A 35-year-old motorcyclist is brought to the emergency department. He is intubated, BP 80/50 mmHg, HR 130 bpm. FAST ultrasound shows free fluid in Morrison's pouch and the splenorenal space. After two litres of crystalloid, BP is 78/48 mmHg. Chest X-ray is normal. What is the ATLS-based classification of haemorrhagic shock and the appropriate immediate intervention?
- A Class IV shock — emergency damage control surgery with balanced 1:1:1 blood product resuscitation ✓
- B Class II shock — continue crystalloid resuscitation to 3 litres then reassess
- C Class III shock — transfuse packed red cells and consider immediate surgery
- D Class I shock — observation and monitoring in the emergency department
Correct answer: A. Class IV shock — emergency damage control surgery with balanced 1:1:1 blood product resuscitation
Explanation
Class IV haemorrhagic shock (>40% blood volume loss) is characterised by BP <90 mmHg, HR >140 bpm, mental status changes, and non-response to initial crystalloid resuscitation. This represents immediately life-threatening haemorrhage requiring emergency damage control surgery (DCS) in the operating room and balanced blood product resuscitation in a 1:1:1 ratio (pRBC:FFP:platelets) as per the damage control resuscitation (DCR) principle. Continuing crystalloid exacerbates the 'lethal triad' of acidosis, hypothermia, and coagulopathy.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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