Symptoms include [6]:

•  Anxiety
•  Low or no urine output 
•  Profuse sweating
•  Dizziness
•  Confusion
•  Loss of consciousness
•  Chest pain
•  Tachycardia with weak pulse
•  Hypotension
•  Decreased urine output

Other signs may be:

•  Abdominal pain (in case of internal hemorrhage)
•  Melena and/or hematuria (in case of internal hemorrhage)
•  Progressive weakness leading to unconsciousness 
•  Peripheral and central cyanosis 

• Hypothermia

  Massively bleeding patients in hypovolemic shock should be treated with damage control resuscitation principles including limited crystalloid, whole blood or balance blood component transfusion to permissive hypotension, preventing hypothermia, and stopping [ncbi.nlm.nih.gov]

  A patient that is cool is losing body heat and is therefore at risk for hypothermia. (2) In cool weather, cover the casualty with a blanket, poncho, or other available materials to keep him warm and dry (figure 7-2). [brooksidepress.org]

  Warm all fluids: hypothermia increases mortality. In massive haemorrhage, give fresh frozen plasma and platelets early. Hypovolaemic shock is a clinical state in which loss of blood or plasma causes inadequate tissue perfusion. [bmj.com]

  In the meantime, follow these steps: Keep the person comfortable and warm (to avoid hypothermia ). Have the person lie flat with the feet lifted about 12 inches (30 centimeters) to increase circulation. [medlineplus.gov]

• Unconsciousness

  Loss of consciousness Chest pain Tachycardia with weak pulse Hypotension Decreased urine output Other signs may be: Abdominal pain (in case of internal hemorrhage) Melena and/or hematuria (in case of internal hemorrhage) Progressive weakness leading to unconsciousness [symptoma.com]

  If severe it can lead to unconsciousness. It is usually diagnosed based on the clinical features and physical exam, blood tests and other diagnostic methods might be needed to determine the exact cause of shock if it is not clear. [burn-injury-resource-center.com]

  The signs and symptoms of hypovolemia include: • Cold skin • Agitation and anxiety • Decrease in the output of urine • Confusion • Feeling of weakness in general • Paleness in skin • Rapidness in breathing • Moist skin and increased sweating • Falling unconscious [healthguidance.org]

  Critical Essential Core Tested Community Questions (5) Sorry, this question is for PEAK Premium Subscribers only (M2.CV.201) A 46-year-old male was found unconscious in the field and brought to the emergency department by EMS. [medbullets.com]

  This helps the blood in the veins of his legs to return to his heart. (4) Place a small log, field pack, box, rolled field jacket, or other stable object under the casualty’s feet or ankles to maintain the elevation. (5) If the casualty is unconscious [brooksidepress.org]

• Congestive Heart Failure

  heart failure, myocardial infarction, arrhythmia, pericarditis, or myocarditis Swollen extremities, edema Congestive heart failure, venous obstruction, prolonged sitting or standing (resulting in venous pooling) Symptoms on awakening or after a meal [aafp.org]

  Most experts will probably agree it remains entirely appropriate to use colloids in selected patients in shock, especially when volume overload is a concern (e.g., concomitant decompensated congestive heart failure or cirrhosis). [pulmccm.org]

  This type may be caused by conditions that interfere with the function of the heart as a pump, such as severe myocardial infarction, severe heart failure, and certain disorders of rate and rhythm. Pathogenesis of shock. [medical-dictionary.thefreedictionary.com]

  Etiologies include 1) congenital heart disease, 2) myocardial infarction (e.g., Kawasaki's), 3) myocarditis or pericarditis, 4) congestive heart failure, 5) cardiac trauma, 6) dysrhythmia, or 7) drugs affecting myocardial contractility. [hawaii.edu]

  failure (myocardial infarction, arrhythmia, cardiomyopathy, heart valve disease) 7,27 Obstructive shock: Cardiac tamponade (muffled heart tones, distended neck veins) 2,7 Tension pneumothorax (displaced trachea, decreased breathing sounds on one side [ehealthstar.com]

• Pallor

  This can be due to: Burns Diarrhea Excessive perspiration Vomiting Symptoms Symptoms may include: Anxiety or agitation Cool, clammy skin Confusion Decreased or no urine output General weakness Pale skin color (pallor) Rapid breathing Sweating, moist skin [mountsinai.org]

  Shock is recognized by increased heart rate [tachycardia], decrease in blood pressure [hypotension], pallor on the skin [due to vasoconstriction] and decreased capillary refill [not that reliable] The patient may feel dizzy and develops a thirst. [boneandspine.com]

  Tachycardia (> 120 bpm) Extreme tachycardia (> 140 bpm) with weak pulse Respiratory rate Normal Increased (> 20) Tachypneic (> 30) Extreme tachypnea Mental status Normal Slight anxiety, restless Altered, confused Decreased LOC, lethargy, coma Skin Pallor [en.wikipedia.org]

  This is most easily detected in the skin as central pallor, peripheral cyanosis, and sluggish capillary return. Other clinical evidence could include a raised respiratory rate, confusion, or coma. [emj.bmj.com]

• Fatigue

  Headache, fatigue, nausea, profuse sweating, dizziness may occur as the condition develops. [en.wikipedia.org]

  Mild symptoms Mild symptoms can include: headache fatigue nausea profuse sweating dizziness Severe symptoms Severe symptoms, which must be taken seriously and warrant emergency medical attention, include: cold or clammy skin pale skin rapid, shallow breathing [healthline.com]

  As a result, symptoms of central nervous system hypoperfusion may occur, including feelings of weakness, nausea, headache, neck ache, lightheadedness, dizziness, blurred vision, fatigue, tremulousness, palpitations, and impaired cognition. 1 Vertigo also [aafp.org]

• Tachypnea

  […] tachycardia with weak and faint pulse Extreme tachypnea Unconsciousness/coma Very little urine output It can be prevented by emergency medicine provided as early as possible. [symptoma.com]

  Increased breathing frequency (tachypnea) Capillary refill time (CRT) >2 seconds in infants, children and adults (CRT in healthy, especially in old people can be prolonged in cold ambient) >3 sec corresponds to ~10% drop of blood volume Body weight is [ehealthstar.com]

  […] in mental status (confusion, anxiety, agitation) Sweating with cool, pale skin Delayed capillary refill Urine output of approximately 20 milliliters/hour Stage 4 Loss greater than 40% (>2000 mL) Extreme tachycardia (>140) with weak pulse Pronounced tachypnea [boneandspine.com]

  Tachypnea and hyperventilation may be present. BP tends to be low ( 90 mm Hg systolic) or unobtainable; direct measurement by intra-arterial catheter, if done, often gives higher and more accurate values. Urine output is low. [merckmanuals.com]

  […] physical exam must include: 1) general appearance/alertness/eye contact/activity, 2) heart rate, 3) skin perfusion, a) capillary refill, b) color, c) skin temperature, 4) oliguria (if an observation period is permitted), 5) altered mental status, 6) tachypnea [hawaii.edu]

• Abdominal Pain

  Among 61 episodes of abdominal pain and hemoconcentration, 58 were responsive to albumin infusion. This suggested the presence of hypovolemia. Twenty patients had abdominal pain without hemoconcentration, and 18 of them had primary peritonitis. [ncbi.nlm.nih.gov]

• Hematochezia

  UGI patients may present with blood in their vomit as well as melena or hematochezia. [artifactsjournal.missouri.edu]

• Hypotension

  […] to posttraumatic hypovolemia or other causes of hypotension. [ncbi.nlm.nih.gov]

  Shock is characterised by systemic hypotension due either to reduced cardiac output or to reduced effective circulating blood volume. [symptoma.com]

  Algorithm for the evaluation of orthostatic hypotension. Evaluation of Orthostatic Hypotension FIGURE 1. Algorithm for the evaluation of orthostatic hypotension. [aafp.org]

  Acute decreases in blood volume of this magnitude in other clinical situations have often been associated with shock or hypotension (16-21). [annals.org]

• Tachycardia

  Symptoms include: Anxiety Low or no urine output Profuse sweating Dizziness Confusion Loss of consciousness Chest pain Tachycardia with weak pulse Hypotension Decreased urine output Other signs may be: Abdominal pain (in case of internal hemorrhage) Melena [symptoma.com]

  There may be tachycardia and a fall in blood pressure (BP) or postural hypotension. Tachycardia and cold peripheries from vasoconstriction may occur before a fall in BP, especially in children and young adults. [patient.info]

  Tachycardia Hypotension Tachycardia, very weak pulse. Capillary refill is undetectable. The skin is pale and moist. Blood pressure very low or undetectable. 19. [slideshare.net]

  Tachycardia is sensitive but not specific indicator. Prolonged capillary refill (> 2 seconds), especially when combined with tachycardia, is more specific, although it may be difficult to measure. Cold skin and decreased urine output may be present. [openanesthesia.org]

  Subsequently, the patient had acute pulmonary edema, hypotension, and tachycardia developed. [omicsonline.org]

• Weak Pulse

  Weak pulse or absent pulses (they are more significant than weak pulses). Skin: pale, moist and cool. Tachycardia Hypotension Tachycardia, very weak pulse. Capillary refill is undetectable. The skin is pale and moist. [slideshare.net]

  Weak pulses, mottling, cyanosis, and impaired consciousness may all precede hypotension. In fact, hypotension is an ominous sign in pediatric patients Hypovolemia in Pediatrics: Signs Tachycardia : sensitive but not specific. [openanesthesia.org]

  Symptoms of shock include Confusion or lack of alertness Loss of consciousness Sudden and ongoing rapid heartbeat Sweating Pale skin A weak pulse Rapid breathing Decreased or no urine output Cool hands and feet Shock is a life-threatening medical emergency [icdlist.com]

  Symptoms include: Anxiety Low or no urine output Profuse sweating Dizziness Confusion Loss of consciousness Chest pain Tachycardia with weak pulse Hypotension Decreased urine output Other signs may be: Abdominal pain (in case of internal hemorrhage) Melena [symptoma.com]

  Symptoms include: anxiety blue lips and fingernails low or no urine output profuse (excessive) sweating shallow breathing dizziness confusion chest pain loss of consciousness low blood pressure rapid heart rate weak pulse External hemorrhaging (bleeding [healthline.com]

• Heart Disease

  The amount of time it takes to increase the blood volume can depend on: the stage of shock the rate of blood loss the extent of blood loss underlying medical conditions, such as heart disease or taking blood thinners Hypovolemic shock and older adults [medicalnewstoday.com]

  Area 12: cardiogenic shock complicating end-stage heart disease 1- Patients with severe chronic heart disease should be assessed for their heart transplant eligibility in a center equipped for this intervention (strong agreement). 2- A patient with end-stage [annalsofintensivecare.springeropen.com]

  Etiologies include 1) congenital heart disease, 2) myocardial infarction (e.g., Kawasaki's), 3) myocarditis or pericarditis, 4) congestive heart failure, 5) cardiac trauma, 6) dysrhythmia, or 7) drugs affecting myocardial contractility. [hawaii.edu]

  He has a medical history of ischaemic heart disease treated with quadruple coronary artery bypass grafting five years ago. He has been unwell for the past 48 hours with a productive cough, lethargy, and fever. [emj.bmj.com]

  […] failure, hypertension, diabetes, chronic liver disease, and chronic heart disease), and concurrent drug intake (alcohol, antihypertensive, anti-arrhythmic, β-blockers, steroids, vasodilators, inotrops, and insulin) play different significant roles in [oadoi.org]

• Orthostatic Hypotension

  Algorithm for the evaluation of orthostatic hypotension. Evaluation of Orthostatic Hypotension FIGURE 1. Algorithm for the evaluation of orthostatic hypotension. [aafp.org]

  hypotension, which means there can be lowered blood pressure. [healthguidance.org]

  To be eligible, patients had to be in objective shock, and also to have evidence for hypovolemia with a low cardiac index, measured invasively or noninvasively (orthostatic hypotension, increased pulse pressure variation, or clinical signs). [pulmccm.org]

  2,7 Hemorrhagic pneumothorax Pulmonary embolism 27 Arteriovenous malformations 2 Vasodilation as a side effect of drugs, such as barbiturates, nitrates, opiates, antihypertensives (beta blockers, vasodilators) 7,25,26 Temporary autonomic dysfunction: Orthostatic [ehealthstar.com]

  Orthostatic hypotension is more common in diabetes patients ( 1, 2, 5, 10, 11 ), but diabetes patients with no detectable or only mild CAN also have an increased risk of hypotension during orthostatic stress and surgery, indicating the presence of other [care.diabetesjournals.org]

• Cold, Clammy Skin

  clammy skin; (c) oliguria; (d) increased serum lactate. [annalsofintensivecare.springeropen.com]

• Increased Sweating

  The signs and symptoms of hypovolemia include: • Cold skin • Agitation and anxiety • Decrease in the output of urine • Confusion • Feeling of weakness in general • Paleness in skin • Rapidness in breathing • Moist skin and increased sweating • Falling [healthguidance.org]

• Oliguria

  Oliguria. There is oliguria or decreased urine output of less than 25ml/hour. Clammy skin. The patient develops cool, clammy, and pale skin. Prevention For prevention of hypovolemic shock, the following must be implemented: Early detection. [nurseslabs.com]

  Severe oliguria or anuria 18. Heart • Cardiovascular signs are due to adrenergic response to blood loss. (Shock class I) (Shock class II) (Shock class III) (Shock class IIII) NONE Tachycardia due to catecholamine release. [slideshare.net]

  The kidneys are injured when renal perfusion is critically reduced, leading to acute tubular necrosis and renal insufficiency manifested by oliguria and progressive rise in serum creatinine. [merckmanuals.com]

  Clinical characteristics include hypotension; hyperventilation; cold, clammy, cyanotic skin; a weak and rapid pulse; oliguria; and mental confusion, combativeness, or anxiety. insulin shock a hypoglycemic reaction to overdosage of insulin, a skipped meal [medical-dictionary.thefreedictionary.com]

• Renal Injury

  Furthermore, lower maximum SOFA scores and an absence of acute renal injury were observed in the HES group. [dx.doi.org]

• Anuria

  Severe oliguria or anuria 18. Heart • Cardiovascular signs are due to adrenergic response to blood loss. (Shock class I) (Shock class II) (Shock class III) (Shock class IIII) NONE Tachycardia due to catecholamine release. [slideshare.net]

• Confusion

  A confused patient presented with hypovolemic shock and signs of arterial and venous obstruction of the left lower extremity; the correct diagnosis of urinary retention was made after phlebography. [ncbi.nlm.nih.gov]

  Anxiety, confusion. Confusion, drowsiness, and coma 21. [slideshare.net]

  Symptoms of shock include Confusion or lack of alertness Loss of consciousness Sudden and ongoing rapid heartbeat Sweating Pale skin A weak pulse Rapid breathing Decreased or no urine output Cool hands and feet Shock is a life-threatening medical emergency [icdlist.com]

• Dizziness

  Symptoms include: Anxiety Low or no urine output Profuse sweating Dizziness Confusion Loss of consciousness Chest pain Tachycardia with weak pulse Hypotension Decreased urine output Other signs may be: Abdominal pain (in case of internal hemorrhage) Melena [symptoma.com]

  The person feels dizzy and might even lose consciousness. Hypovolemia can hinder the amount of blood that the heart pumps to the organs. This indicates that there are many signs related to the heart caused by hypovolemia. [healthguidance.org]

  Headache, fatigue, nausea, profuse sweating, dizziness may occur as the condition develops. [en.wikipedia.org]

  Symptoms include: anxiety blue lips and fingernails low or no urine output profuse (excessive) sweating shallow breathing dizziness confusion chest pain loss of consciousness low blood pressure rapid heart rate weak pulse External hemorrhaging (bleeding [healthline.com]

  (Shock class I) (Shock class II) (Shock class III) (Shock class IIII) None or orthostatic dizziness. Restlessness, anxiety, agitation. Anxiety, confusion. Confusion, drowsiness, and coma 21. [slideshare.net]

• Agitation

  Restlessness, anxiety, agitation. Anxiety, confusion. Confusion, drowsiness, and coma 21. [slideshare.net]

  Signs and symptoms: Anxiety or agitation. Cold, pale skin. Confusion. General weakness. Low blood pressure. Rapid pulse. Decreased or no urine output. If severe it can lead to unconsciousness. [burn-injury-resource-center.com]

  The signs and symptoms of hypovolemia include: • Cold skin • Agitation and anxiety • Decrease in the output of urine • Confusion • Feeling of weakness in general • Paleness in skin • Rapidness in breathing • Moist skin and increased sweating • Falling [healthguidance.org]

  This can be due to: Burns Diarrhea Excessive perspiration Vomiting Symptoms Symptoms may include: Anxiety or agitation Cool, clammy skin Confusion Decreased or no urine output General weakness Pale skin color (pallor) Rapid breathing Sweating, moist skin [mountsinai.org]

• Lethargy

  Plasma loss Blood loss (external or internal bleeding or blood donation) Vasodilation Loss of electrolytes like sodium Pregnancy-associated conditions Severe diarrhea and vomiting Symptoms Symptoms and signs may include: Light headedness Dizziness and lethargy [symptoma.com]

  Late Symptoms Early symptoms plus the following: Dizziness Fainting Weakness Confusion Lethargy Late Signs Early signs plus the following: Mottled, cyanotic skin Increase of tachycardia, bradycardia or arrhythmia Increased breathing rate (tachypnea: > [ehealthstar.com]

  […] tachycardia (> 100 bpm) Tachycardia (> 120 bpm) Extreme tachycardia (> 140 bpm) with weak pulse Respiratory rate Normal Increased (> 20) Tachypneic (> 30) Extreme tachypnea Mental status Normal Slight anxiety, restless Altered, confused Decreased LOC, lethargy [en.wikipedia.org]

  […] milliliters/hour Stage 4 Loss greater than 40% (>2000 mL) Extreme tachycardia (>140) with weak pulse Pronounced tachypnea [increased respiratory rate] Significantly decreased systolic blood pressure of 70 mm Hg or less Decreased level of consciousness, lethargy [boneandspine.com]

  Also observe for restlessness, agitation, or lethargy. Compare your results with the baseline assessment to see if anything has changed. And check for laboratory results that indicate metabolic or electrolyte abnormalities. [163.178.103.176]

• Altered Mental Status

  […] diastolic blood pressure, systolic pressure maintained Tachypnea Mild anxiety Urine output of 20-30 millilitres/hour Stage III Blood loss up to 30-40% of total blood volume Hypotension Tachycardia Tachypnea Altered mental status Urine output 20 millilitres [symptoma.com]

  mental status (eg, lethargy, confusion, somnolence) is a common sign of shock. [merckmanuals.com]

  Altered mental status. .. .. c. Depressed anterior fontanelle. .. .. d. Hypotension. .. .. e. Absent distal pulses 5. An alert, 6 month old male has a history of vomiting and diarrhea. [hawaii.edu]

  mental status; (b) cold, clammy skin; (c) oliguria; (d) increased serum lactate. [annalsofintensivecare.springeropen.com]

Work up consists of a detailed history and physical examination.

Laboratory Tests

• Complete blood count
• Serum electrolytes 
• Kidney function tests
• Urinary catheterisation and urine output checking 
• Blood sugar levels 
• Arterial blood gases
• Prothrombin time and APTT

Imaging Studies

• Echocardiogram to assess heart function
• ECG
• Ultrasound
• X-ray
• CT scan of head, chest and abdomen to check for internal bleeding

Test Results

On the basis of history, physical assessment of the patient and test results, a diagnosis of hypovolemic shock can be made and intensive treatment should be immediately begun.

Control Bleeding

The cause of bleeding should be immediately identified and treated. Treatment could be surgical or via medications, depending upon the cause.

Treatment of burns

If the hypovolemia is due to severe burns, the primary goal of treatment should be to replace the lost volume.

Treating other underlying cause

If the cause of hypovolemia is due to a pregnancy-associated condition, or due to gastrointestinal disturbances or disease, or due to any other cause, that underlying cause should be identified and promptly treated.

Fluid resuscitation

Many fluids have been studied for use in resuscitation; these include isotonic sodium chloride solution, lactated Ringer solution [7], FFP, hypertonic saline, dextran 70, albumen, etc. The loss of blood volume should be recompensed with appropriate fluids to avoid systemic effects.

Oxygen

Emergency oxygen should be immediately employed to increase the efficiency of the patient's remaining blood supply. This intervention can be life saving [8].

Transfusions

Blood should be matched and transfusions should be performed to replace the lost blood volume.

Medications

Vasopressers and thrombogenic drugs may be administered if needed, to prevent further episodes of bleeding.

Prognosis depends upon how early treatment is begun. If patients are brought to the emergency and treated accordingly, prognosis is excellent. However, if the hypovolemia has extended to multiorgan failure, death may ensue.

Complications

Possible complications include the following:

•  Myocardial infarction
•  Cardiac arrest or fatal arrhythmias
•  Brain damage
•  Kidney damage
•  Multiorgan failure
•  Gangrene of extremities 
•  Coma
•  Death 

Hypovolemic shock results from low cardiac output due to the loss of blood or plasma volume, such as can occur with massive hemorrhage or fluid loss from severe burns [1]. Hemorrhage is the most common cause of hypovolemic shock.

Less common causes include plasma loss in severe burns, or into the abdominal cavity in acute pancreatitis, inappropriate vasodilatation in bacteraemic shock and anaphylactic shock, and excess urinary fluid loss as in diabetic ketoacidosis [3].

Excessive diarrhea and severe vomiting may also cause hypovolemic shock. Pregnancy associated conditions such as ectopic pregnancy rupture or placenta previa may cause hypovolemia, and so can arteriovenous malformations, gastrointestinal disturbances such as Mallory-Weiss tears, esophageal varices and peptic ulcers.

Incidence

More than 1 million patients present in shock or develop shock in the US hospitals each year, at an annual cost of more than $100 billion [2].

Sex

It has no known gender prevalence.

Age
Hypovolemic shock may occur at any age, depending upon the underlying etiology. It may occur in young children who have suffered severe burns or it may occur in adults who have had a serious accident leading to heavy blood loss. 

As discussed in the previous section, the commonest cause of hypovolemia is hemorrhage. Hemorrhage decreases the filling pressure of the circulation and, as a consequence, decreases venous return. As a result, the cardiac output falls below normal and shock may ensue [4]. Hypovolemia occurs so commonly due to hemorrhage that the term hypovolemic shock is sometimes used interchangeably with hemorrhagic shock.

The severity of hypovolemia can be staged. The stages include the following:

Stage I

• Blood loss up to 15% of total blood volume
• Normal or slightly low blood pressure 
• Normal mental status
• Normal respiratory rate 
• Normal urine output [5]

Stage II

• Blood loss up to 20-30% of total blood volume
• Increased diastolic blood pressure, systolic pressure maintained 
• Tachypnea 
• Mild anxiety
• Urine output of 20-30 millilitres/hour [5]

Stage III

• Blood loss up to 30-40% of total blood volume
• Hypotension
• Tachycardia
• Tachypnea 
• Altered mental status 
• Urine output 20 millilitres/hour

Stage IV

• Blood loss >40% of total blood volume
• Extreme tachycardia with weak and faint pulse 
• Extreme tachypnea
• Unconsciousness/coma
• Very little urine output

It can be prevented by emergency medicine provided as early as possible. First aid is critical in the prevention of hypovolemic shock.

Shock is characterised by systemic hypotension due either to reduced cardiac output or to reduced effective circulating blood volume [1]. Hypovolemic shock occurs due to a rapid fall in blood volume resulting in life threatening hypotension and may lead to multi organ failure, and ultimately, death.

Definition

Hypovolemic shock is a potentially life threatening condition that occurs when around 20% of the body's fluid volume is lost.

Cause

Common causes of hypovolemia are [9]:

• Plasma loss
• Blood loss (external or internal bleeding or blood donation [10])
• Vasodilation
• Loss of electrolytes like sodium
• Pregnancy-associated conditions
• Severe diarrhea and vomiting

Symptoms

Symptoms and signs may include:

• Light headedness
• Dizziness and lethargy
• Anxiety
• Increased heart rate with decreased pulse
• Hypotension
• Chest pain
• Unconsciousness

Diagnosis

Diagnosis is made by evaluating a combination of factors like history, physical examination and laboratory tests.

Treatment

Treatment includes fluid replacement, blood transfusions, oxygen and sometimes, surgical repair.

Prevention

Hypovolemic shock can be prevented by giving first aid on development of symptoms and admitting the patient to a hospital as soon as possible.

1. Robbins and Cotran. Pathologic Basis of Disease, 8th ed. Pa:Saunders Elsevier. Ch.4 p129
2. Rivers E. Approach to the patient with shock. In: Goldman L, Schafer L, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 106
3. Guyton and Hall. Textbook of Medical Physiology. 12th ed. Ch.24. Pa: Sanders Elsevier
4. Davidson's Principles and Practice of Medicine. Christopher RWE, Ian ADB, eds. 16th ed. Ch.8 p282 
5. Elizabeth D Agabegi; Agabegi, Steven S. (2008). Step Up To Medicine (Step-Up Series). Hagerstwon, MD: Lippincott Williams and Wilkins. ISBN 0-7817-7153-6
6. Rachel N, reviewed by Brenda B. Spriggs. Hypovolemic Shock. June 22, 2012. Retrieved on 17th Sept 2014. 
7. Ghafari MH, Moosavizadeh SA, Moharari RS, Khashayar P. Hypertonic saline 5% vs. lactated Ringer for resuscitating patients in hemorrhagic shock. Middle East J Anesthesiol. Oct 2008;19(6):1337-47 [Medline]
8. Takasu A, Prueckner S, Tisherman SA, Stezoski SW, Stezoski J, Safar P. (2000), Effects of increased oxygen breathing in a volume controlled hemorrhagic shock outcome model in rats. PMID 10959021. 
9. Sircar, S. Principles of Medical Physiology. Thieme Medical Pub. ISBN 9781588905727. 
10. Danic B, Gouezec H, Bigant E, Thomas T (June 2005). "[Incidents of Blood Donation]". Transfus Clinic Biol (in French) 12 (2):153-9. doi:10.1016/j.tracli.2005.04.003 PMID 15894504.