OR1.2 | Shock in Orthopaedic Trauma — Summary & Reflection

KEY TAKEAWAYS

Shock in orthopaedic trauma is most commonly haemorrhagic but may be neurogenic (spinal cord injury) or obstructive (tension pneumothorax, tamponade).

Key points:
- Shock = inadequate tissue perfusion; hypotension is a late sign in young patients
- Haemorrhagic shock follows a cascade: blood loss → sympathetic compensation (tachycardia + vasoconstriction) → decompensation → multi-organ failure
- ATLS Class I–IV: blood loss <15%, 15–30%, 30–40%, >40% circulating volume; tachycardia precedes hypotension
- Narrow pulse pressure and tachycardia are the earliest clinical signs; lactate and base deficit quantify severity
- Femoral shaft: 1–2 L blood loss; pelvic ring: 2–4 L; these volumes correspond to Class II–IV shock
- Management: simultaneous haemorrhage control (pelvic binder, tourniquet, traction splint) + haemostatic resuscitation (1:1:1 pRBC:FFP:platelets, TXA within 3 hours)
- Neurogenic shock: hypotension + BRADYCARDIA + warm flushed peripheries — from cervical/high thoracic SCI; treat with vasopressors + MAP ≥85 mmHg
- Haemorrhagic vs neurogenic: tachycardia distinguishes them — neurogenic shock has paradoxical bradycardia
- Spinal shock (loss of reflexes below injury) is a neurological phenomenon; neurogenic shock is haemodynamic — do not confuse them

REFLECT

You are called to the emergency department for a 45-year-old construction worker who fell three metres onto his side. He has a pelvic fracture on the bedside X-ray. His BP is 100/65 mmHg, HR 102/min, and he is anxious but cooperative. The nurse asks if you should give 2 litres of normal saline while awaiting blood products. What would you say, and why? How does your answer differ from what you might have been taught two years ago, and what evidence changed the recommendation? Consider writing a one-page note for yourself on the shift in trauma resuscitation philosophy — from 'fill the tank with fluid' to 'haemostatic resuscitation' — to consolidate this conceptual change before your surgical posting.