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Hypovolemic Shock


Presentation

Symptoms include [6]:

Other signs may be:

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]
  • ) 30/min Pronounced tachypnea Heart rate Slightly increased but 100/min 120/min 140/min Pulse Normal Weak Weak Weak or absent Capillary refill Normal ( Delayed ( 2 sec) Delayed ( 2 sec) Absent Urine output Normal ( 30 mL/hour) 20-30 mL/hour Negligible[ehealthstar.com]
  • CONCLUSIONS Traditionally, a patient in a state of shock was considered when presenting clinical data such as: tachycardia, tachypnea, TAS less than 90 mmHg, however, current evidence suggests that traditional vital signs are insensitive markers of early[ri.uaq.mx]
  • […] 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]
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]
  • Keep the individual warm to avoid hypothermia from developing Avoid providing the individual with fluids to drink orally Remember not to elevate the head or remove any debris or dirt from the site of injury.[firstaidwinnipeg.ca]
  • 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]
  • 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]
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[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 thirst.[boneandspine.com]
  • 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]
Severe Abdominal Pain
  • This time she presented with severe abdominal pain and profound hypovolemic shock requiring replacement of great amounts of fluids in addition to fresh frozen plasma. There was no evidence of bleeding, and the patient recovered rapidly.[ncbi.nlm.nih.gov]
Pelvic Mass
  • These cases suggest that intraperitoneal hemorrhage associated with uterine leiomyoma, although rare, should be considered in women with hypovolemic shock and a large pelvic mass.[ncbi.nlm.nih.gov]
Hypotension
  • […] to posttraumatic hypovolemia or other causes of hypotension.[ncbi.nlm.nih.gov]
  • Severe bleeding and hypovolemic shock causing hypotension are most often associated with tachycardia.[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]
  • We report a case of an individual who suffered a more severe form of this disease, presenting with profound hypotension and acute renal failure, secondary to hypovolemic shock.[ncbi.nlm.nih.gov]
  • 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]
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]
  • Severe bleeding and hypovolemic shock causing hypotension are most often associated with tachycardia.[ncbi.nlm.nih.gov]
  • 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]
  • Subsequently, the patient had acute pulmonary edema, hypotension, and tachycardia developed.[omicsonline.org]
  • The common signs include low blood pressure, thready pulse, clammy skin, tachycardia, rapid breathing, and reduced urinary output.[medical-dictionary.thefreedictionary.com]
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]
  • 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]
  • pulse rate Weakness Lightheadedness Bluish lips and fingernails Loss of consciousness Management If hypovolemic shock is left untreated, it will lead to death.[firstaidwinnipeg.ca]
  • 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]
Peripheral Pulse Decreased
  • Recognition of Pediatric Shock • Tachycardia: • Increased Systemic Vascular Resistance (Vasoconstriction) — slowed capillary refill, — cool, pale, and mottled skin — weak peripheral pulsesdecreased urine output • Increased Cardiac Contractility: •[slideshare.net]
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]
Cold, Clammy Skin
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]
Kidney Failure
  • Acute tubular necrosis is a kidney disorder involving damage to the tubule cells of the kidneys, which can lead to acute kidney failure . Disseminated intravascular coagulation .[nurseslabs.com]
Bladder Distention
  • Vascular complication in bladder distention is unusual and diagnosis may require radiologic investigation.[ncbi.nlm.nih.gov]
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]
  • This finding should be recognized so as to avoid confusion with thyroid or vascular injury or other incidental etiology.[ncbi.nlm.nih.gov]
  • 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]
  • Anxiety, confusion. Confusion, drowsiness, and coma 21.[slideshare.net]
  • When you lose between 30% and 40% of your blood volume -- around a half-gallon -- your blood pressure will drop, you'll breathe fast, and you may get confused or flustered.[webmd.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]
  • Mild symptoms Fatigue Headache Nausea Dizziness Profuse sweating Severe symptoms The severe symptoms should be taken seriously and requires immediate emergency care which includes the following: Pale skin Cold or clammy skin Rapid heart rate Rapid, shallow[firstaidwinnipeg.ca]
  • 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]
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: 30[ehealthstar.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]
  • […] 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]
  • […] myocarditis, drugs Abnormalities of cardiac rhythm Tachycardia, bradycardia Cardiac structural disorder Acute mitral or aortic regurgitation, ruptured interventricular septum, prosthetic valve malfunction Symptoms and Signs Altered mental status (eg, lethargy[merckmanuals.com]
Altered Mental Status
  • 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[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]
Paresthesia
  • […] and supine hypertension. 14 , 15 Midodrine (ProAmitine), a vasoconstrictor, is effective in some cases of orthostatic hypotension. 17 [Evidence level A, randomized controlled trial] The most common side effects are pupillary dilation, piloerection, paresthesias[aafp.org]

Workup

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.

Treatment

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

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:

Etiology

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.

Epidemiology

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. 

Sex distribution
Age distribution

Pathophysiology

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

Stage IV

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

Prevention

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

Summary

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.

Patient Information

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:

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.

References

Article

  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. 

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Last updated: 2018-06-22 07:30