Critical Care and Shock

Management of hemorrhagic shock with severe brain hypoperfusion: Application of targeted temperature management


Background: Hemorrhagic shock is one of the leading causes of death. It is attributable to half of death in the trauma setting and can be iatrogenic such as the one that happened during surgery. (1) Despite prompt management, morbidity, and mortality remain high, because of brief response time. (2)

Case presentation: This is a case of 27 y.o male, admitted to the Intensive Care Unit (ICU) due to hemorrhagic shock that occurred during surgery. The patient was admitted to the ICU with a high dose of inotropes and vasopressor and showed no signs of brainstem reflexes including dilated pupils, despite lack of use of atropine intra-operatively and beyond the duration of action of muscle relaxants. He was managed with massive transfusion protocol and mechanical ventilation, combined with targeted temperature management in order to limit brain damage. Later on, he developed disseminated intravascular coagulation (DIC), which was managed accordingly.

Conclusion: Aggressive management is required in hemorrhagic shock. In cases where the patient exhibits signs of severe brain perfusion impairment, targeted temperature management might be a feasible strategy despite its controversy as part of the triad of death.