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  • • Inadequate circulating blood volume

    • Inadequate end organ perfusion

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Epidemiology

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  • • Hemorrhage

    • Protracted vomiting

    • Protracted diarrhea

    • Fluid sequestration in gut lumen

    • Loss of plasma into tissues (burns, trauma)

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Symptoms and Signs

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  • • 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

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Laboratory Findings

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  • • Concentrated urine

    • Initial Hct is of no value in acute blood loss

    • ST depression, Q waves

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Rule Out

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  • • Intoxication

    • Hypoglycemia

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  • • Physical exam/trauma work-up

    • Serial Hgb

    • ABG measurements

    • UA

    • Blood glucose

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  • • 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

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Surgery

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Indications

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  • • Evidence of internal bleeding

    • Unstable vitals despite resuscitation

    • Ongoing fluid requirements

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Treatment Monitoring

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  • • Blood pressure monitoring

    • Urinary output

    • ECG

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Prognosis

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  • • Varies with etiology and severity

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References

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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