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Updated: Dec 4 2021

Hypovolemic Shock

  • 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 TypeSkin

      Wedge Pressure (PCWP) (Preload)

      Systemic Vascular Resistance (SVR) (Afterload)
      Cardiac Output
      Hyovolemic Cold and clammy skin ↓↓
      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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