Hypovolemia

Hypovolemia
Classification and external resources
ICD-10	E86, R57.1, T81.1
ICD-9	276.52
MeSH	D020896

In physiology and medicine, hypovolemia (also hypovolaemia) is a state of decreased blood volume; more specifically, decrease in volume of blood plasma.^[1][2] It is thus the intravascular component of volume contraction (or loss of blood volume due to things such as hemorrhaging or dehydration), but, as it also is the most essential one, hypovolemia and volume contraction are sometimes used synonymously.

Hypovolemia is characterized by salt (sodium) depletion and thus differs from dehydration, which is defined as excessive loss of body water.^[3]

Causes

Common causes of hypovolemia are dehydration, bleeding, vomiting,^[4] severe burns^[5][6] and drug vasodilators typically used to treat hypertensive individuals. Rarely, it may occur as a result of a blood donation,^[7] sweating,^[4] and alcohol consumption.^[4] It is also common during surgery due to the use of anesthetics, nil-by-mouth, and in-operation bleeding. A ruptured ovarian cyst associated with (PCOS - polycystic ovarian syndrome) may cause severe internal bleeding, causing hypovolemic shock.

Diagnosis

Clinical symptoms may not be present until 10–20% of total whole-blood volume is lost.

Hypovolemia can be recognized by tachycardia, diminished blood pressure,^[8] and the absence of perfusion as assessed by skin signs (skin turning pale) and/or capillary refill on forehead, lips and nail beds. The patient may feel dizzy, faint, nauseated, or very thirsty. These signs are also characteristic of most types of shock.

Note that in children, compensation can result in an artificially high blood pressure despite hypovolemia. Children will typically compensate (maintain blood pressure despite loss of blood volume) for a longer period than adults, but will deteriorate rapidly and severely once they do begin to decompensate. This is another reason (aside from initial lower blood volume) that even the possibility of internal bleeding in children should almost always be treated aggressively.

Also look for obvious signs of external bleeding while remembering that people can bleed to death internally without any external blood loss.

Also consider possible mechanisms of injury that may have caused internal bleeding such as ruptured or bruised internal organs. If trained to do so and the situation permits, conduct a secondary survey and check the chest and abdomen for pain, deformity, guarding, discoloration or swelling. Bleeding into the abdominal cavity can cause the classical bruising patterns of Grey Turner's sign or Cullen's sign.

Stages of hypovolemic shock

Most sources state that there are 4 stages of hypovolemic shock,^[9][10] however a number of other systems exist with as many as 5 stages.^[11]

The 4 stages are sometimes known as the "Tennis" staging of hypovolemic shock, as the 4 stages of % volume of blood loss mimic the scores in a game of tennis: 15, 15-30, 30-40, 40.^[9][10] It is basically the same as used in classifying bleeding by blood loss.

Stage 1

• Up to 15% blood volume loss (750 mL)^[9]
• Compensated by constriction of vascular bed
• Blood pressure maintained
• Normal respiratory rate
• Pallor of the skin
• Normal mental status^[12] to slight anxiety
• Normal capillary refill^[12]
• Normal urine output^[12]

Stage 2

• 15–30% blood volume loss (750–1500 mL)^[9]
• Cardiac output cannot be maintained by arterial constriction
• Tachycardia >100bpm
• Increased respiratory rate
• Blood pressure maintained
• Increased diastolic pressure
• Narrow pulse pressure
• Sweating from sympathetic stimulation
• Mildly anxious/Restless
• Delayed capillary refill^[12]
• Urine output of 20-30 milliliters/hour^[12]

Stage 3

• 30–40% blood volume loss (1500–2000 mL)^[9]
• Systolic BP falls to 100mmHg or less
• Classic signs of hypovolemic shock
• Marked tachycardia >120 bpm
• Marked tachypnea >30 bpm
• Alteration in mental status (confusion,^[12] anxiety, agitation)
• Sweating with cool, pale skin
• Delayed capillary refill^[12]
• Urine output of approximately 20 milliliters/hour^[12]

Stage 4

• Loss greater than 40% (>2000 mL)^[9]
• Extreme tachycardia (>140^[12]) with weak pulse
• Pronounced tachypnea
• Significantly decreased systolic blood pressure of 70 mmHg or less
• Decreased level of consciousness, lethargy,^[12] coma^[12]
• Skin is sweaty, cool, and extremely pale (moribund)
• Absent capillary refill^[12]
• Negligible urine output^[12]

Treatment

Minor hypovolemia from a known cause that has been completely controlled (such as a blood donation from a healthy patient who is not anemic) may be countered with initial rest for up to half an hour. Oral fluids that include moderate sugars and electrolytes are needed to replenish depleted sodium ions. Furthermore the advice for the donor is to eat good solid meals with proteins for the next few days. Typically, this would involve a fluid volume of less than one liter, although this is highly dependent on body weight. Larger people can tolerate slightly more blood loss than smaller people.

More serious hypovolemia should be assessed by a physician.

First aid

External bleeding should be controlled by direct pressure. If direct pressure fails, a tourniquet should be used in the case of hemorrhage that cannot be controlled by direct pressure. If left on for more than 8 hours, the use of a tourniquet can kill all the tissue below its application upon a limb, making amputation necessary.

The US Military now suggests applying a tourniquet to a bleeding extremity first, because direct pressure does not usually stop bleeding. Other techniques such as elevation and pressure points usually fail completely.

If a first-aid provider recognizes internal bleeding the life-saving measure to take is to immediately call for emergency assistance.

Field care

Emergency oxygen should be immediately employed to increase the efficiency of the patient's remaining blood supply^{[citation needed]}. This intervention can be life-saving^{[citation needed]}.

The use of intravenous fluids (IVs) may help compensate for lost fluid volume, but IV fluids cannot carry oxygen in the way that blood can, however blood substitutes are being developed which can. Infusion of colloid or crystalloid IV fluids will also dilute clotting factors within the blood, increasing the risk of bleeding. It is current best practice to allow permissive hypotension in patients suffering from hypovolemic shock^[13] both to ensure clotting factors are not overly diluted but also to stop blood pressure being artificially raised to a point where it "blows off" clots that have formed.

Hospital treatment

If the hypovolemia was caused by medication, the administration of antidotes may be appropriate but should be carefully monitored to avoid shock or the emergence of other pre-existing conditions^{[citation needed]}.

Fluid replacement is beneficial in hypovolemia of stage 2, and is necessary in stage 3 and 4.^[12] Blood transfusions coupled with surgical repair are the definitive treatment for hypovolemia caused by trauma^{[citation needed]}. See also the discussion of shock and the importance of treating reversible shock while it can still be countered.

For a patient presenting with hypovolemic shock in hospital the following investigations would be carried out:

• Blood tests: U+Es/Chem7, FBC, Glucose, Cross-match
• Central Venous Line/Blood Pressure
• Arterial Line/Arterial Blood Gases
• Urine output measurements (via urinary catheter)
• Blood pressure
• SpO2 Oxygen saturations

The following interventions would be carried out:

• IV access
• Oxygen as required
• Surgical repair at sites of hemorrhage
• Inotrope therapy (Dopamine, Noradrenaline)
• Fresh frozen plasma/whole blood

History

Hypovolemia has historically been termed desanguination (from Latin sanguis, blood), meaning a massive loss of blood. The term was widely used by the Hippocrates in traditional medicine practiced in the Greco-Roman civilization and in Europe during the Middle Ages. The word was possibly used to describe the lack of personality (by death or by weakness) that often occurred once a person suffered hemorrhage or massive blood loss.

In cases in which loss of blood volume is clearly attributable to bleeding (as opposed to, e.g., dehydration), most medical practitioners of today prefer the term exsanguination for its greater specificity and descriptiveness, with the effect that the latter term is now more common in the relevant context.^[14]

In popular culture

In The Simpsons episode "Blood Feud" (7F22: Season 2, Episode 22), C. Montgomery Burns suffers an attack of hypovolemia, described by Dr. Julius Hibbert as "hypohemia, meaning 'low blood'"; writers coined the latter term to satirize the proliferation of complex medical terms for conditions easily describable in plain English. The writers used the same roots occurring in the first and last elements of hypovolemia, with the added h being a transliteration of the breath mark placed over the initial alpha of the Greek root -[h]aim- when that element occurs at the start of a word or (in English words coined from Greek roots, but not in classical Greek) after an element that ends in a vowel.

In the horror film Saw V, two victims are each forced to provide 5 US pints (2,370 mL) of blood, producing markedly noticeable symptoms of hypovolemia.

See also

• Volume status
• Hypervolemia
• Exsanguination

References

1. ^ MedicineNet > Definition of Hypovolemia Retrieved on July 2, 2009
2. ^ TheFreeDictionary.com --> hypovolemia Citing Saunders Comprehensive Veterinary Dictionary, 3 ed. Retrieved on July 2, 2009
3. ^ MedicineNet > Definition of Dehydration Retrieved on July 2, 2009
4. ^ ^{a b c} Carlson, N. R. (2005). Foundations of Physiological Psychology: Custom edition for SUNY Buffalo. Boston, MA: Pearson Custom Publishing.
5. ^ http://www.totalburncare.com/orientation_burn_shock.htm
6. ^ http://www.patient.co.uk/doctor/Resuscitation-in-Hypovolaemic-Shock.htm
7. ^ Danic B, Gouézec H, Bigant E, Thomas T (June 2005). "[Incidents of blood donation]" (in French). Transfus Clin Biol 12 (2): 153–9. doi:10.1016/j.tracli.2005.04.003. PMID 15894504. 
8. ^ http://www.stagesofshock.com/stage3/index.html
9. ^ ^{a b c d e f} http://www.ambulancetechnicianstudy.co.uk/shock.html
10. ^ ^{a b} http://dynamicnursingeducation.com/class.php?class_id=47&pid=18
11. ^ http://www.stagesofshock.com/stage1/index.html
12. ^ ^{a b c d e f g h i j k l m n} Elizabeth D Agabegi; Agabegi, Steven S. (2008). Step-Up to Medicine (Step-Up Series). Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-7153-6. 
13. ^ http://www.trauma.org/archive/resus/permissivehypotension.html Permissive Hypotension
14. ^ L. Geeraedts Jr., H. Kaasjager, A. van Vugt, and J. Frölke, "Exsanguination in trauma: A review of diagnostics and treatment options", Injury, Volume 40, Issue 1, pages 11-20.

External links

• CRISP Thesaurus 00004050
• DDB 29217