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hypovolemic shock
Shock resulting from loss of >20% of the circulating blood volume.
Etiology:
1) hemorrhage
2) dehydration
3) hypoadrenal (Addisonian) crisis
Pathology:
1) decreased central venous pressure (CVP)
2) low cardiac filling pressures
3) low cardiac output [3]
4) compensatory increase in systemic vascular resistance
Clinical manifestations:
- hypotension generally manifests when > 30% of blood volume is lost [4]
- more sensitive indicators of impending shock include:
- anxiety
- tachypnea
- weak peripheral pulse
- cool extremities with pale or mottled skin
Complications:
- coagulopathy
- hypercoagulable state with fibrinolysis shutdown
- dilutional coagulopathy due to crystalloid infusion
Management:
1) general strategies
a) rapid volume expansion
- intravenous (IV) fluids
- colloid
- blood products
- prehospital plasma transfusion lowers mortality in unstable trauma patients transported by air [5]
b) consider hemodynamic monitoring if coexisting medical problems
- congestive heart failure
- valvular heart disease
- myocardial ischemia
- renal insufficiency
2) specific strategies
- correct coagulopathy & thrombocytopenia
- correct electrolyte imbalances
- endoscopy
- interventional radiology
- surgery
- REBOA for pelvic or abdominal bleeding
3) avoid vasopressor use in hemorrhagic shock [2]
Specific
hypoadrenal (Addisonian) crisis; acute adrenal insufficiency
General
hypovolemia (extracellular volume depletion)
shock
References
- Manual of Medical Therapeutics, 28th ed, Ewald &
McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 136
- Sperry JL et al,
Early use of vasopressors after injury: Caution before
constriction.
J Trauma 2008, 64:9
PMID: 18188092
- Medical Knowledge Self Assessment Program (MKSAP) 14, 17.
American College of Physicians, Philadelphia 2006, 2015
- Rothaus C
Hemorrhagic Shock
NEJM Resident 360. Jan 24, 2018
https://resident360.nejm.org/content_items/hemorrhagic-shock
- Sperry JL, Guyette FX, Brown JBet al.
Prehospital plasma during air medical transport in trauma
patients at risk for hemorrhagic shock.
N Engl J Med 2018 Jul 26; 379:315
PMID: 30044935
https://www.nejm.org/doi/10.1056/NEJMoa1802345