Updated: 12/21/2019

Hypovolemic Shock

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Questions
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Evidence
9
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Topic
Snapshot
  • A 55-year-old man presents to the emergency room after collapsing while hiking. His hiking group reports that he had not had any water to drink as he was nauseous from food poisoning the night before when he had copious amounts of diarrhea. His blood pressure is 85/53 mmHg. On physical exam, he has no jugular venous distention, his mucous membranes are dry and skin is cold and clammy with reduced skin turgor. He is given fluids. (Hypovolemic shock)
Introduction
  • Clinical definition
    • shock secondary to ↓ intravascular volume
  • Etiology
    • hemorrhagic
      • trauma
      • gastrointestinal bleeding
      • ruptured aneurysm or hematoma
      • fistula
      • post-partum hemorrhage
    • non-hemorrhagic
      • gastrointestinal fluid losses
      • skin losses (e.g., burns or Stevens-Johnson syndrome)
      • renal losses
      • third space losses
  • Pathogenesis
    • an underlying event causes ↓ intravascular volume
    • ↓ intravascular volume → ↓ cardiac output (CO) + wedge pressure and compensatory ↑ systemic vascular resistance (SVR) 
Presentation
  • Symptoms
    • typically present with features of the underlying cause
  • Physical exam
    • hypotension
    • tachycardia
    • reduced skin turgor
    • nondistended jugular veins
    • dry mucous membranes
    • cold and clammy skin
Imaging
  • Imaging as needed to identify the underlying cause
Studies
  • Pulmonary artery catheterization  
    • findings
      • ↓ pulmonary capillary wedge pressure (PCWP < 15 mmHg)
      • ↓ cardiac output as severity progresses
      • ↑ systemic vascular resistance
  • Making the diagnosis
    • most cases are clinically diagnosed
Differential
 
Different Types of Shock
Shock Type Skin 

Wedge Pressure (PCWP) (Preload)

Systemic Vascular Resistance (SVR) (Afterload)
Cardiac Output
Hyovolemic Cold and clammy skin  ↓↓ 
Cardiogenic
Obstructive ↑ or ↓ ↔ or ↓↓
Distributive Warm or dry skin ↔ or ↓  ↓↓ ↓ or ↑
 
Treatment
  • Management approach
    • treat the underlying cause
    • establish the ABCs - airway, breathing, and circulation  
  • Medical
    • intravenous fluids with large-bore IVs
      • indications
        • for all patients
    • transfuse blood for hemorrhagic shock  
Complications
  • Acute renal failure
 

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Questions (6)
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(M2.CV.17.4690) A 34-year-old man presents to the emergency department by ambulance after being involved in a fight. On arrival, there is obvious trauma to his face and neck, and his mouth is full of blood. Seconds after suctioning the blood, his mouth rapidly fills up with blood again. As a result, he is unable to speak to you. An attempt at direct laryngoscopy fails as a result of his injuries. His vital signs are pulse 102/min, blood pressure 110/75 mmHg, and O2 saturation 97%. Which of the following is indicated at this time?

QID: 107575
1

Endotracheal intubation

10%

(1/10)

2

Cricothyroidotomy

70%

(7/10)

3

Nasogastric tube

0%

(0/10)

4

Continuous positive airway pressure (CPAP)

10%

(1/10)

5

Cardiopulmonary resusication

0%

(0/10)

M 7 D

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(M2.CV.15.57) A 17-year-old male is brought to the emergency department following a motor vehicle accident. He has suffered several wounds and is minimally responsive. There is a large laceration on his forehead as well as a fracture of his nasal bridge. He appears to be coughing and spitting blood. He is already wearing a soft collar. Vitals are as follows: T 36.4C, BP 102/70 mmHg, HR 126 bpm, and RR 18 rpm, and SpO2 is 88% on RA. He has 2 peripheral IVs and received 2L of IV normal saline on route to the hospital. There is frank blood in the oropharynx. Breath sounds are present bilaterally. Abdomen is distended and tender. Pulses are 1+. Which of the following should be the first step in management?

QID: 106374
1

Blood transfusion with unmatched blood

0%

(0/22)

2

Focused Assessment with Sonography for Trauma (FAST) scan

18%

(4/22)

3

Orotracheal intubation

45%

(10/22)

4

Type and screen for matched blood transfusion

5%

(1/22)

5

Cricothyroidotomy

27%

(6/22)

M 7 E

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(M2.CV.13.201) A 46-year-old male was found unconscious in the field and brought to the emergency department by EMS. The patient was intubated in transit and given a 2 liter bolus of normal saline. On arrival, the patient's blood pressure is 80/60 mmHg and temperature is 37.5C. Jugular veins are flat and capillary refill time is 4 seconds.

Vascular parameters are measured and are as follows:
Cardiac index - Low;
Pulmonary capillary wedge pressure (PCWP) - Low;
Systemic vascular resistance - High.

Which of the following is the most likely diagnosis?

QID: 106224
1

Septic shock

3%

(1/31)

2

Hypovolemic shock

81%

(25/31)

3

Anaphylactic shock

0%

(0/31)

4

Neurogenic shock

3%

(1/31)

5

Cardiogenic shock

10%

(3/31)

M 6 E

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Evidence (9)
EXPERT COMMENTS (7)
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