HYPOVOLEMIC

SHOCK
Definition
◦ Hypovolemic shock refers to a medical or surgical condition in which rapid fluid
loss results in multiple organ failure due to inadequate circulating volume and
subsequent inadequate perfusion.
◦ The functions of the endothelium are highly altered following hypovolemic shock
due to ischemia of the endothelial cells and by reperfusion due to resuscitation
with fluids. Due to oxygen deprivation, endothelial cell apoptosis is induced
following hypovolemic shock.
◦ Most often, hypovolemic shock is secondary to rapid blood loss (hemorrhagic
shock).
Causes
◦ Traumatic
Traumatic causes can result from penetrating and blunt trauma. Common traumatic injuries
that can result in hemorrhagic shock are myocardial laceration and rupture, major vessel
laceration, solid abdominal organ injury, pelvic and femoral fractures, and scalp lacerations.
◦ Vascular
Include aneurysms, dissections, and arteriovenous malformations.
◦ GI disorders
Include the following: bleeding esophageal varices, bleeding peptic ulcers, Mallory-Weiss
tears, and aortointestinal fistulas.
◦ Pregnancy-related disorders
Include ruptured ectopic pregnancy, placenta previa, and abruption of the placenta.
Physical Examination
◦ The physical examination should always begin with an assessment of the airway,
breathing, and circulation.
◦ Classes of hemorrhage have been defined, based on the percentage of blood
volume loss:
◦ Class I hemorrhage (loss of 0-15%)
In the absence of complications, only minimal tachycardia is seen. Usually, no changes in BP,
pulse pressure, or respiratory rate occur. A delay in capillary refill of longer than 3
seconds corresponds to a volume loss of approximately 10%.
◦ Class II hemorrhage (loss of 15-30%)
Clinical symptoms include tachycardia (rate >100 beats per minute), tachypnea, decrease in
pulse pressure, cool clammy skin, delayed capillary refill, and slight anxiety.
◦ Class III hemorrhage (loss of 30-40%)
By this point, patients usually have marked tachypnea and tachycardia, decreased systolic
BP, oliguria, and significant changes in mental status, such as confusion or agitation.
◦ Class IV hemorrhage (loss of >40%)
Symptoms include the following: marked tachycardia, decreased systolic BP, narrowed pulse
pressure (or immeasurable diastolic pressure), markedly decreased (or no) urinary output,
depressed mental status (or loss of consciousness), and cold and pale skin. This amount of
hemorrhage is immediately life threatening.
The workup for the patient with trauma and signs and symptoms of hypovolemia is directed toward
finding the source of blood loss. If patients are suspected:
◦ Abdominal aortic aneurysm → Ultrasonographic examination
◦ GI bleeding → nasogastric tube + gastric lavage
◦ Pregnancy test in all female patients of childbearing age.
◦ Pregnant + shock → surgical consultation + consideration of bedside pelvic ultrasonography
◦ Thoracic dissection → transesophageal echocardiography, aortography, or CT scanning of the
chest.
◦ Traumatic abdominal injury → abdominal sonography for trauma (FAST) for stable/unstable
patients, CT scanning for stable patients.
◦ Fracture → radiographs
Emergency Department Care
1. Maximizing Oxygen Delivery
Patient’s airway should be assessed immediately and stabilized if necessary. High flow supplemental
oxygen and ventilatory support should be given if needed. Once IV access is obtained, initial fluid
resuscitation is performed with an isotonic crystalloid, such as lactated Ringer solution or normal
saline. An initial bolus of 1-2 L is given in an adult (20 mL/kg in a pediatric patient), and the patient's
response is assessed. The position of the patient can be used to improve circulation as such raising
the hypotensive patient's legs while fluid is being given.
2. Controlling further blood loss
Control of further hemorrhage depends on the source of bleeding and often requires surgical
intervention. In the patient with trauma, external bleeding should be controlled with direct pressure;
internal bleeding requires surgical intervention. Long-bone fractures should be treated with traction to
decrease blood loss.
3. Resuscitation
Antisecretory agents: these agents have vasoconstrictive properties and can reduce blood flow to
portal systems.
◦ Somatostatin (Zecnil)
Naturally occurring tetradecapeptide isolated from the hypothalamus and pancreatic and enteric
epithelial cells. Diminishes blood flow to portal system because of vasoconstriction. Has
similar effects as vasopressin but does not cause coronary vasoconstriction. Rapidly cleared from
the circulation, with an initial half-life of 1-3 min.
◦ Octreotide (Sandostatin)
Synthetic octapeptide. Compared to somatostatin, has similar pharmacological actions with
greater potency and longer duration of action. Used as adjunct to nonoperative management
of secreting cutaneous fistulas of the stomach, duodenum, small intestine (jejunum and ileum), or
pancreas.
Complications
◦ Neurological sequelae
◦ Death
◦ The prognosis is dependent on the degree of volume loss.