What is the treatment for hypovolemic shock in adults and children?

Treatment of Hypovolemic Shock

Immediately administer 20 mL/kg boluses of isotonic crystalloid (normal saline or lactated Ringer's solution) rapidly over 5-10 minutes in children, or 500-1000 mL boluses over 15-30 minutes in adults, with repeat dosing up to 60 mL/kg in the first hour for children (up to 200 mL/kg total if no fluid overload) and 30 mL/kg within 3 hours for adults, stopping only if signs of fluid overload develop. 1, 2, 3

Initial Fluid Resuscitation

Pediatric Patients

• First-line therapy: Isotonic saline (0.9% NaCl) or lactated Ringer's solution as 20 mL/kg boluses administered rapidly over 5-10 minutes 1, 2, 3
• Repeat dosing: Reassess immediately after each bolus and repeat up to 60 mL/kg in the first hour if perfusion does not normalize 1, 2
• Maximum volume: Up to 200 mL/kg total may be given if signs of fluid overload are absent 2, 3
• Access: Establish IV or intraosseous (IO) access immediately; use IO if IV cannot be rapidly obtained 1

Adult Patients

• First-line therapy: Isotonic crystalloid (lactated Ringer's preferred over normal saline) as 500-1000 mL boluses over 15-30 minutes 3
• Target volume: 30 mL/kg within the first 3 hours 3
• Reassessment: Evaluate response after each bolus by monitoring perfusion parameters 3

Critical Stopping Points

Stop or slow fluid administration immediately if any of these signs of fluid overload develop: 2, 3

• Hepatomegaly (new or worsening)
• Pulmonary rales/crackles (new or worsening)
• Gallop rhythm on cardiac auscultation
• Increased work of breathing
• Decreased oxygen saturation
• Increased jugular venous pressure (adults)

Resuscitation Endpoints

Target these specific clinical parameters to determine adequate resuscitation: 2, 4, 3

• Capillary refill ≤2 seconds
• Normal heart rate for age (children) or improved heart rate (adults)
• Warm extremities with strong peripheral pulses equal to central pulses
• Normal mental status
• Urine output >1 mL/kg/hour (children) or >0.5 mL/kg/hour (adults)
• Normal blood pressure for age (children) or MAP ≥65 mmHg (adults)
• Decreasing lactate levels (when available)

Vasopressor Support

Initiate norepinephrine if shock persists after 40-60 mL/kg in children or 30 mL/kg in adults, targeting MAP of 65 mmHg. 2, 4, 3

• First-line vasopressor: Norepinephrine 2, 4
• Alternative: Epinephrine as addition or alternative when necessary 4
• Pediatric bridge: Consider peripheral low-dose dopamine or epinephrine infusion through second peripheral IV/IO while establishing central access 3

Fluid Choice Rationale

The evidence strongly supports isotonic crystalloids over colloids. The Dutch Pediatric Society guideline found excess mortality in albumin-treated trauma patients compared to crystalloid-treated groups, with no evidence that synthetic colloids are superior 1, 2. The 2010 American Heart Association guidelines confirmed crystalloids may have survival benefit over colloids for children with trauma, traumatic brain injury, and burns 1. Lactated Ringer's solution is preferred in adults to avoid hyperchloremic metabolic acidosis associated with large volumes of normal saline 1, 5.

Special Considerations

Hemorrhagic Shock

• Do not delay hemorrhage control: Correction of major bleeding takes precedence over transfer 1
• Permissive hypotension: May be appropriate until hemorrhage is controlled (not explicitly detailed in provided guidelines but implied by trauma management principles) 6
• Coagulation management: Early tranexamic acid and fibrinogen administration; target hemoglobin 7-9 g/dL; use 4:4:1 ratio of RBC:plasma:platelets for massive transfusion 6

Traumatic Brain Injury

• Maintain adequate systolic blood pressure for age 2
• Use isotonic saline exclusively (avoid hypotonic solutions) 2

Burns

• Early administration: Give 20 mL/kg within first hour for adults with ≥15% TBSA or children with ≥10% TBSA 1
• Balanced crystalloids preferred: Ringer's Lactate recommended as first-line 1

Critical Pitfalls to Avoid

• Do not use hypotonic fluids for shock resuscitation in any age group 3
• Do not rely solely on blood pressure to guide therapy; assess comprehensive perfusion parameters including capillary refill, mental status, and urine output 3
• Do not continue aggressive fluid without reassessment for overload after each bolus 3
• Do not delay vasopressor initiation in fluid-refractory shock beyond 40-60 mL/kg in children or 30 mL/kg in adults 3
• Do not use etomidate for intubation in pediatric patients with septic shock due to associated higher mortality 1