Hemorrhagic Shock

Shock is a lecture I've heard at least a dozen times. It's such a core concept to emergency medicine and critical care that it's a perennial topic in the medical student and resident syllabus. Almost every time I hear about it (and when I teach it to students), it's categorized the same way: cardiogenic, hypovolemic, distributive, (and occasionally obstructive). Most of the time, the least interesting shock is hypovolemic shock. In this state, a patient's tissue perfusion is low because they have no blood volume: either they're severely dehydrated or they're bleeding to death. The consequent physiologic parameters (blood pressure, heart rate, central venous pressure, etc.) and treatment are straightforward. They don't have enough fluid? Give them volume. Not enough blood? Transfuse.

It is the least interesting shock until you have to deal with it in person. An octogenarian with breast cancer metastatic to bone sustains a hip fracture and is taken emergently for a hip replacement. Her bone is more than osteoporotic; it is riddled with tumor. Because the tumor is highly vascular, this is a surgery that will bleed without remorse. Going in, I knew we were going to lose a lot of blood, but once the surgeons got to work, I realized we were in hypovolemic hemorrhagic shock. Her blood pressure sagged relentlessly; while it responded to boluses of pressors, what she needed was volume. I ran in liters of saline and hetastarch, bottles of albumin, units of blood and frozen plasma. I realized this shock was no small entity, no uninteresting bystander. As I ordered product after product, did my best to catch up with the blood pouring from the surgical side, I learned not to underestimate hemorrhagic shock. Without central access or an echocardiogram, I was relying mostly on clinical signs, the surgical field, physical exam, and the patient's responsiveness to assess where I was with regard to volume status. It was challenging, but a surprisingly satisfying enterprise. She probably lost a whole blood volume - an amount equal to all the blood in her circulation when we started - but when I woke her up at the end of the case, extubated her, and took her to recovery, I could not be more proud that we'd made it through. She opened her eyes and said, "Hey, you're my anesthesiologist right? Are we done with the surgery already?"