Hypovolemic Shock

Hypovolemic shock
this ppt discuss the different aspect of shock including ( definition & causes & symptoms & signs & work up & treatment)

1. HYPOVOLEMIC SHOCK Abdallah Sabry EL Gameel House officer Alexandria main university hospital

2. Definition Shock : it ’s a problem that occurs at the cellular level caused by decrease tissue perfusion . H ypovolemic shock : shock results from decrease circulatory volume often secondary to haemorrhag e . Signs of decrease tissue perfusion D ecrease GCS T achypnea Tachycardia Decrease urine output Delayed capillary refilling Mottled skin Increase serum lactate

3. Causes Haemorrhage T rauma ( external/internal ) e.g. Scalp lacerations & pelvic fracture. Rupture AAA / ectopic pregnancy Git bleeding Salt and water loss Diarrhoea Vomiting Polyurea ( DI / DM ) Burns Heat 3rd space loss Ascites Acute pancreatitis Intestinal obstructions I nadequate fluid intake e.g. S tarvation

4. Symptoms Symptoms of underlying disease Trauma to chest & limb & abdomen Pain in chest & abdomen & back M elena & haematemesis Diarrhoea & Urinary frequency Epigastric pain radiating to the back Abdominal swelling / bloating Dizziness on standing ( +/- lying ) S hortening of breathing C hest pain

5. Signs Vitals Blood pressure : < 100 mmHg or a drop of > 40 mmHg from the baseline. Heart rate: >100 / min . Weak, thready Respiratory rate: increase Extrimities C ool / pale / mottled periperies Delayed capillary refilling > 2 sec. Decrease JVP CNS Decrease GCS / restlessness / confusion. Renal function Oligourea (< 0.5 ml/kg/hr ) OR acute increase in serum creatinine. G lobal Increase lactate ( in absence of hypoxaemia )

6. Sign s Sign of underlying disease Obivious source of bleeding ( wounds & GIT bleeding) Internal source of bleeding ( haemothorax & ascites & tense abdomen & Pelvic instability & Swollen thighs B urns Palpable AAA Tender epigastrium & grey turner’s syndrome & Cullen’S sign Melena & fresh blood in PR

7. Note to Know Tachycardia be absent in pt on rate- limiting medications e.g. ( beta blockers & CCB) Absolute values of HR and BP are less informative than monitoring of trends over time. Some patients may maintain BP within normal limits despite organ dys f unction, but consider local pathology if there is single organ dysfunction, e.g. oliguria, without clear evidence of haemodynamic compromise .

8. Warning sign s Blood pressure < 90 mmHg Decrease GCS& restlessness Oligourea Mottled skin not respond to IV fluids Ongoing bleeding

9. Work up Full blood count …. ( decrease Hb BUT mey be normal in early acute blood loss ) Urea …… ( increase in GIT bleeding ) Electrolyte s …… ( K decrease in diarrhea & vomiting ) LFT & Amylase Clotting & osmolality & X-match ( consider O –ve and types specific blood while awaiting match ) ABG …….. ( Acidosis in DKA & haemorrhage & pancreatitis )( Alkalosis in vomiting ) ECG ….. Ischaemia X- ray ... ( Haemothorax & pelvic fracture ) U/S Abdomen ….. ( AAA & free intra-abdominal fluid ) Urine analysis …. ( Na and osmolality in diabetes insipidus ) Stool analysi s …… microscopic / C&S ( Ova & cyst s & parasite )

10. Note to Know Treat all hypotensive patients, especially if HR >100 or <50. A BP of 100mmHg systolic may be critically low if the patient is normally hypertensive ( eg elderly); use HR and other clinical markers as a guide. Always consider giving a fluid challenge early, particularly if you remain unclear on the type of shock you are faced with. In the ab s ence of florid evidence of failure, you are unlikely to push any adult into gross cardiac failure with e.g. 500mL 0.9% saline IV, which should help with circulatory support while you assess and plan further .

11. treatment Lay pt flat and elevated legs Oxygen 15 L/ min. IV access ( 2 large bore cannula and take sample for investigation ) 1 litre saline 0.9 % A ttempt to stop bleeding by compression if there external bleeding. C onsider another 1 litre saline 0.9 % If no increase in Bp or decrease in HR Consider early blood transfusion as excessive fluid cause haemodilution of the clotting factors Treatment of the cause D ocument blood and fluid carefully

12. Note to Know Permissive hypotension Is empolyed in the early phase of haemorrhagic shock so don’t Push systolic pressure above 100 mmHg . Permissive hypotension : means maintaining of blood pressure below normal during resuscitation in traumatic patients is allowed as Aggressive fluid resuscitation in trauma promotes deleterious effects such as clot disruption, dilutional coagulopathy and hypothermia .

13. Thank you