External bleeding should be controlled by direct pressure.

Intravenous access should be established by two 14- or 16-gauge short peripheral lines through which, after insertion, blood may be drawn for type and cross-matching and other studies, and normal saline or Ringer’s lactate solution rapidly infused if signs of hypovolemia are present.

Central’s lines should not be used for initial fluid resuscitation because their placement, even in experienced hands, is time consuming, associated with a higher rate of complications, and, most important, results in a dramatically reduced rate of fluid delivery as a function of catheter-dependent resistance. A 16-gauge, 8-inch line, for example, delivers approximately half the fluid of a 16-gauge, 2-inch catheter for any given unit of time.

Adults presenting with hypotension or established or evolving shock should be treated initially with 2 L of normal saline or Ringer lactate solution; this may be administered to adults as rapidly as possible, usually over 5 to 10 minutes.

Children may be administered 20 mL/kg over the same interval.

Although subsequent therapy will be dictated by the patient’s response to the initial fluid challenge, patients presenting with hypotension will require blood replacement, and a minimum of 4 U should be made available.

Although cross-matched blood is clearly preferable, its preparation requires between 50 and 70 minutes, and in many patients presenting with severe hypotension or exsanguinating hemorrhage, an abbreviated cross-match (which requires 15-20 minutes), type-specific blood (which requires ∽10 minutes), or O-negative blood (which should be available immediately) must be transfused.

Blood should be administered through macropore (160 μm) filters and, if possible, warmed before or during transfusion; however, warming is often impractical because of the urgency of transfusion.

Vasopressors have no role in the routine management of hemorrhagic shock; aggressive re-expansion of intravascular volume with crystalloid, blood, or both remains the focus of initial treatment.

In general, patients who rapidly respond to the initial fluid challenge by relative normalization of blood pressure and who remain stable have lost relatively little blood (<15%-20%) and may not necessarily require additional fluid challenge or blood replacement; however, 4 to 6 U of packed red cells should be available for emergent transfusion.