What are the signs and management of hypovolemic shock?

From the Guidelines

Hypovolemic shock is a life-threatening condition that requires immediate attention, and the signs include tachycardia, hypotension, decreased urine output, cool/clammy skin, altered mental status, and weak peripheral pulses. The management of hypovolemic shock begins with securing airway, breathing, and circulation, followed by establishing large-bore IV access for fluid resuscitation.

• Key signs of hypovolemic shock include:
  • Tachycardia
  • Hypotension (systolic BP <90 mmHg)
  • Decreased urine output (<0.5 mL/kg/hr)
  • Cool/clammy skin
  • Altered mental status
  • Weak peripheral pulses According to the most recent and highest quality study 1, the initial fluid for the treatment of shock should be an isotonic crystalloid solution, such as lactated Ringer’s solution or normal saline, with a bolus of 20 mL/kg.
• The management strategy includes:
  • Securing airway, breathing, and circulation
  • Establishing large-bore IV access (two 16-18G catheters) for fluid resuscitation
  • Administering 1-2 L of isotonic crystalloids rapidly, then reassessing
  • Using blood products for hemorrhagic shock, with packed red blood cells given for hemoglobin <7 g/dL
  • Considering a 1:1:1 ratio of PRBCs, plasma, and platelets for massive transfusion
  • Using vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min) if fluid resuscitation alone is insufficient
  • Identifying and treating the underlying cause (controlling bleeding, replacing fluid losses)
  • Continuously monitoring vital signs, urine output, lactate levels, and base deficit to guide resuscitation Early intervention is critical as shock progresses through compensated, uncompensated, and irreversible stages, with mortality increasing significantly in later stages due to cellular damage from inadequate oxygen delivery and subsequent multi-organ dysfunction 1.

From the FDA Drug Label

Emergency Treatment of Hypovolemic Shock Plasbumin-25 is hyperoncotic and on intravenous infusion will expand the plasma volume by an additional amount, three to four times the volume actually administered, by withdrawing fluid from the interstitial spaces, provided the patient is normally hydrated interstitially or there is interstitial edema. Removal of ascitic fluid from a patient with cirrhosis may cause changes in cardiovascular function and even result in hypovolemic shock.

The signs of hypovolemic shock are not explicitly stated in the drug label, but it can be inferred that hypovolemic shock may occur in situations where there is a significant loss of fluid volume, such as:

• Removal of ascitic fluid from a patient with cirrhosis
• Burns
• Major surgery
• Sepsis or intensive care patients The management of hypovolemic shock includes the administration of Plasbumin-25 to expand plasma volume and support blood pressure 2. The dosage and administration of Plasbumin-25 should be adapted to the response of the individual patient, with careful monitoring of hemodynamic parameters to avoid circulatory overload 2.

From the Research

Signs of Hypovolemic Shock

• Decreased blood volume, which can lead to inadequate perfusion of vital organs 3
• Subtle pathophysiologic tissue insults in the early stages, progressing to multi-system organ dysfunction in the late stages 4
• Compensatory mechanisms, such as increased heart rate and vasoconstriction, may be overwhelmed, leading to hemodynamic instability and circulatory collapse 4

Management of Hypovolemic Shock

• Fluid resuscitation with colloids or crystalloids to restore blood volume and improve perfusion of vital organs 5, 6, 7
• Choice of fluid resuscitation may depend on the specific patient population, with some studies suggesting that balanced crystalloids may be preferred in non-traumatic brain injury patients 7
• Monitoring of the compensatory reserve (CR) may help detect hypovolemic shock earlier, allowing for more timely interventions 4
• Use of hydroxyethyl starches, gelatins, and albumins may not have a significant mortality benefit compared to crystalloids 6
• Hypertonic saline may have a similar effect on overall mortality as isotonic crystalloids 6

Key Considerations

• Early detection and intervention are critical in improving outcomes for patients with hypovolemic shock 4, 3
• The critical care nurse plays an important role in the resuscitation and ongoing care of patients with hypovolemic shock 3
• Further research is needed to determine the optimal fluid resuscitation strategy for patients with hypovolemic shock 5, 6, 7