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  • • Inadequate circulating blood volume

    • Inadequate end organ perfusion

Epidemiology

  • • 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

Surgery

Indications

  • • Evidence of internal bleeding

    • Unstable vitals despite resuscitation

    • Ongoing fluid requirements

Treatment Monitoring

  • • Blood pressure monitoring

    • Urinary output

    • ECG

Prognosis

  • • Varies with etiology and severity

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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