Management of Hemorrhagic Shock for pre-hospital providers

Hard Signs of Vascular Injury:
Hard signs of vascular injury include those assessment findings for which there should be no hesitation for intervention.

• Pulsatile bleeding, the classic spurting bleeding that is often seen and described with arterial bleeding.
• Expanding hematoma, or swelling that is seen over seconds to minutes vs. hours and days with normal inflammation. This is severe arterial bleeding that is happening under the skin, commonly seen with humerus and femur fractures with no breakage of the skin. 
• Audible bruit/palpable thrill, which are best described as being able to hear blood flow with a stethoscope, which is called bruit, or being able to feel the blood flowing from a disrupted vessel by palpating a suspected area for vascular trauma.
• Evidence of ischemia, which is also known as the 6 Ps of ischemia
  1. Pain;
  2. Pallor;
  3. Paresthesia;
  4. Pulselessness (Be aware that 20% of arterial injuries may have an intact peripheral pulse.);
  5. Paralysis, and
  6. Poikilothermism, or cold extremity.