Hypovolemia

Hypovolemia
Classification and external resources
Specialty Emergency medicine
ICD-10 E86, R57.1, T81.1
ICD-9-CM 276.52
MedlinePlus 000167
MeSH D020896

Hypovolemia (also hypovolaemia or oligemia) is a state of decreased blood volume; more specifically, decrease in volume of blood plasma.[1][2] It is thus the intravascular component of volume contraction (or loss of blood volume due to things such as bleeding or dehydration), but, as it also is the most essential one, hypovolemia and volume contraction are sometimes used synonymously.

Hypovolemia is characterized by sodium (salt) depletion and thus differs from dehydration, which is defined as excessive loss of body water.[3]

Causes

Common causes of hypovolemia are[4]

Excessive sweating is not a cause of hypovolemia, because the body eliminates significantly more water than sodium.[8]

Diagnosis

Clinical symptoms may not be present until 10–20% of total whole-blood volume is lost.

Hypovolemia can be recognized by tachycardia, diminished blood pressure,[9] and the absence of perfusion as assessed by skin signs (skin turning pale) and/or capillary refill on forehead, lips and nail beds. The patient may feel dizzy, faint, nauseated, or very thirsty. These signs are also characteristic of most types of shock.

Note that in children, compensation can result in an artificially high blood pressure despite hypovolemia. Children will typically compensate (maintain blood pressure despite loss of blood volume) for a longer period than adults, but will deteriorate rapidly and severely once they do begin to decompensate. This is another reason (aside from initial lower blood volume) that even the possibility of internal bleeding in children should almost always be treated aggressively.

Also look for obvious signs of external bleeding while remembering that people can bleed to death internally without any external blood loss. ("Blood on the floor, plus 4 more" = intrathoracic, intraperitoneal, retroperitoneal, pelvis/thigh)

Also consider possible mechanisms of injury that may have caused internal bleeding such as ruptured or bruised internal organs. If trained to do so and the situation permits, conduct a secondary survey and check the chest and abdomen for pain, deformity, guarding, discoloration or swelling. Bleeding into the abdominal cavity can cause the classical bruising patterns of Grey Turner's sign or Cullen's sign.

Stages of hypovolemic shock

Video explanation of shock

Usually referred to as "class" of shock. Most sources state that there are 4 stages of hypovolemic shock;[10] however, a number of other systems exist with as many as 6 stages.[11]

The 4 stages are sometimes known as the "Tennis" staging of hypovolemic shock as the stages of blood loss (under 15% of volume, 15-30% of volume, 30-40% of volume and above 40% of volume) mimic the scores in a game of tennis: 15, 15-30, 30-40 and 40.[12] It is basically the same as used in classifying bleeding by blood loss.

The signs and symptoms of the major stages of hypovolemic shock include:[13]

Stage 1 Stage 2 Stage 3 Stage 4
Blood loss Up to 15% (750mL) 15-30% (750-1500mL) 30-40% (1500-2000mL) Over 40% (over 2000mL)
Blood pressure Normal (Maintained
by vasoconstriction) 		Increased diastolic BP Systolic BP < 100 Systolic BP < 70
Heart rate Normal Slight tachycardia (> 100bpm) Tachycardia (> 120bpm) Extreme tachycardia (> 140bpm) 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 Pale, cool, clammy Increased diaphoresis Extreme diaphoresis; mottling possible
Capillary refill Normal Delayed Delayed Absent
Urine output Normal 20-30mL/hr 20ml/hr Negligible

Treatment

Field care

Emergency oxygen should be immediately employed to increase the efficiency of the patient's remaining blood supply. This intervention can be life-saving.[14]

The use of intravenous fluids (IVs) may help compensate for lost fluid volume, but IV fluids cannot carry oxygen in the way that blood can, however blood substitutes are being developed which can. Infusion of colloid or crystalloid IV fluids will also dilute clotting factors within the blood, increasing the risk of bleeding. It is current best practice to allow permissive hypotension in patients suffering from hypovolemic shock,[15] both to ensure clotting factors are not overly diluted but also to stop blood pressure being artificially raised to a point where it "blows off" clots that have formed.

Hospital treatment

Fluid replacement is beneficial in hypovolemia of stage 2, and is necessary in stage 3 and 4.[13] See also the discussion of shock and the importance of treating reversible shock while it can still be countered.

For a patient presenting with hypovolemic shock in hospital the following investigations would be carried out:

The following interventions would be carried out:

History

In cases in which loss of blood volume is clearly attributable to bleeding (as opposed to, e.g., dehydration), most medical practitioners of today prefer the term exsanguination for its greater specificity and descriptiveness, with the effect that the latter term is now more common in the relevant context.[16]

See also

References

  1. ↑ "Hypovolemia definition - MedicineNet - Health and Medical Information Produced by Doctors". Medterms.com. 2012-03-19. Retrieved 2015-11-01.
  2. ↑ "Hypovolemia | definition of hypovolemia by Medical dictionary". Medical-dictionary.thefreedictionary.com. Retrieved 2015-11-01.
  3. ↑ "Dehydration definition - MedicineNet - Health and Medical Information Produced by Doctors". Medterms.com. 2013-10-30. Retrieved 2015-11-01.
  4. ↑ Sircar, S. Principles of Medical Physiology. Thieme Medical Pub. ISBN 9781588905727
  5. ↑ Danic B, Gouézec H, Bigant E, Thomas T (June 2005). "[Incidents of blood donation]". Transfus Clin Biol (in French) 12 (2): 153–9. doi:10.1016/j.tracli.2005.04.003. PMID 15894504.
  6. ↑ "Burn Shock / House Staff Manual". Total Burn Care. Retrieved 2015-11-01.
  7. ↑ "Resuscitation in Hypovolaemic Shock. Information page | Patient". Patient.info. Retrieved 2015-11-01.
  8. ↑ "Saladin 5e Extended Outline : Chapter 24 : Water, Electrolyte, and Acid–Base Balance". Highered.mcgraw-hill.com. Retrieved 2015-11-01.
  9. ↑ "Stage 3: Compensated Shock". Archived from the original on 2010-06-11.
  10. ↑ Hudson, Kristi. "Hypovolemic Shock - 1 Nursing CE". Archived from the original on 2009-06-06.
  11. ↑ "Stage 1: Anticipation stage (a new paradigm)"". Archived from the original on 2010-01-16.
  12. ↑ Greaves, Ian; Porter, Keith; Hodgetts, Timothy; et al., eds. (2006). Emergency Care: A Textbook for Paramedics. Elsevier Health Sciences. p. 229. ISBN 9780702025860.
  13. 1 2 Elizabeth D Agabegi; Agabegi, Steven S. (2008). Step-Up to Medicine (Step-Up Series). Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-7153-6.
  14. ↑ 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
  15. ↑ "Permissive Hypotension". Trauma.Org. 1997-08-31. Retrieved 2015-11-01.
  16. ↑ L. Geeraedts Jr., H. Kaasjager, A. van Vugt, and J. Frölke,. "Exsanguination in trauma: A review of diagnostics and treatment options". Injury 40 (1): 11–20. doi:10.1016/j.injury.2008.10.007.

External links

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