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What Is Hypovolemic Shock: Definition

Hypovolemic shockis an urgent medical condition, which occurs when a rapid decrease of the volume of
the intravascular fluidusually due to severe bleedingresults in inadequate perfusion of the peripheral
tissues and, eventually, in multiple organ failure1,43.
Hemorrhagic shockis hypovolemic shock caused by bleeding.
Typical symptoms and signs:a person does not look right, is anxious, has pale, cool and sweaty skin
and weak pulse, is lethargic and may lose consciousness.
Treatmentincludes stopping bleeding, intravenous fluid infusion, oxygen and drugs.

Table 1. Hypovolemic shock at a glance:

vital signs and first aid
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Causes and Risk Factors

The most common cause of hypovolemic shock in adults issevere bleeding,and in childrendiarrhea1.
Causes ofhypovolemia:
Loss of blood1
External bleeding:penetrating injury, heavy menstruation, scalp tear1
Gastrointestinal or rectal bleeding (blood in the stool):
Rupture of the esophageal varices (in chronic alcohol abuse with liver cirrhosis)
Esophageal tear due to violent vomiting, mostly in alcoholics (Mallory-Weiss syndrome)
Rupture of hemorrhoids
Aorto-intestinal fistula1
Bleeding peptic (gastric or duodenal) ulcer or gastric perforation (stomach cancer) or Meckels
diverticulum1,23
Ulcerative colitis
Ischemic colitis
Intestinal perforation (for example, in diverticulitis)
Iron toxicity5
Colorectal cancer (after age of 50)
Bleeding disorders, such as hemophilia23
Other causes of internal bleeding:
Spleen rupture in car/motorbike accidents1
Rupture of the aortic aneurysm or aortic dissection1
Rupture of hepatic hemangioma44
Retroperitoneal bleeding (anticoagulant therapy with warfarin or heparin in individuals with deep
venous thrombosis)3
Fracture of the pelvis or femur1
Hemorrhagic pancreatitis
Disseminated intravascular coagulation (DIC) after snake bite or in malaria14
Minor injuries in hemophilia
Bleeding during or after surgery
Pregnancy-related bleeding:
Ruptured ectopic pregnancy1
Placenta previa1
Placental detachment (abruptio placentae)1
Uterine rupture3
Bleeding after delivery2
Blood donation
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Loss of blood plasma

Severe burns affecting >15% skin surface2,23
Decreased water intake23
Water loss
Excessive sweating
Repeated vomiting
Severe diarrhea: gastroenteritis caused by rotavirus in small children (stomach flu), cholera2,3
Excessive urination or polyuria:
Diabetes mellitus15, diabetic ketoacidosis23
Diabetes insipidus
Diuretics
Salt-wasting kidney diseases (polycystic kidney disease)15
Hypercalcemia21
Endocrine causes:
Severe, acute thyrotoxicosis (thyroid storm) with high fever, excessive sweating and diarrhea36
Acute adrenal insufficiency (adrenal crisis) in acute Addisons disease with polyuria, vomiting and
diarrhea42
Second spacing:The fluid moves from the blood into the second space (the space between the cells,
which is also called extracellular or interstitial space) and causes edema:
Hyponatremia(a decrease in osmotic pressure of the blood results in a shift of water from the blood
into the body cells)
Congestive heart failure (blood pooling in the venous system and consequent escape of water into
the interstitial tissue [edema] and a decrease of the blood volume in the arteries (arterial
hypovolemia)11
In anaphylactic and septic shock, the permeability of the blood vessels increases, so some fluid
escapes from the blood into the interstitial space18
Third spacing:Fluid accumulation in the body spaces where normally is no or only little fluid (the
abdominal cavity, retroperitoneal space, lungs, pleural space, pericardial sac):
Aortic dissection (blood pooling in the newly formed space in the aortic wall)
Burns fluid accumulation in the skin blisters18
Soft tissue trauma
Pancreatitis pancreatic enzymes and cytokines damage the blood vessels what results in the
escape of fluid from the blood15,19
Peritonitis15
Pulmonary edema
Pleural effusion15
Intestinal obstruction, paralytic ileus, volvulus3
A decrease of oncotic pressure of the blood plasma due to low blood protein levels and
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hypoalbuminemia can result in the escape of fluid from the blood into the body tissues and cavities:
Kidney disease with nephrotic syndrome with anasarca [generalized edema]12
Protein malnutrition [Kwashiorkor]can result in distended bellies in starving children12
Liver cirrhosis resulting in ascites accumulation of the fluid in the abdominal cavity13
Protein losing enteropathy23
Ovarian hyperstimulation syndrome20
Sickle cell anemia with splenic sequestration, mostly in young children28
Systemic capillary leak syndrome24
NOTE: Many authors use the term third spacing for both second as third spacing.

Differential Diagnosis
There are other types of shock and other conditions that may resemble hypovolemic shock:
Distributive shockdue to massive vasodilation with an increase in the volume of the intravascular
space with insufficient volume of the existing blood to fill this space and therefore a drop of blood
pressure
Septic shock due to infection7
Toxic shock syndrome, mainly in women in which a tampon-associated infection with staphylococci
or streptococci results in vasodilation, high fever and rash)7
Anaphylactic shock7
Neurogenic shock due to spinal cord injury above Th4 or Th65(low blood pressure, no tachycardia,
warm skin, paraplegia or tetraplegia, numbness2,8
Toxic shock (poisoning with nitroprusside, bretylium)
Cardiogenic shockdue to heart failure (myocardial infarction, arrhythmia, cardiomyopathy, heart valve
disease)7,27
Obstructive shock:
Cardiac tamponade (muffled heart tones, distended neck veins)2,7
Tension pneumothorax (displaced trachea, decreased breathing sounds on one side)2,7
Hemorrhagic pneumothorax
Pulmonary embolism27
Arteriovenous malformations2
Vasodilationas a side effect of drugs, such as barbiturates, nitrates, opiates, antihypertensives (beta
blockers, vasodilators)7,25,26
Temporary autonomic dysfunction:
Orthostatic hypotension9
Vasovagal syncope10
The term relative hypovolemic shock can be used when the volume of the circulatory system increases due
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to vasodilation, for example in neurogenic shock, and the volume of the blood remains the same but
insufficient to perfuse peripheral organs.

Pathophysiology
Compensated Shock
Shock is compensated until the cardiac output (CO) and systolic blood pressure (BP) remain normal and thus
manage to maintain proper perfusion of peripheral tissues.
Baroreceptor reflex.Bleeding or other cause of fluid loss results in a drop of blood volume and hence
blood pressure, which is detected by baroreceptors in the aortic and carotid arch. Baroreceptors activate
the sympathetic systemsympathetic nerves, which release norepinephrine (noradrenaline) and adrenal
medulla, which releases epinephrine (adrenaline), which results in the constriction of the peripheral
blood vessels in the skin and increased heart contractility and heart rate. The brain, heart and kidney
arteries have an ability of autoregulation, which means they can maintain adequate blood perfusion
despite a gross reduction of the blood pressure (systolic BP 60-100 mm Hg). All these changes result in
the redirection of the blood flow from the skin, muscles and gastrointestinal tract toward the heart, brain
and kidneys.
Fluid retention
Atrial volume receptors sense the drop of the blood volume and stimulate the release of
theantidiuretic hormone (ADH)from the pituitary gland, which reduces water excretion through
the kidneys.
Osmoreceptors in the hypothalamus detect the increase of blood osmolality and trigger the release
of the ADH45.
Decreased perfusion of the juxtaglomerular apparatus in the kidneys stimulates renin >> angiotensin
I >> angiotensin II and finallyaldosteronerelease from the adrenal cortex, which causes the
retention of sodium and hence water in the kidneys, which helps to maintain blood volume.
Movement of fluid from intracellular and interstitial space into the blood.
Bronchodilationandhyperventilationtriggered by increased sympathetic activity results in increased
oxygen delivery to the tissues.
References1,13,23,38

Progressive or Decompensated Shock

Shock is decompensated when cardiac output and blood pressure drop to the point where they can not
maintain proper perfusion of the tissues any more. This results in decreased oxygen delivery to the tissues
and switch from aerobic to anaerobic metabolism, which results in lactate production andlactic acidosis.

Irreversible Shock
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Shock is irreversible when the damage of the vital organs is so extensive that death cannot be prevented
despite treatment. The patient can still survive up to three weeks after the onset of irreversible shock32.

Table 2. Stages(Classes, Grades) of

Hypovolemic Shock; Vital Signs
Compensated

Decompensated

Stage 1

Stage

Stage 2

Stage 4

Blood

<15% (< 750

15-30%

30-40%

>40%

volume

mL)

(750-1,500

(1,500-

(>2,000 mL)

mL)

2,000 mL)

(immediately

loss

life
threatening)
2

Cardiac

Compensated

output

by

Lower

Lower

Lower

Normal

<100 mm

<70 mm Hg

constriction of
vascular bed

Systolic

Normal

Hg

blood
pressure

Diastolic
blood

Normal

Increased

Often not
detectable
due to narrow

pressure

gap between
syst and diast

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BP

Respiratory

Normal

>30/min

(tachypnea)

rate

Heart rate

Increased

Slightly

Pronounced
tachypnea

>100/min

>120/min

>140/min

Weak

Weak

Weak or

increased but
<100/min

Pulse

Normal

absent

Capillary

Normal (<2

Delayed (>2

Delayed

refill

sec)

sec)

(>2 sec)

Urine

Normal (>30

20-30

<20

output

mL/hour)

mL/hour

mL/hour

Skin

Pale

Pale,

Cool, pale,

Cool,

sweaty

sweaty

extremely

Absent

Negligible

pale, sweaty

Mental

Slight anxiety

status

Slight

Confusion,

Lethargy,

anxiety,

agitation

coma

restlessness

Table 2 references:2,38

Therapeutical/Physiological Classification of Hemorrhagic Shock

MILD:Normal blood pressure
MODERATE:Low blood pressure that responds to fluid replacement
SEVERE:Low blood pressure that does not respond to fluid replacement test
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CRITICAL:>40% blood loss or brain or heart involvement (coma, bradycardia)

Reference53

Early/First Symptoms
Clinical symptoms and signs may not be present until 10-20% of the total blood volume in adults or up to 30%
in infants is lost.
Thirst due to hypovolemia (hypovolemic thirst) can appear after 15% blood loss
Nausea
Anxiety, irritability, agitation, sleepiness, confusion
Pale, clammy skin (indehydration, especially inheat stroke, skin is initially dry and warm)
Symptoms of bleeding: vomiting blood (hematemesis), blood in the stool (melena), blood in the urine,
bruising, chest or back pain (rupture of the thoracic aorta), abdominal orflank pain(rupture of the
abdominal aortic aneurysm, stabbing), vaginal bleeding outside of menstruation.

Early Signs
Paleness, excessive sweating (diaphoresis)
NOTE: in heat stroke, the skin would be dry and warm
Dilated pupils
Increased heart rate (tachycardia; may not occur early in patients who take beta-blockers)
Weak, wide pulse, initially due to increased adrenaline release and subsequent peripheral
vasoconstriction and increased diastolic blood pressure
Blood pressure may not fall until about 20% blood (in infants 30%) is lost. Older people with high blood
pressure or atherosclerosis may be in the stage of decompensated shock even if their blood pressure is
at 120 mm Hg or above53.
Increased breathing frequency (tachypnea)
Capillary refill time (CRT)
>2 seconds in infants, children and adults (CRT in healthy, especially in old people can be
prolonged in cold ambient)
>3 sec corresponds to ~10% drop of blood volume
Body weight is decreased in external bleeding and dehydration, but not changed in internal bleeding,
septic, anaphylactic or toxic shock.
Early signs of dehydration: poorskin turgor, sunken fontanelle in infants, decrease in body weight
Signs of internal bleeding: abdominal tenderness, swelling, discoloration, guarding, bruising pattern of
Grey, Turner sign and Cullens sign
Signs of gastrointestinal bleeding: blood in the nose, mouth, throat or rectum (rectal examination).
NOTE: In infants, early symptoms and signs of hypovolemic shock are less obvious than in adults23.
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Late Symptoms
Early symptoms plus the following:
Dizziness
Fainting
Weakness
Confusion
Lethargy

Late Signs
Early signs plus the following:
Mottled, cyanotic skin
Increase of tachycardia for at least 30/min upon standing17, or bradycardia; arrhythmia
Increased breathing rate (tachypnea: >30/min) or decreased breathing rate (bradypnea: <12/min)2,48
Capillary refill time (CRT) >5 seconds or absent
Decreased body temperature (hypothermia)
Low, narrow blood pressure (systolic pressure falls earlier than diastolic, because it is more dependent
on blood volume; systolic blood pressure may not fall until 30% blood is lost).
Decreased or absent urination (<20 mL/hour)
Coma
References:1,2,7,17,23,29,30,35

First Aid (ABC)

Check for airway, breathing, circulation and, if necessary, start with resuscitation (artificial breathing, heart
massage).

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Do not move a conscious person or his/her head with a suspected spinal cord injury(most
possible in head injury, direct blow to the spine, fall from the height, traffic accident).
Move anunconscious person,including the one with a suspected spinal cord injury, into arecovery
position51. At least two other people should assist you, if possible, to provide minimal twisting of the
neck and back.
Call for an ambulance(USA, Canada: 911, UK: 999, Australia: 000, India: 102).

Stopping External Bleeding

Wear gloves, if possible.
If the person does not seem to have an injured spinal cord (intact sensation in the arms and legs), move
him/her in a lying position withthe bleeding part about 12 inches or 30 cm above the heart,if
possible.
Check the wound and remove free foreign objects (sand, cloth, etc.).DO NOT remove or move objects
that are stuck in the wound,such as a knife or a sharp piece of wood).
If possible, pull the edges of the wound together and fix them with a bandage
Cover the wound with a gauze and apply pressure with the hands for 20 minutes to stop bleeding
(if possible the injured person can do it); during this time do not check if the bleeding has stopped. If
no gauze is available, use a part of the clothing or a clean plastic bag or bare hands (clean, if possible). If
a gauze becomes saturated with the blood do not remove it but add another gauze over it. If the bleeding
does not stop apply pressure with your fingers to one of thepressure points(behind the knee or in the
groin, on the inner side of the elbow or below the armpit). There are different opinions about using
atourniqueton a bleeding limb: some doctors say not to use a tourniquet or use it as a last resort50,
others say use at least 2 inches (5 cm) wide tourniquet between the wound and the body until bleeding
stops54.
If the person feels cold, cover him/her with a blanket.
DO NOT give a person anything to drink or eat, even if he/she is severely thirsty50.
Reference50

First Aid in Suspected Internal Bleeding

Internal bleeding may not be visible; it can be suspected in high speed injuries, traffic accidents, falls from the
height, after stabbing, etc.
A person with a suspected internal bleeding who does not likely has a spinal injury shouldlie flat with
the feet raised about 12 inches (30 cm) above the level of the heart.
DO NOT give a person anything to drink or eat, even if he/she is severely thirsty50.

Laboratory Tests in Hypovolemia

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Initial Tests and Procedures

When internal bleeding is suspected:
Auscultation:
No lung sounds on one side in pneumothorax/hemothorax
Diagnostic peritoneal lavage
Ultrasonography or CT of the thorax or abdomen
Nasogastric tube and gastric lavage and upper endoscopy
Chest X-ray if perforated ulcer or hemothorax is suspected
Colonoscopy
Angiography
X-ray of limbs, when fractures are suspected
Pregnancy test, when ectopic pregnancy is suspected
Central vein catheter
Thoracic tube to drain hemothorax
ECG can be done to exclude heart attack or other causes of cardiogenic shock.
References:4,31,40

Monitoring of Hemodynamic Changes

ECG to exclude cardiogenic shock.
Central Venous Pressure (CVP) <4 mm Hg (<5 mm water) indicates hypovolemia35
Pulmonary Artery Occlusion Pressure (PAOP) also called Pulmonary Wedge Pressure (PWP) or
Pulmonary Capillary Wedge Pressure (PCWP) is usually decreased38
Cardiac Output (CO) is reduced23.
References:23,35,38

Blood Tests:
CBC in bleeding is initially normal.
Hemoglobin (Hb) can be low in chronic bleeding, but not in the first hours of acute bleeding.
Hematocrit (HCT):
Normal up to eight hours after onset of bleeding. After 8-12 hours, the redistribution of the interstitial
fluid into the blood occurs, so HCT and Hb fall.
Increased in fluid loss without red cell loss:
Dehydration (diarrhea, vomiting, polyuria, excessive sweating)
Plasma loss (burns)
Sodium (Na):
Normal in bleeding (initially)
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Decreased in hypovolemic hyponatremia

Potassium (K)
Chloride (Cl)
Blood Urea Nitrogen (BUN) can be increased in dehydration, gastrointestinal bleeding, rhabdomyolysis,
urinary outlet obstruction or sepsis17
Creatinine: normal, except in renal failure23,31
Urea: normal, except in renal failure31
Glucose levels: initially hyperglycemia (gluconeogenesis, glycogenolysis due to increased epinephrine),
later hypoglycemia (due to glycogen exhaustion)38
Bleeding time: prolonged in late shock
Activated partial thromboplastin time (aPPT): prolonged in coagulation disorders31
Prothrombin time (PT): prolonged in coagulation disorders31
Arterial blood gases (ABGs):
pH<7.3 = acidosis31
Respiratory alkalosis progressing to metabolic acidosis (due to lactic acidosis)13
Metabolic acidosis can also occur in severe diarrhea23
HCO3(bicarbonate) is decreased in metabolic acidosis
Base deficit increases (become more negative) with acidosis which increases with the extent of
hypovolemia (mild base deficit: 2 to -5; moderate: -6 to -14; over -15)46. Base deficit is usually
expressed as a negative base excess (BE). So, base deficit can be used as a guide for fluid
resuscitation.

Urine Tests
Urine specific gravity is usually increased23
hCG (pregnancy test) to test for ectopic pregnancy23

Treatment
The following is an overview of the usual procedures and it is not meant as treatment instructions.

1. Ventilation
In a decompensated shock, 100% oxygen should be given by a non-rebreathable facial mask25.

2. Immobilization
Immobilization of the neck spine and limbs in a patient with trauma should be done before transport.

3. Transport
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The patient should be transported to the hospital as soon as possible.

The first goal in treatment of hypovolemic shock is to correct hypotension38.

4. Fluid Deficit Replacement

Fluid deficit replacement can start during transport35,38,40. Fluids, which should be warmed, should be given
via 2 large bore i.v. lines. The following fluids can be used41:
Crystalloids (3 liters are needed to restore 1 liter of lost blood).
Isotonic saline (0.9% NaCl)
Ringer lactate
Colloids (1 liter is needed to restore 1 liter of lost blood):
Hetastarch
Pentastarch
Albumin
Dextran
Blood products (when 2,000 mL crystalloids does not help):
Fresh frozen plasma (FFP)
Packed red blood cells (PRBCs)
Whole blood transfusion
Products to assist normal blood function55:
Tranexamic acid (decreases mortality)
Recombinant human factor VIIa
Prothrombin complex
NOTE: Using large amounts of fluid before surgery has been questioned lately53.

5. Stopping Internal Bleeding

Internal bleeding can be reduced by certain drugs or stopped by an immediate surgery.
Gastrointestinal bleeding40:
Intravenous H2 blockers
Vasopressin (can have severe side effects)
Somatostatin, octreotide
Surgery

6. Medications
Vasoconstrictorsmedications that increase blood pressureshould not be given before hypovolemia has
been corrected by fluids.There is insufficient evidence in using vasoconstrictors in improving survival in the
55
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acute phase of trauma55.

Norepinephrine (Noradrenaline)
Norepinephrine is released from the nerve endings of sympathetic nerves. It stimulates alpha 1 and beta 1
receptors and causes peripheral vasoconstriction, increases heart rate and contractility and rises both systolic
and diastolic blood pressure32. Norepinephrine as a drug can be used in acute fall of the blood pressure.
Epinephrine (Adrenaline)
Adrenaline stimulates alpha 1 and beta 1 receptors. It causes peripheral vasoconstriction, increases heart
rate and contractility and systolic blood pressure32.
Other Possible Medications:
Dopamine in high doses, which increases vasoconstriction (dopamine in low doses causes
vasodilation)53
Phenylephrine
Dobutamine
Isoproterenol
Milrinone

Complications
Multiple Organ Dysfunction Syndrome (MODS)
Lungs: Acute Respiratory Distress Syndrome (ARDS)
Kidneys: Acute tubular necrosis resulting in acute renal failure
Heart: heart attack (myocardial infarct)
Brain: seizures (in hypovolemic hyponatremia and heat stroke)
Blood: disseminated intravascular coagulation (DIC) due to hypothermia and acidosis
Gastrointestinal tract: stress ulcers, ileus, ischemic bowel (dead gut), leaky gut syndrome, abdominal
compartment syndrome
Liver necrosis
Limbs: gangrene
Hypothermia (due to low tissue perfusion, cold intravenous fluids, cold environment)
Hyperthermia (in heat stroke or sepsis)
Hemorrhagic shock and encephalopathy syndrome in infants and children (rare) (high fever, seizures)
References:7,13,16,23,39,49

Prognosis
Prognosis of hypovolemic shock mainly depends on the volume of blood lost, the speed of fluid replacement
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and underlying health conditions.

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