Updated: 12/21/2019

Hypovolemic Shock

0%
Topic
Review Topic
0
0
0%
0%
Questions
6 6
0
0
0%
0%
Evidence
9 9
0
0
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
 
 

Please rate topic.

Average 4.8 of 9 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(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? Review Topic | Tested Concept

QID: 107575
1

Endotracheal intubation

0%

(0/2)

2

Cricothyroidotomy

50%

(1/2)

3

Nasogastric tube

0%

(0/2)

4

Continuous positive airway pressure (CPAP)

50%

(1/2)

5

Cardiopulmonary resusication

0%

(0/2)

L 3 C

Select Answer to see Preferred Response

You have 100% on this question.
Just skip this one for now.

(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? Review Topic | Tested Concept

QID: 106374
1

Blood transfusion with unmatched blood

0%

(0/19)

2

Focused Assessment with Sonography for Trauma (FAST) scan

16%

(3/19)

3

Orotracheal intubation

53%

(10/19)

4

Type and screen for matched blood transfusion

0%

(0/19)

5

Cricothyroidotomy

26%

(5/19)

L 3 E

Select Answer to see Preferred Response

You have 100% on this question.
Just skip this one for now.

(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?
Review Topic | Tested Concept

QID: 106224
1

Septic shock

3%

(1/30)

2

Hypovolemic shock

80%

(24/30)

3

Anaphylactic shock

0%

(0/30)

4

Neurogenic shock

3%

(1/30)

5

Cardiogenic shock

10%

(3/30)

L 2 E

Select Answer to see Preferred Response

Evidences (9)
Topic COMMENTS (7)
Private Note