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  • • Inadequate circulating blood volume

    • Inadequate end organ perfusion




  • • Hemorrhage

    • Protracted vomiting

    • Protracted diarrhea

    • Fluid sequestration in gut lumen

    • Loss of plasma into tissues (burns, trauma)


Symptoms and Signs


  • • Postural hypotension

    • Cutaneous vasoconstriction

    • Sweating

    • Neck vein collapse

    • Concentrated urine

    • Oliguria (< 0.5 mL/kg/h in adult)

    • Decreasing Hgb with fluid administration

    • Delayed capillary refill (> 2 seconds)

    • Thirst

    • Hypotension (degree varies with severity of volume loss)

    • Confusion, restlessness, lethargy

    • Irregular heart rate

    • Little correlation between heart rate and severity of hypovolemia


Laboratory Findings


  • • Concentrated urine

    • Initial Hct is of no value in acute blood loss

    • ST depression, Q waves


Rule Out


  • • Intoxication

    • Hypoglycemia


  • • Physical exam/trauma work-up

    • Serial Hgb

    • ABG measurements

    • UA

    • Blood glucose


  • • Establish airway

    • Nasal oxygen at minimum

    • Control external hemorrhage

    • Preparations for surgery for patients with internal bleeding

    • Large bore venous catheters

    • 2 L crystalloid (normal saline or lactated Ringer's solution) wide open for initial resuscitation of severe shock

    • Third liter of crystalloid over 10 min should be adequate in patients in whom bleeding has been controlled

    • In general, blood should be withheld until bleeding has been controlled

    • Blood should be started in those who remain unstable after 3 L of crystalloid






  • • Evidence of internal bleeding

    • Unstable vitals despite resuscitation

    • Ongoing fluid requirements


Treatment Monitoring


  • • Blood pressure monitoring

    • Urinary output

    • ECG




  • • Varies with etiology and severity



Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342:1301.
Velmahos GC et al. Endpoints of resuscitation of critically injured patients: normal or supranormal? A prospective randomized trial. Ann Surg. 2000;232:409.  [PubMed: 10973391]
Carson JL et al: Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion. Transfusion 2002;42:812.  [PubMed: 12375651]
Cotton BA et al: The cellular, metabolic, and systemic consequences of aggressive fluid resuscitation strategies. Shock 2006;26:115.  [PubMed: 16878017]
Eastridge BJ et al: Hypotension begins at 110 mm Hg: redefining “hypotension” with data. J Trauma 2007;63:291.  [PubMed: 17693826]

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