and severe postpartum hemorrhage.

Notes:

·       Any patient requiring ACLS care should have an ALS intercept if logistically possible.

EMR/EMT - Emergency Medical Responder

1. Follow *Initial Trauma Care Protocol, *Medical Hypotension/Shock Protocol, and *Obstetrical Emergencies & Childbirth Protocol when applicable.
2. Transport according to protocol. No intervention should delay transport.
3. Administer oxygen if indicated.
4. Assist ventilations if RR < 8/min or > 35/min.
5. Call for ALS intercept

EMT- Emergency Medical Technician perform/confirm all above interventions

1. Ensure ALS intercept is en route.
2. Transport as early as possible
3. Reassess VS & lung sounds often during transport

AEMT – Advanced Emergency Medicine Tech / Intermediate Perform/Confirm All Above Interventions

1. Initiate IV (Do not delay transport).
2. If there are signs of hypotension, administer NS or LR IV/IO fluid bolus IV/IO
   1. Adults ( ≥14 years of age): up to 1 liter
   2. Pediatrics (<14 years of age): up to 20 mL/kg
3. Consider other causes of traumatic hypotension and treat accordingly (such as tension pneumothorax, see protocol).
4. Hypotensive patients should receive additional IV/IO fluid boluses as indicated by hemodynamic state.
   1. Adults (≥14 years of age): repeat IV/IO fluid bolus to a maximum of 2 liters.
   2. Pediatrics (<14 years of age): repeat dose of 20 mL/kg to a maximum of 40 mL/kg.
   3. Monitor for pulmonary edema.
   4. If pulmonary edema presents, stop fluids and contact Medical Control for direction.
5. Report Lung Sounds.

Paramedic   perform/confirm all above interventions

1. Attach cardiac monitor if not already done.
2. If bleeding is uncontrolled and non-compressible, administer Tranexamic Acid (TXA) if injury or insult leading to hemorrhage has been less than 3 hours.
   1. Trauma-related: Draw up and mix 2 grams of TXA into a 100 mL bag of normal saline solution or D5 solution.
   2. Non-trauma related: Draw up and mix 1 gram of TXA into a 100 mL bag of normal saline solution or D5 solution.
   3. Administer mixed medication into IV/IO line over 10 minutes.
   4. Hospital Notification and Documentation
      1. Contact Medical Control - the receiving hospital must be verbally notified that TXA has been given prior to arrival
      2. A verbal report that TXA was administered must be provided to hospital ED staff (receiving physician preferred) upon hand-off of the patient from EMS.
      3. The administration of TXA MUST be clearly documented on the EMS patient care record.
   5. Contact Medical Control-Medical Control may order TXA for selected patients with suspected compensated shock not meeting the above criteria.
3. Special Dosing Considerations:
   1. Pediatric:

15 mg/kg (Max 1g) IV/IO

Weight		Dosage
GRAY	3-5 kg	75 mg
PINK	6-7 kg	100 mg
RED	8-9 kg	130 mg
PURPLE	10-11 kg	150 mg
YELLOW	12-14 kg	200 mg
WHITE	15-18 kg	250 mg
BLUE	19-23 kg	300 mg
ORANGE	24-29 kg	400 mg
GREEN	30-36 kg	500 mg
40 kg		600 mg
50 kg		750 mg
60 kg		900 mg
70 kg +		1000 mg

1. NEBULIZED Route:
   1. 500 mg if >25 kg
   2. 250 mg if <25 kg; mix with 2.5 ml of normal saline to get total of 5 ml
2. TOPICAL Route:
   1. Use up to 1 g (10 ml) topically

Special Hemorrhagic Scenarios:

Post-Tonsillectomy Bleeding AND Life-Threatening Hemoptysis

1. After initial assessment, if the patient is requiring oxygen, has unstable vital signs (HR >100, SBP <90, RR >20 or <8, GCS <15), or evidence of large volume hemorrhage (>500 mL), the patient requires ALS intervention.
2. If there is evidence of respiratory distress in the setting of post-tonsillectomy bleeding or life-threatening hemoptysis, consider intubation.
3. If the patient appears stable and is maintaining their airway, Paramedics can consider the use of TXA via nebulizer.
   1. Dispense dose of TXA from the vial into a nebulizer and give a TXA nebulizer as you would an albuterol nebulizer. May repeat x1 neb. Watch closely for ongoing bleeding or need for further airway management.
   2. Dosing:
      1. 500 mg if >25 kg
      2. 250 mg if <25 kg; mix with 2.5 ml of normal saline to get total of 5 ml

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Post-Dental Surgery Bleeding OR Epistaxis

1. Control bleeding with direct pressure.
   1. Dental bleeding: Fashion gauze into a small square and place into the socket with patient closing teeth to exert pressure
   2. Epistaxis: Place nasal clamp.
2. TXA may be used by Paramedics for refractory bleeding
   1. TXA comes in 1 g per 10 cc vials.
   2. For gum bleeding (e.g. dental extraction) - if you can see the source of bleeding, dispense entire TXA vial in a medicine cup. Soak 4x4 gauze in TXA and apply firm direct pressure to bleeding site. This can be done by having the patient close their teeth over the gauze to exert pressure.
   3. For epistaxis - dispense entire TXA vial in a medical cup. Soak 4x4 gauze in TXA and insert intranasally into the side that is hemorrhaging. Place nasal clamp.