Which finding is a risk factor for hypovolemic shock?
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HistoryIn a patient with possible shock secondary to hypovolemia, the history is vital in determining the possible causes and in directing the workup. Hypovolemic shock secondary to external blood loss typically is obvious and easily diagnosed. Internal bleeding may not be as obvious as patients may complain only of weakness, lethargy, or a change in mental status. Symptoms of shock, such as weakness, lightheadedness, and confusion, should be assessed in all patients. In the patient with trauma, determine the mechanism of injury and any information that may heighten suspicion of certain injuries (eg, steering wheel damage or extensive passenger compartment intrusion in a motor vehicle accident). If conscious, the patient may be able to indicate the location of pain. Vital signs, prior to arrival in the emergency department, should also be noted. Chest, abdominal, or back pain may indicate a vascular disorder. The classic sign of a thoracic aneurysm is a tearing pain radiating to the back. Abdominal aortic aneurysms usually result in abdominal, back, or flank pain. In patients with gastrointestinal (GI) bleeding, inquiry about hematemesis, melena, alcohol drinking history, excessive nonsteroidal anti-inflammatory drug use, and coagulopathies (iatrogenic or otherwise) is very important. The chronology of vomiting and hematemesis should be determined. The patient who presents with hematemesis after multiple episodes of forceful vomiting is more likely to have Boerhaave syndrome or a Mallory-Weiss tear, whereas a patient with a history of hematemesis from the start is more likely to have peptic ulcer disease or esophageal varices. If a gynecologic cause is being considered, gather information about the following: last menstrual period, risk factors for ectopic pregnancy, vaginal bleeding (including amount and duration), vaginal passage of products of conception, and pain. All women of childbearing age should undergo a pregnancy test, regardless of whether they believe that they are pregnant. A negative pregnancy test typically excludes ectopic pregnancy as a diagnosis.  Physical ExaminationThe physical examination should always begin with an assessment of the airway, breathing, and circulation. Once these have been evaluated and stabilized, the circulatory system should be evaluated for signs and symptoms of shock. Do not rely on systolic BP as the main indicator of shock; this practice results in delayed diagnosis. Compensatory mechanisms prevent a significant decrease in systolic BP until the patient has lost 30% of the blood volume. More attention should be paid to the pulse, respiratory rate, and skin perfusion. Also, patients taking beta-blockers may not present with tachycardia, regardless of the degree of shock. Classes of hemorrhage have been defined by the American College of Surgeons Advanced Trauma Life Support (ATLS), based on the percentage of blood volume loss. However, the distinction between these classes in the hypovolemic patient often is less apparent. Treatment should be aggressive and directed more by response to therapy than by initial classification. Class I hemorrhage (loss of 0-15%)In the absence of complications, only minimal tachycardia is seen. Usually, no changes in BP, pulse pressure, or respiratory rate occur. A delay in capillary refill of longer than 3 seconds corresponds to a volume loss of approximately 10%. Class II hemorrhage (loss of 15-30%)Clinical symptoms include tachycardia (rate >100 beats per minute), tachypnea, decrease in pulse pressure, cool clammy skin, delayed capillary refill, and slight anxiety. The decrease in pulse pressure is a result of increased catecholamine levels, which causes an increase in peripheral vascular resistance and a subsequent increase in the diastolic BP. Class III hemorrhage (loss of 30-40%)By this point, patients usually have marked tachypnea and tachycardia, decreased systolic BP, oliguria, and significant changes in mental status, such as confusion or agitation. In patients without other injuries or fluid losses, 30-40% is the smallest amount of blood loss that consistently causes a decrease in systolic BP. Most of these patients require blood transfusions, but the decision to administer blood should be based on the initial response to fluids. Class IV hemorrhage (loss of >40%)Symptoms include the following: marked tachycardia, decreased systolic BP, narrowed pulse pressure (or immeasurable diastolic pressure), markedly decreased (or no) urinary output, depressed mental status (or loss of consciousness), and cold and pale skin. This amount of hemorrhage is immediately life threatening. Issues to considerA study found substantial variability between blood loss and clinical signs. This study concluded that it was difficult to establish specific cutoff points for clinical signs that could be used as triggers for clinical interventions. [8] In the patient with trauma, hemorrhage usually is the presumed cause of shock. However, it must be distinguished from other causes of shock. These include cardiac tamponade (muffled heart tones, distended neck veins), tension pneumothorax (deviated trachea, unilaterally decreased breath sounds), and spinal cord injury (warm skin, lack of expected tachycardia, neurological deficits). The four areas in which life-threatening hemorrhage can occur are as follows: chest, abdomen, thighs, and outside the body. Note the following:
In the patient without trauma, the majority of the hemorrhage is in the abdomen. The abdomen should be examined for tenderness, distension, or bruits. Look for evidence of an aortic aneurysm, peptic ulcer disease, or liver congestion. Also check for other signs of bruising or bleeding. In the pregnant patient, perform a sterile speculum examination. However, with third-trimester bleeding, the examination should be performed as a "double set-up" in the operating room. Check for abdominal, uterine, or adnexal tenderness.
Author Paul Kolecki, MD, FACEP Associate Professor, Department of Emergency Medicine, Director of Undergraduate Emergency Medicine Student Education, Thomas Jefferson University Hospital, Jefferson Medical College of Thomas Jefferson University; Consultant, Philadelphia Poison Control Center Paul Kolecki, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians Disclosure: Nothing to disclose. Coauthor(s) Carl R Menckhoff, MD, FACEP Emergency Medicine Physician Carl R Menckhoff, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians Disclosure: Nothing to disclose. Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Amin Antoine Kazzi, MD Professor of Clinical Emergency Medicine, Department of Emergency Medicine, American University of Beirut, Lebanon Amin Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine Disclosure: Nothing to disclose. Chief Editor Barry E Brenner, MD, PhD, FACEP Program Director, Emergency Medicine, Einstein Medical Center Montgomery Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Additional Contributors Daniel J Dire, MD, FACEP, FAAP, FAAEM Professor of Pediatrics and Emergency Medicine, University of Texas Health Science Center at San Antonio, Joe R and Teresa Lozano Long School of Medicine Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, Association of Military Surgeons of the US Disclosure: Nothing to disclose. What are risk factors for hypovolemic shock?Hypovolemic shock can affect anyone who's had a traumatic accident that causes a lot of bleeding. A loss of fluids from throwing up, sweating or having diarrhea can also affect anyone, and any of these can lead to hypovolemic shock.
What are 5 signs of hypovolemia?Hypovolemia is a condition that occurs when your body loses fluid, like blood or water.. Dizziness when standing.. Dry skin and dry mouth.. Feeling tired (fatigue) or weak.. Muscle cramps.. Unable to pee (urinate) or the color of your urine is darker than normal.. Which of the following assessment findings is an early indication of hypovolemic shock?During the earliest stage of hypovolemic shock, a person loses less than 20% of their blood volume. This stage can be difficult to diagnose because blood pressure and breathing will still be normal. The most noticeable symptom at this stage is skin that appears pale. The person may also experience sudden anxiety.
Which assessment findings indicate that a patient is experiencing hypovolemic shock?Symptoms include the following: marked tachycardia, decreased systolic BP, narrowed pulse pressure (or immeasurable diastolic pressure), markedly decreased (or no) urinary output, depressed mental status (or loss of consciousness), and cold and pale skin. This amount of hemorrhage is immediately life threatening.
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