Paeds · acute-care-resuscitation-and-toxicology
Hypovolaemic and haemorrhagic shock
Also known as Haemorrhagic shock · Hypovolaemic shock · Massive transfusion in children · Damage control resuscitation · Tranexamic acid in paediatric trauma
A fellowship approach to hypovolaemic and haemorrhagic shock in children. Recognise compensated shock before hypotension, control catastrophic bleeding first, resuscitate with aliquots of crystalloid for non-haemorrhagic loss and with blood products and damage control resuscitation for haemorrhage, give tranexamic acid within three hours of injury, run a paediatric massive transfusion protocol, prevent the lethal triad, and escalate early to surgical and critical-care support.
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Target exams
Red flags
- Tachycardia, weak central pulses, prolonged capillary refill, cold mottled skin or altered consciousness with a normal blood pressure: treat as compensated shock now, do not wait for hypotension
- Uncontrolled external haemorrhage: apply direct pressure or a windlass tourniquet proximal to the bleed before any other action
- Suspected pelvic fracture with shock: apply a pelvic binder and do not palpate the pelvis repeatedly
- Signs of massive haemorrhage or a transfusion need likely to exceed one blood volume: activate the massive transfusion protocol immediately, do not wait for laboratory results
- Injury more than three hours old: the tranexamic acid benefit window may be closing, and late administration may cause harm
- Falling heart rate with poor perfusion, or a bradycardic collapsing child: imminent arrest, prepare for advanced life support
- Rising potassium, falling ionised calcium, worsening acidosis and hypothermia during massive transfusion: treat the biochemical storm in parallel
- Deterioration despite treatment, or a need for surgical bleeding control, intensive care or retrieval unavailable locally: escalate now
Life stages
Care settings
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Board mappings
- Acute Care
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Current 2026 PREP curriculum — Learning Objective 2.2.3: Perform acute resuscitation and advanced life support
- Current 2026 PREP curriculum — Learning Objective 2.4.4: Assess and manage infants, children and young people with potential cardiac, respiratory or neurological emergencies or acute sepsis
- Renewed curriculum for first-year trainees from 2027 — Learning goal 11: Acute care and procedures
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 4. Professional skills and knowledge: Patient management
- 5. Professional skills and knowledge: Decision making, clinical and reasoning
- 7. Patient safety, including safe prescribing
- General Paediatrics: Resuscitates, stabilises and treats extremely unwell babies, children and young people, liaising with specialist teams, as necessary
- General Paediatrics: Assumes the role of Acute Paediatric Team Leader
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- Video
- General Pediatrics Content Outline — Domain 7: Emergency and Critical Care
- General Pediatrics Content Outline — Universal Task 1: Physiology and Pathophysiology
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- General Pediatrics EPA 7: Recognizing a Severely Ill Patient, Providing Initial Management, and Mobilizing Resources Needed for Continued Care
- Patient Care 3: Organize and Prioritize Patient Care
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Interpersonal and Communication Skills 2: Interprofessional and Team Communication
- Medical Expert
- Pediatrics: Core EPA #2 — Resuscitating and stabilizing critically ill patients
Overview & Definition
A pale, tachycardic child with cool limbs and a rapid, thready pulse after a fall from a height is in shock until you prove otherwise. That child has hypovolaemic shock: the heart cannot deliver enough oxygen to the tissues because circulating volume has been lost. The loss is either of blood (haemorrhagic shock, from trauma, a gastrointestinal bleed or surgery) or of fluid and electrolytes (non-haemorrhagic hypovolaemia, from diarrhoea, vomiting, diabetic ketoacidosis, burns or fluid shifted into a third space). The mechanism differs, but the early priority is the same: restore perfusion before the child decompensates. [1] [2]
The decisive clinical skill is not naming the shock but recognising it before the blood pressure drops. Children defend their blood pressure fiercely through tachycardia and vasoconstriction, so compensated shock is common, looks deceptively well, and is missed by anyone who waits for hypotension. Once you find signs of poor perfusion, treat the direction of change: a child moving from anxious and tachycardic to drowsy and mottled is failing, regardless of the number on the cuff. [2] [11]
Haemorrhagic shock needs a different resuscitation strategy from non-haemorrhagic hypovolaemia, and confusing the two harms children. Crystalloid alone in major bleeding dilutes clotting factors, worsens acidosis and hypothermia, and drives the coagulopathy that kills the bleeding trauma patient. So the fork in the road is early: if the child is bleeding, stop the bleeding and resuscitate with blood products; if the child is volume-depleted without bleeding, resuscitate with fluid aliquots. This topic holds both pathways, with the haemorrhagic pathway carrying the massive transfusion protocol, tranexamic acid and damage control resuscitation. [5] [9]
[2] [5]References11ShowHide
- [1]Topjian AA, Raymond TT, Atkins D, et al. Part 4: Pediatric Basic and Advanced Life Support 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Pediatrics, 2021.PMID 33087552
- [2]Bjorklund A, Resch J, Slusher T Pediatric Shock Review Pediatrics in review, 2023.PMID 37777656
- [3]Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection The New England journal of medicine, 2011.PMID 21615299
- [4]Weiss, Scott L Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026 Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2026.PMID 41869844
- [5]Russell, Russell T Pediatric traumatic hemorrhagic shock consensus conference recommendations The journal of trauma and acute care surgery, 2023.PMID 36245074
- [6]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet (London, England), 2010.PMID 20554319
- [7]Borgman MA, Nishijima DK Tranexamic acid in pediatric hemorrhagic trauma The journal of trauma and acute care surgery, 2023.PMID 36044459
- [8]Noland DK, Apelt N, Greenwell C, et al. Massive transfusion in pediatric trauma: An ATOMAC perspective Journal of pediatric surgery, 2019.PMID 30389149
- [9]Neff LP, Beckwith MA, Russell RT, et al. Massive Transfusion in Pediatric Patients Clinics in laboratory medicine, 2021.PMID 33494884
- [10]Beno S, Ackery AD, Callum J, et al. Tranexamic acid in pediatric trauma: why not? Critical care (London, England), 2014.PMID 25043066
- [11]Fleming S, Thompson M, Stevens R, et al. Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies Lancet (London, England), 2011.PMID 21411136