Hypovolemia: Difference between revisions

Hypovolemia
Hypovolemia
Other names	Oligemia, hypovolaemia, oligaemia, hypovolæmia, volume depletion
	A diagram showing the formation of interstitial fluid from the bloodstream
Specialty	Emergency medicine
Symptoms	Headache, fatigue, nausea, profuse sweating, dizziness
Complications	Hypovolemic shock
Differential diagnosis	Dehydration

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Hypovolemia, also known as volume depletion or volume contraction, is a state of abnormally low extracellular fluid in the body.^[1] This may be due to either a loss of both salt and water or a decrease in blood volume.^[2]^[3] Hypovolemia refers to the loss of extracellular fluid and should not be confused with dehydration.^[4]

Hypovolemia is caused by a variety of events, but these can be simplified into two categories: those that are associated with kidney function and those that are not.^[5] The signs and symptoms of hypovolemia worsen as the amount of fluid lost increases.^[6] Immediately or shortly after mild fluid loss (from blood donation, diarrhea, vomiting, bleeding from trauma, etc.), one may experience headache, fatigue, weakness, dizziness, or thirst. Untreated hypovolemia or excessive and rapid losses of volume may lead to hypovolemic shock.^[7] Signs and symptoms of hypovolemic shock include increased heart rate, low blood pressure, pale or cold skin, and altered mental status. When these signs are seen, immediate action should be taken to restore the lost volume.

Signs and symptoms

Signs and symptoms of hypovolemia progress with increased loss of fluid volume.^[5]

Early symptoms of hypovolemia include headache, fatigue, weakness, thirst, and dizziness. The more severe signs and symptoms are often associated with hypovolemic shock. These include oliguria, cyanosis, abdominal and chest pain, hypotension, tachycardia, cold hands and feet, and progressively altering mental status.^{[citation needed]}

Causes

The causes of hypovolemia can be characterized into two categories:^[5]

Kidney

Loss of body sodium and consequent intravascular water (due to impaired reabsorption of salt and water in the tubules of the kidneys)
- Osmotic diuresis: the increase in urine production due to an excess of osmotic (namely glucose and urea) load in the tubules of the kidneys
- Overuse of pharmacologic diuretics
- Impaired response to hormones controlling salt and water balance (see mineralocorticoids)
- Impaired kidney function due to tubular injury or other diseases

Other

Loss of bodily fluids due to:^{[citation needed]}
- Gastrointestinal losses; e.g. vomiting and diarrhea
- Skin losses; e.g. excessive sweating and burns
- Respiratory losses; e.g. hyperventilation (breathing fast)
Build up of fluid in empty spaces (third spaces) of the body due to:^{[citation needed]}
- Acute pancreatitis
- Intestinal obstruction
- Increase in vascular permeability
- Dysautonomia such as Vasovagal syncope or POTS Postural orthostatic tachycardia syndrome
- Hypoalbuminemia
Loss of blood (external or internal bleeding or blood donation^[8])

Pathophysiology

The signs and symptoms of hypovolemia are primarily due to the consequences of decreased circulating volume and a subsequent reduction in the amount of blood reaching the tissues of the body.^[9] In order to properly perform their functions, tissues require the oxygen transported in the blood.^[10] A decrease in circulating volume can lead to a decrease in bloodflow to the brain, resulting in headache and dizziness.^{[citation needed]}

Baroreceptors in the body (primarily those located in the carotid sinuses and aortic arch) sense the reduction of circulating fluid and send signals to the brain to increase sympathetic response (see also: baroreflex).^[11] This sympathetic response is to release epinephrine and norepinephrine, which results in peripheral vasoconstriction (reducing size of blood vessels) in order to conserve the circulating fluids for organs vital to survival (i.e. brain and heart). Peripheral vasoconstriction accounts for the cold extremities (hands and feet), increased heart rate, increased cardiac output (and associated chest pain). Eventually, there will be less perfusion to the kidneys, resulting in decreased urine output.^{[citation needed]}

Diagnosis

Hypovolemia can be recognized by a fast heart rate, low blood pressure,^[12] and the absence of perfusion as assessed by skin signs (skin turning pale) and/or capillary refill on forehead, lips and nail beds. The patient may feel dizzy, faint, nauseated, or very thirsty. These signs are also characteristic of most types of shock.^[13]

In children, compensation can result in an artificially high blood pressure despite hypovolemia (a decrease in blood volume). Children typically are able to compensate (maintain blood pressure despite hypovolemia) for a longer period than adults, but deteriorate rapidly and severely once they are unable to compensate (decompensate).^[14] Consequently, any possibility of internal bleeding in children should be treated aggressively.^[15]^[16]

Signs of external bleeding should be assessed, noting that individuals can bleed internally without external blood loss or otherwise apparent signs.^[16]

There should be considered possible mechanisms of injury that may have caused internal bleeding, such as ruptured or bruised internal organs. If trained to do so and if the situation permits, there should be conducted a secondary survey and checked the chest and abdomen for pain, deformity, guarding, discoloration or swelling. Bleeding into the abdominal cavity can cause the classical bruising patterns of Grey Turner's sign (bruising along the sides) or Cullen's sign (around the navel).^[17]

Examination

In a hospital, physicians respond to a case of hypovolemic shock by conducting these examinations:^{[citation needed]}

Blood tests: U+Es/Chem7, full blood count, glucose, blood type and screen
Central venous catheter
Arterial line
Urine output measurements (via urinary catheter)
Blood pressure
SpO2 oxygen saturation monitoring

Stages

Untreated hypovolemia can lead to shock (see also: hypovolemic shock). Most sources state that there are 4 stages of hypovolemia and subsequent shock;^[18] however, a number of other systems exist with as many as 6 stages.^[19]

The 4 stages are sometimes known as the "Tennis" staging of hypovolemic shock, as the stages of blood loss (under 15% of volume, 15–30% of volume, 30–40% of volume and above 40% of volume) mimic the scores in a game of tennis: 15, 15–30, 30–40 and 40.^[20] It is basically the same as used in classifying bleeding by blood loss.^{[citation needed]}

The signs and symptoms of the major stages of hypovolemic shock include:^[21]^[22]

	Stage 1	Stage 2	Stage 3	Stage 4
Blood loss	Up to 15% (750 mL)	15–30% (750–1500 mL)	30–40% (1500–2000 mL)	Over 40% (over 2000 mL)
Blood pressure	Normal (Maintained by vasoconstriction)	Increased diastolic BP	Systolic BP < 100	Systolic BP < 70
Heart rate	Normal	Slight tachycardia (> 100 bpm)	Tachycardia (> 120 bpm)	Extreme tachycardia (> 140 bpm) with weak pulse
Respiratory rate	Normal	Increased (> 20)	Tachypneic (> 30)	Extreme tachypnea
Mental status	Normal	Slight anxiety, restless	Altered, confused	Decreased LOC, lethargy, coma
Skin	Pale	Pale, cool, clammy	Increased diaphoresis	Extreme diaphoresis; mottling possible
Capillary refill	Normal	Delayed	Delayed	Absent
Urine output	Normal	20–30 mL/h	20 mL/h	Negligible

Treatment

Field care

The most important step in treatment of hypovolemic shock is to identify and control the source of bleeding.^[23]

Medical personnel should immediately supply emergency oxygen to increase efficiency of the patient's remaining blood supply. This intervention can be life-saving.^[24]

Also, the respiratory pump is especially important during hypovolemia as spontaneous breathing may help reduce the effect of this loss of blood pressure on stroke volume by increasing venous return.^[25]

The use of intravenous fluids (IVs) may help compensate for lost fluid volume, but IV fluids cannot carry oxygen the way blood does—however, researchers are developing blood substitutes that can. Infusing colloid or crystalloid IV fluids also dilutes clotting factors in the blood, increasing the risk of bleeding. Current best practice allow permissive hypotension in patients with hypovolemic shock,^[26] both avoid overly diluting clotting factors and avoid artificially raising blood pressure to a point where it "blows off" clots that have formed.^[27]^[28]

Hospital treatment

Fluid replacement is beneficial in hypovolemia of stage 2, and is necessary in stage 3 and 4.^[21] See also the discussion of shock and the importance of treating reversible shock while it can still be countered.

The following interventions are carried out:^{[citation needed]}

IV access
Oxygen as required
Fresh frozen plasma or blood transfusion
Surgical repair at sites of bleeding

Vasopressors (such as dopamine and noradrenaline) should generally be avoided, as they may result in further tissue ischemia and don't correct the primary problem. Fluids are the preferred choice of therapy.^[29]

History

In cases where loss of blood volume is clearly attributable to bleeding (as opposed to, e.g., dehydration), most medical practitioners prefer the term exsanguination for its greater specificity and descriptiveness, with the effect that the latter term is now more common in the relevant context.^[30]

References

^ McGee S (2018). Evidence-based physical diagnosis. Philadelphia, PA: Elsevier. ISBN 978-0-323-39276-1. OCLC 959371826. The term hypovolemia refers collectively to two distinct disorders: (1) volume depletion, which describes the loss of sodium from the extracellular space (i.e., intravascular and interstitial fluid) that occurs during gastrointestinal hemorrhage, vomiting, diarrhea, and diuresis; and (2) dehydration, which refers to the loss of intracellular water (and total body water) that ultimately causes cellular desiccation and elevates the plasma sodium concentration and osmolality.
^ "Hypovolemia definition – MedicineNet". Medterms.com. 2012-03-19. Archived from the original on 2014-01-23. Retrieved 2015-11-01.
^ "Hypovolemia | definition of hypovolemia by Medical dictionary". Medical-dictionary.thefreedictionary.com. Retrieved 2015-11-01.
^ Bhave G, Neilson EG (August 2011). "Volume depletion versus dehydration: how understanding the difference can guide therapy". American Journal of Kidney Diseases. 58 (2): 302–09. doi:10.1053/j.ajkd.2011.02.395. PMC 4096820. PMID 21705120.
^ ^a ^b ^c Jameson, J. Larry; Kasper, Dennis L.; Longo, Dan L.; Fauci, Anthony S.; Hauser, Stephen L.; Loscalzo, Joseph, eds. (2018). Harrison's principles of internal medicine (20th ed.). New York: McGraw-Hill Education. ISBN 9781259644030. OCLC 1029074059.
^ "Hypovolemic shock: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2019-09-02.
^ Kolecki P (October 13, 2016). "Hypovolemic Shock". Medscape.
^ Danic B, Gouézec H, Bigant E, Thomas T (June 2005). "[Incidents of blood donation]". Transfusion Clinique et Biologique (in French). 12 (2): 153–59. doi:10.1016/j.tracli.2005.04.003. PMID 15894504.
^ Taghavi S, Askari R (2019), "Hypovolemic Shock", StatPearls, StatPearls Publishing, PMID 30020669, retrieved 2019-09-02
^ Carreau A, El Hafny-Rahbi B, Matejuk A, Grillon C, Kieda C (June 2011). "Why is the partial oxygen pressure of human tissues a crucial parameter? Small molecules and hypoxia". Journal of Cellular and Molecular Medicine. 15 (6): 1239–53. doi:10.1111/j.1582-4934.2011.01258.x. PMC 4373326. PMID 21251211.
^ Armstrong M, Moore RA (2019). "Physiology, Baroreceptors". StatPearls. StatPearls Publishing. PMID 30844199. Retrieved 2019-09-02.
^ "Stage 3: Compensated Shock". Archived from the original on 2010-06-11.
^ Alpert JS, Ewy GA (2002). Manual of Cardiovascular Diagnosis and Therapy. Lippincott Williams & Wilkins. p. 101. ISBN 978-0-7817-2803-4.
^ Henry MC, Stapleton ER, Edgerly D (2011). EMT Prehospital Care. Jones & Bartlett Publishers. pp. 471–. ISBN 978-0-323-08533-5.
^ Assuma Beevi (2012). Pediatric Nursing Care Plans. JP Medical Ltd. pp. 47–. ISBN 978-93-5025-868-2.
^ ^a ^b Clement I (2013). Textbook on First Aid and Emergency Nursing. Jaypee Brothers Publishers. pp. 113–. ISBN 978-93-5025-987-0.
^ Blaber A, Harris G (2011). Assessment Skills For Paramedics. McGraw-Hill Education. pp. 83–. ISBN 978-0-335-24199-6.
^ Hudson, Kristi. "Hypovolemic Shock – 1 Nursing CE". Archived from the original on 2009-06-06.
^ "Stage 1: Anticipation stage (a new paradigm)". Archived from the original on 2010-01-16.
^ Greaves I, Porter K, Hodgetts T, et al., eds. (2006). Emergency Care: A Textbook for Paramedics. Elsevier Health Sciences. p. 229. ISBN 9780702025860.
^ ^a ^b Agabegi ED, Steven S A (2008). Step-Up to Medicine (Step-Up Series). Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 978-0-7817-7153-5.
^ Kumar, Vinay; Abbas, Abul K.; Aster, Jon C., eds. (2015). Robbins and Cotran pathologic basis of disease. Illustrated by Perkins, James A. (9th ed.). Philadelphia, PA: Saunders. ISBN 9781455726134. OCLC 879416939.
^ Bulger, E. M.; et al. (2014). "An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma". Prehospital Emergency Care. 18 (2): 163–173. doi:10.3109/10903127.2014.896962. PMID 24641269. S2CID 15742568.
^ Takasu, A.; Prueckner, S.; Tisherman, S. A.; Stezoski, S. W.; Stezoski, J.; Safar, P. (2000). "Effects of increased oxygen breathing in a volume controlled hemorrhagic shock outcome model in rats". Resuscitation. 45 (3): 209–220. doi:10.1016/s0300-9572(00)00183-0. PMID 10959021.
^ Skytioti M, Søvik S, Elstad M (May 2018). "Respiratory pump maintains cardiac stroke volume during hypovolemia in young, healthy volunteers". J Appl Physiol. 124 (5): 1319–1325. doi:10.1152/japplphysiol.01009.2017. hdl:10852/72205. PMID 29494288. S2CID 3626450.
^ "Permissive Hypotension". Trauma.Org. 1997-08-31. Archived from the original on 2013-11-27. Retrieved 2015-11-01.
^ Kennamer M, American Academy of Orthopaedic Surgeons (AAOS) (2013). Intravenous Therapy for Prehospital Providers. Jones & Bartlett Publishers. pp. 63–. ISBN 978-1-4496-4204-4.
^ de Franchis R, Dell'Era A (2014). Variceal Hemorrhage. Springer Science & Business Media. pp. 113–. ISBN 978-1-4939-0002-2.
^ Nordin, A. J.; Mäkisalo, H.; Höckerstedt, K. A. (1996-08-31). "Failure of dobutamine to improve liver oxygenation during resuscitation with a crystalloid solution after experimental haemorrhagic shock". The European Journal of Surgery = Acta Chirurgica. 162 (12). Pubmed-NCBI: 973–979. PMID 9001880. Retrieved 2017-11-21.
^ Geeraedts LM, Kaasjager HA, van Vugt AB, Frölke JP (January 2009). "Exsanguination in trauma: A review of diagnostics and treatment options". Injury. 40 (1): 11–20. doi:10.1016/j.injury.2008.10.007. PMID 19135193.

[McGee_2018_p.-1] McGee S (2018). Evidence-based physical diagnosis. Philadelphia, PA: Elsevier. ISBN 978-0-323-39276-1. OCLC 959371826. The term hypovolemia refers collectively to two distinct disorders: (1) volume depletion, which describes the loss of sodium from the extracellular space (i.e., intravascular and interstitial fluid) that occurs during gastrointestinal hemorrhage, vomiting, diarrhea, and diuresis; and (2) dehydration, which refers to the loss of intracellular water (and total body water) that ultimately causes cellular desiccation and elevates the plasma sodium concentration and osmolality.

[2] "Hypovolemia definition – MedicineNet". Medterms.com. 2012-03-19. Archived from the original on 2014-01-23. Retrieved 2015-11-01.

[3] "Hypovolemia | definition of hypovolemia by Medical dictionary". Medical-dictionary.thefreedictionary.com. Retrieved 2015-11-01.

[4] Bhave G, Neilson EG (August 2011). "Volume depletion versus dehydration: how understanding the difference can guide therapy". American Journal of Kidney Diseases. 58 (2): 302–09. doi:10.1053/j.ajkd.2011.02.395. PMC 4096820. PMID 21705120.

[:0-5] Jameson, J. Larry; Kasper, Dennis L.; Longo, Dan L.; Fauci, Anthony S.; Hauser, Stephen L.; Loscalzo, Joseph, eds. (2018). Harrison's principles of internal medicine (20th ed.). New York: McGraw-Hill Education. ISBN 9781259644030. OCLC 1029074059.

[6] "Hypovolemic shock: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2019-09-02.

[7] Kolecki P (October 13, 2016). "Hypovolemic Shock". Medscape.

[8] Danic B, Gouézec H, Bigant E, Thomas T (June 2005). "[Incidents of blood donation]". Transfusion Clinique et Biologique (in French). 12 (2): 153–59. doi:10.1016/j.tracli.2005.04.003. PMID 15894504.

[9] Taghavi S, Askari R (2019), "Hypovolemic Shock", StatPearls, StatPearls Publishing, PMID 30020669, retrieved 2019-09-02

[10] Carreau A, El Hafny-Rahbi B, Matejuk A, Grillon C, Kieda C (June 2011). "Why is the partial oxygen pressure of human tissues a crucial parameter? Small molecules and hypoxia". Journal of Cellular and Molecular Medicine. 15 (6): 1239–53. doi:10.1111/j.1582-4934.2011.01258.x. PMC 4373326. PMID 21251211.

[11] Armstrong M, Moore RA (2019). "Physiology, Baroreceptors". StatPearls. StatPearls Publishing. PMID 30844199. Retrieved 2019-09-02.

[12] "Stage 3: Compensated Shock". Archived from the original on 2010-06-11.

[Alpert_Ewy-13] Alpert JS, Ewy GA (2002). Manual of Cardiovascular Diagnosis and Therapy. Lippincott Williams & Wilkins. p. 101. ISBN 978-0-7817-2803-4.

[Stapleton-14] Henry MC, Stapleton ER, Edgerly D (2011). EMT Prehospital Care. Jones & Bartlett Publishers. pp. 471–. ISBN 978-0-323-08533-5.

[Beevi-15] Assuma Beevi (2012). Pediatric Nursing Care Plans. JP Medical Ltd. pp. 47–. ISBN 978-93-5025-868-2.

[Clement-16] Clement I (2013). Textbook on First Aid and Emergency Nursing. Jaypee Brothers Publishers. pp. 113–. ISBN 978-93-5025-987-0.

[Amanda_Graham-17] Blaber A, Harris G (2011). Assessment Skills For Paramedics. McGraw-Hill Education. pp. 83–. ISBN 978-0-335-24199-6.

[dynamicnursingeducation.com-18] Hudson, Kristi. "Hypovolemic Shock – 1 Nursing CE". Archived from the original on 2009-06-06.

[19] "Stage 1: Anticipation stage (a new paradigm)". Archived from the original on 2010-01-16.

[emergencycare-20] Greaves I, Porter K, Hodgetts T, et al., eds. (2006). Emergency Care: A Textbook for Paramedics. Elsevier Health Sciences. p. 229. ISBN 9780702025860.

[agabegi2nd-21] Agabegi ED, Steven S A (2008). Step-Up to Medicine (Step-Up Series). Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 978-0-7817-7153-5.

[22] Kumar, Vinay; Abbas, Abul K.; Aster, Jon C., eds. (2015). Robbins and Cotran pathologic basis of disease. Illustrated by Perkins, James A. (9th ed.). Philadelphia, PA: Saunders. ISBN 9781455726134. OCLC 879416939.

[23] Bulger, E. M.; et al. (2014). "An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma". Prehospital Emergency Care. 18 (2): 163–173. doi:10.3109/10903127.2014.896962. PMID 24641269. S2CID 15742568.

[24] Takasu, A.; Prueckner, S.; Tisherman, S. A.; Stezoski, S. W.; Stezoski, J.; Safar, P. (2000). "Effects of increased oxygen breathing in a volume controlled hemorrhagic shock outcome model in rats". Resuscitation. 45 (3): 209–220. doi:10.1016/s0300-9572(00)00183-0. PMID 10959021.

[pmid29494288-25] Skytioti M, Søvik S, Elstad M (May 2018). "Respiratory pump maintains cardiac stroke volume during hypovolemia in young, healthy volunteers". J Appl Physiol. 124 (5): 1319–1325. doi:10.1152/japplphysiol.01009.2017. hdl:10852/72205. PMID 29494288. S2CID 3626450.

[26] "Permissive Hypotension". Trauma.Org. 1997-08-31. Archived from the original on 2013-11-27. Retrieved 2015-11-01.

[AAOS-27] Kennamer M, American Academy of Orthopaedic Surgeons (AAOS) (2013). Intravenous Therapy for Prehospital Providers. Jones & Bartlett Publishers. pp. 63–. ISBN 978-1-4496-4204-4.

[Franchis_Dell'Era-28] Franchis R, Dell'Era A (2014). Variceal Hemorrhage. Springer Science & Business Media. pp. 113–. ISBN 978-1-4939-0002-2.

[29] Nordin, A. J.; Mäkisalo, H.; Höckerstedt, K. A. (1996-08-31). "Failure of dobutamine to improve liver oxygenation during resuscitation with a crystalloid solution after experimental haemorrhagic shock". The European Journal of Surgery = Acta Chirurgica. 162 (12). Pubmed-NCBI: 973–979. PMID 9001880. Retrieved 2017-11-21.

[30] Geeraedts LM, Kaasjager HA, van Vugt AB, Frölke JP (January 2009). "Exsanguination in trauma: A review of diagnostics and treatment options". Injury. 40 (1): 11–20. doi:10.1016/j.injury.2008.10.007. PMID 19135193.

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@@ Line 1: / Line 1: @@
 {{short description|Low blood volume}}
 {{Infobox medical condition (new)
-| name            = Hypovolemia
+| name = Hypovolemia
-| synonyms        = Oligemia, hypovolaemia, oligaemia, hypovolæmia, volume depletion
+| synonyms = Oligemia, hypovolaemia, oligaemia, hypovolæmia, volume depletion
-| image           = Capillary microcirculation.svg
+| image = Capillary microcirculation.svg
-| caption         = A diagram showing the formation of [[interstitial fluid]] from the [[blood|bloodstream]].
+| caption = A diagram showing the formation of [[interstitial fluid]] from the [[blood]]stream
-| field           = [[Emergency medicine]]
+| field = [[Emergency medicine]]
-| symptoms        = headache, fatigue, nausea, profuse sweating, dizziness
+| symptoms = Headache, fatigue, nausea, profuse sweating, dizziness
-| complications   = [[Hypovolemic shock]]
+| complications = [[Hypovolemic shock]]
-| onset           =
+| onset =
-| duration        =
+| duration =
+| types =
+| causes =
-| types      df'''Bold text'''     =
-| causes          =
+| risks =
-| risks           =
+| diagnosis =
+| differential = [[Dehydration]]
-| diagnosis       =
+| prevention =
-| differential    = [[Dehydration]]
-| prevention      =
+| treatment =
-| treatment       =
+| medication =
-| medication      =
+| prognosis =
-| prognosis       =
+| frequency =
-| frequency       =
+| deaths =
-| deaths          =
+| alt =
-|alt=}}
+}}
-'''Hypovolemia''', also known as '''volume depletion''' or '''volume contraction''', is a state of abnormally low extracellular fluid in the body.<ref name="McGee 2018 p. ">{{cite book | last=McGee | first=Steven | name-list-style = vanc | title=Evidence-based physical diagnosis | publisher=Elsevier | location=Philadelphia, PA | year=2018 | isbn=978-0-323-39276-1 | oclc=959371826 | quote=The term hypovolemia refers collectively to two distinct disorders: (1) volume depletion, which describes the loss of sodium from the extracellular space (i.e., intravascular and interstitial fluid) that occurs during gastrointestinal hemorrhage, vomiting, diarrhea, and diuresis; and (2) dehydration, which refers to the loss of intracellular water (and total body water) that ultimately causes cellular desiccation and elevates the plasma sodium concentration and osmolality.}}</ref> This may be due to either a loss of both salt and water or a decrease in blood volume.<ref>{{cite web|url=http://www.medterms.com/script/main/art.asp?articlekey=3871 |title=Hypovolemia definition – MedicineNet  |publisher=Medterms.com |date=2012-03-19 |access-date=2015-11-01}}</ref><ref>{{cite web|url=http://medical-dictionary.thefreedictionary.com/hypovolemia |title=Hypovolemia &#124; definition of hypovolemia by Medical dictionary |publisher=Medical-dictionary.thefreedictionary.com |access-date=2015-11-01}}</ref> Hypovolemia refers to the loss of extracellular fluid and should not be confused with [[dehydration]].<ref>{{cite journal | vauthors = Bhave G, Neilson EG | title = Volume depletion versus dehydration: how understanding the difference can guide therapy | journal = American Journal of Kidney Diseases | volume = 58 | issue = 2 | pages = 302–09 | date = August 2011 | pmid = 21705120 | pmc = 4096820 | doi = 10.1053/j.ajkd.2011.02.395 }}</ref>
+'''Hypovolemia''', also known as '''volume depletion''' or '''volume contraction''', is a state of abnormally low [[extracellular fluid]] in the body.<ref name="McGee 2018 p. ">{{Cite book |last=McGee |first=Steven |title=Evidence-based physical diagnosis |publisher=Elsevier |year=2018 |isbn=978-0-323-39276-1 |location=Philadelphia, PA |oclc=959371826 |quote=The term hypovolemia refers collectively to two distinct disorders: (1) volume depletion, which describes the loss of sodium from the extracellular space (i.e., intravascular and interstitial fluid) that occurs during gastrointestinal hemorrhage, vomiting, diarrhea, and diuresis; and (2) dehydration, which refers to the loss of intracellular water (and total body water) that ultimately causes cellular desiccation and elevates the plasma sodium concentration and osmolality. |name-list-style=vanc}}</ref> This may be due to either a loss of both salt and water or a decrease in [[blood volume]].<ref>{{cite web |url=http://www.medterms.com/script/main/art.asp?articlekey=3871 |title=Hypovolemia definition – MedicineNet |publisher=Medterms.com |date=2012-03-19 |access-date=2015-11-01 |archive-date=2014-01-23 |archive-url=https://web.archive.org/web/20140123013022/http://www.medterms.com/script/main/art.asp?articlekey=3871 |url-status=dead }}</ref><ref>{{cite web|url=http://medical-dictionary.thefreedictionary.com/hypovolemia |title=Hypovolemia &#124; definition of hypovolemia by Medical dictionary |publisher=Medical-dictionary.thefreedictionary.com |access-date=2015-11-01}}</ref> Hypovolemia refers to the loss of extracellular fluid and should not be confused with [[dehydration]].<ref>{{Cite journal |vauthors=Bhave G, Neilson EG |date=August 2011 |title=Volume depletion versus dehydration: how understanding the difference can guide therapy |journal=American Journal of Kidney Diseases |volume=58 |issue=2 |pages=302–09 |doi=10.1053/j.ajkd.2011.02.395 |pmc=4096820 |pmid=21705120}}</ref>
-Hypovolemia is caused by a variety of events, but these can be simplified into two categories: those that are associated with kidney function and those that are not.<ref name=":0">{{Cite book|title=Harrison's principles of internal medicine|editor-last1=Jameson|editor-first1=J. Larry|editor-last2=Kasper|editor-first2=Dennis L.|editor-last3=Longo|editor-first3=Dan L.|editor-last4=Fauci|editor-first4=Anthony S.|editor-last5=Hauser|editor-first5=Stephen L.|editor-last6=Loscalzo|editor-first6=Joseph|isbn=9781259644030|edition=20th|location=New York|publisher=[[McGraw-Hill Education]]|oclc=1029074059|date=2018}}</ref>  The signs and symptoms of hypovolemia worsen as the amount of fluid lost increases.<ref>{{Cite web|url=https://medlineplus.gov/ency/article/000167.htm|title=Hypovolemic shock: MedlinePlus Medical Encyclopedia|website=medlineplus.gov|language=en|access-date=2019-09-02}}</ref> Immediately or shortly after mild fluid loss, one may experience headache, fatigue, weakness, dizziness or thirst (as in blood transfusion, diarrhea, vomiting). Untreated hypovolemia or excessive and rapid losses of volume may lead to hypovolemic shock.<ref>{{Cite journal|last=Kolecki|first=Paul| name-list-style = vanc |date=October 13, 2016|title=Hypovolemic Shock|url=https://emedicine.medscape.com/article/760145-overview|journal=Medscape}}</ref> Signs and symptoms of hypovolemic shock include increased heart rate, low blood pressure, pale or cold skin, and altered mental status. When these signs are seen, immediate action should be taken to restore the lost volume.
+Hypovolemia is caused by a variety of events, but these can be simplified into two categories: those that are associated with [[Renal physiology|kidney function]] and those that are not.<ref name=":0">{{Cite book|title=Harrison's principles of internal medicine|editor-last1=Jameson|editor-first1=J. Larry|editor-last2=Kasper|editor-first2=Dennis L.|editor-last3=Longo|editor-first3=Dan L.|editor-last4=Fauci|editor-first4=Anthony S.|editor-last5=Hauser|editor-first5=Stephen L.|editor-last6=Loscalzo|editor-first6=Joseph|isbn=9781259644030|edition=20th|location=New York|publisher=[[McGraw-Hill Education]]|oclc=1029074059|date=2018}}</ref> The signs and symptoms of hypovolemia worsen as the amount of fluid lost increases.<ref>{{Cite web|url=https://medlineplus.gov/ency/article/000167.htm|title=Hypovolemic shock: MedlinePlus Medical Encyclopedia|website=medlineplus.gov|language=en|access-date=2019-09-02}}</ref> Immediately or shortly after mild fluid loss (from [[blood donation]], [[diarrhea]], [[vomiting]], bleeding from trauma, etc.), one may experience [[headache]], [[fatigue]], [[weakness]], [[dizziness]], or [[thirst]]. Untreated hypovolemia or excessive and rapid losses of volume may lead to [[hypovolemic shock]].<ref>{{Cite journal |last=Kolecki|first=Paul|name-list-style=vanc |date=October 13, 2016|title=Hypovolemic Shock|url=https://emedicine.medscape.com/article/760145-overview|journal=Medscape}}</ref> Signs and symptoms of hypovolemic shock include [[Tachycardia|increased heart rate]], [[Hypotension|low blood pressure]], [[Pallor|pale or cold skin]], and [[Altered level of consciousness|altered mental status]]. When these signs are seen, immediate action should be taken to [[Fluid replacement|restore the lost volume]].
 ==Signs and symptoms==
 Signs and symptoms of hypovolemia progress with increased loss of fluid volume.<ref name=":0" />
-Early symptoms of hypovolemia include headache, fatigue, weakness, thirst, and dizziness. The more severe signs and symptoms are often associated with hypovolemic shock. These include [[oliguria]], [[cyanosis]], abdominal and chest pain, [[hypotension]], [[tachycardia]], cold hands and feet, and progressively altering mental status.{{cn|date=November 2021}}
+Early symptoms of hypovolemia include headache, fatigue, weakness, thirst, and dizziness. The more severe signs and symptoms are often associated with hypovolemic shock. These include [[oliguria]], [[cyanosis]], abdominal and chest pain, [[hypotension]], [[tachycardia]], cold hands and feet, and progressively altering mental status.{{citation needed|date=November 2021}}
 ==Causes==
@@ Line 36: / Line 37: @@
 ===Kidney===
-* Loss of body sodium and consequent intravascular water (due to impaired reabsorption of salt and water in the tubules of the kidneys)
+* Loss of body [[sodium]] and consequent intravascular water (due to impaired reabsorption of salt and water in the [[tubule]]s of the kidneys)
-** [[Osmotic diuresis]]: the increase in urine production due to an excess of osmotic (namely glucose and urea) load in the tubules of the kidneys
+** [[Osmotic diuresis]]: the increase in urine production due to an excess of osmotic (namely [[glucose]] and [[urea]]) load in the tubules of the kidneys
-** Overuse of pharmacologic diuretics
+** Overuse of pharmacologic [[diuretic]]s
 ** Impaired response to hormones controlling salt and water balance (see [[mineralocorticoid]]s)
-** Impaired kidney function due to tubular injury or other diseases
+** [[Renal dysfunction|Impaired kidney function]] due to tubular injury or other diseases
 ===Other===
-* Loss of bodily fluids due to:
+* Loss of bodily fluids due to:{{cn|date=June 2022}}
 ** Gastrointestinal losses; e.g. vomiting and diarrhea
 ** Skin losses; e.g. excessive sweating and burns
 ** Respiratory losses; e.g. hyperventilation (breathing fast)
-* Build up of fluid in empty spaces ([[third spaces]]) of the body due to:
+* Build up of fluid in empty spaces ([[third spaces]]) of the body due to:{{cn|date=June 2022}}
 ** [[Acute pancreatitis]]
 ** Intestinal obstruction
-** Increase in vascular permeability
+** Increase in [[vascular permeability]]
+** Dysautonomia such as [[Vasovagal syncope]] or POTS [[Postural orthostatic tachycardia syndrome]]
 ** [[Hypoalbuminemia]]
 * Loss of blood (external or internal [[bleeding]] or [[blood donation]]<ref>{{cite journal | vauthors = Danic B, Gouézec H, Bigant E, Thomas T | title = [Incidents of blood donation] | language = fr | journal = Transfusion Clinique et Biologique | volume = 12 | issue = 2 | pages = 153–59 | date = June 2005 | pmid = 15894504 | doi = 10.1016/j.tracli.2005.04.003 }}</ref>)
@@ Line 57: / Line 59: @@
 [[Image:170225 CVS Hypovolemic Shock Pathophysiology of Disease.png|thumb|upright=1.3|Pathophysiology of hypovolemia]]
-The signs and symptoms of hypovolemia are primarily due to the consequences of decreased circulating volume and a subsequent reduction in the amount of blood reaching the tissues of the body.<ref>{{Citation|last1=Taghavi|first1=Sharven|title=Hypovolemic Shock|date=2019|url=http://www.ncbi.nlm.nih.gov/books/NBK513297/|work=StatPearls|publisher=StatPearls Publishing|pmid=30020669|access-date=2019-09-02|last2=Askari|first2=Reza | name-list-style = vanc }}</ref> In order to properly perform their functions, tissues require the oxygen transported in the blood.<ref>{{cite journal | vauthors = Carreau A, El Hafny-Rahbi B, Matejuk A, Grillon C, Kieda C | title = Why is the partial oxygen pressure of human tissues a crucial parameter? Small molecules and hypoxia | journal = Journal of Cellular and Molecular Medicine | volume = 15 | issue = 6 | pages = 1239–53 | date = June 2011 | pmid = 21251211 | pmc = 4373326 | doi = 10.1111/j.1582-4934.2011.01258.x }}</ref> A decrease in circulating volume can lead to a decrease in bloodflow to the brain, resulting in headache and dizziness.{{cn|date=November 2021}}
+The signs and symptoms of hypovolemia are primarily due to the consequences of decreased circulating volume and a subsequent reduction in the amount of blood reaching the tissues of the body.<ref>{{Citation|last1=Taghavi|first1=Sharven|title=Hypovolemic Shock|date=2019|url=http://www.ncbi.nlm.nih.gov/books/NBK513297/|work=StatPearls|publisher=StatPearls Publishing|pmid=30020669|access-date=2019-09-02|last2=Askari|first2=Reza | name-list-style = vanc }}</ref> In order to properly perform their functions, tissues require the oxygen transported in the blood.<ref>{{Cite journal |vauthors=Carreau A, El Hafny-Rahbi B, Matejuk A, Grillon C, Kieda C |date=June 2011 |title=Why is the partial oxygen pressure of human tissues a crucial parameter? Small molecules and hypoxia |journal=Journal of Cellular and Molecular Medicine |volume=15 |issue=6 |pages=1239–53 |doi=10.1111/j.1582-4934.2011.01258.x |pmc=4373326 |pmid=21251211}}</ref> A decrease in circulating volume can lead to a decrease in bloodflow to the brain, resulting in headache and dizziness.{{citation needed|date=November 2021}}
-Baroreceptors in the body (primarily those located in the [[carotid sinus]]es and [[aortic arch]]) sense the reduction of circulating fluid and send signals to the brain to increase sympathetic response (''see also: [[baroreflex]]'').<ref>{{cite book | vauthors = Armstrong M, Moore RA | chapter = Physiology, Baroreceptors | date = 2019 | pmid = 30844199 | chapter-url = http://www.ncbi.nlm.nih.gov/books/NBK538172/ | access-date = 2019-09-02 | publisher = StatPearls Publishing | title = StatPearls }}</ref> This sympathetic response is to release [[Adrenaline|epinephrine]] and [[norepinephrine]], which results in peripheral vasoconstriction (reducing size of blood vessels) in order to conserve the circulating fluids for organs vital to survival (i.e. brain and heart). Peripheral vasoconstriction accounts for the cold extremities (hands and feet), increased heart rate, increased cardiac output (and associated chest pain). Eventually, there will be less perfusion to the kidneys, resulting in decreased urine output.{{citation needed|date=July 2020}}
+[[Baroreceptor]]s in the body (primarily those located in the [[carotid sinus]]es and [[aortic arch]]) sense the reduction of circulating fluid and send signals to the brain to increase sympathetic response (''see also: [[baroreflex]]'').<ref>{{Cite book |title=StatPearls |vauthors=Armstrong M, Moore RA |date=2019 |publisher=StatPearls Publishing |chapter=Physiology, Baroreceptors |pmid=30844199 |access-date=2019-09-02 |chapter-url=http://www.ncbi.nlm.nih.gov/books/NBK538172/}}</ref> This sympathetic response is to release [[Adrenaline|epinephrine]] and [[norepinephrine]], which results in peripheral [[vasoconstriction]] (reducing size of blood vessels) in order to conserve the circulating fluids for organs vital to survival (i.e. brain and heart). Peripheral vasoconstriction accounts for the cold extremities (hands and feet), increased heart rate, increased cardiac output (and associated chest pain). Eventually, there will be less [[perfusion]] to the kidneys, resulting in decreased urine output.{{citation needed|date=July 2020}}
 ==Diagnosis==
 {{see also|Shock index}}
-Hypovolemia can be recognized by a [[fast heart rate]], [[low blood pressure]],<ref>{{cite web|url=http://www.stagesofshock.com/stage3/index.html |title=Stage 3: Compensated Shock|archive-url=https://web.archive.org/web/20100611035541/http://www.stagesofshock.com/stage3/index.html |archive-date=2010-06-11}}</ref> and the absence of [[perfusion]] as assessed by skin signs (skin turning pale) and/or [[capillary refill]] on [[forehead]], [[lip]]s and [[nail beds]].  The patient may feel dizzy, faint, nauseated, or very thirsty.  These signs are also characteristic of most types of [[Shock (circulatory)|shock]].<ref name="Alpert Ewy">{{cite book| first1 = Joseph S. | last1 = Alpert | first2 = Gordon A. | last2 = Ewy | name-list-style = vanc |title=Manual of Cardiovascular Diagnosis and Therapy|url=https://books.google.com/books?id=Qr9umARYOBYC&pg=PA101|year=2002|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-2803-4|page=101}}</ref>
+Hypovolemia can be recognized by a [[fast heart rate]], [[low blood pressure]],<ref>{{cite web|url=http://www.stagesofshock.com/stage3/index.html |title=Stage 3: Compensated Shock|archive-url=https://web.archive.org/web/20100611035541/http://www.stagesofshock.com/stage3/index.html |archive-date=2010-06-11}}</ref> and the absence of [[perfusion]] as assessed by skin signs (skin turning pale) and/or [[capillary refill]] on [[forehead]], [[lip]]s and [[nail beds]].  The patient may feel dizzy, faint, nauseated, or very thirsty.  These signs are also characteristic of most types of [[Shock (circulatory)|shock]].<ref name="Alpert Ewy">{{Cite book |last1=Alpert |first1=Joseph S. |url=https://books.google.com/books?id=Qr9umARYOBYC&pg=PA101 |title=Manual of Cardiovascular Diagnosis and Therapy |last2=Ewy |first2=Gordon A. |publisher=Lippincott Williams & Wilkins |year=2002 |isbn=978-0-7817-2803-4 |page=101 |name-list-style=vanc}}</ref>
-In children, compensation can result in an artificially high blood pressure despite hypovolemia (a decrease in blood volume). Children typically are able to compensate (maintain blood pressure despite hypovolemia) for a longer period than adults, but deteriorate rapidly and severely once they are unable to compensate ([[Decompensation|decompensate]]).<ref name="Stapleton">{{cite book| first1 = Mark C | last1 = Henry | first2 = Edward R | last2 = Stapleton | first3 = Dennis | last3 = Edgerly | name-list-style = vanc |title=EMT Prehospital Care |url= https://books.google.com/books?id=LPoXkd4yN1AC&pg=PA471 |year=2011|publisher=Jones & Bartlett Publishers|isbn=978-0-323-08533-5|pages=471–}}</ref> Consequently, any possibility of [[internal bleeding]] in children should be treated aggressively.<ref name="Beevi">{{cite book|author=Assuma Beevi|title=Pediatric Nursing Care Plans|url=https://books.google.com/books?id=2pQGoymRB9YC&pg=PT47|year=2012|publisher=JP Medical Ltd|isbn=978-93-5025-868-2|pages=47–}}</ref><ref name="Clement" />
+In children, compensation can result in an artificially high blood pressure despite hypovolemia (a decrease in blood volume). Children typically are able to compensate (maintain blood pressure despite hypovolemia) for a longer period than adults, but deteriorate rapidly and severely once they are unable to compensate ([[Decompensation|decompensate]]).<ref name="Stapleton">{{Cite book |last1=Henry |first1=Mark C |url=https://books.google.com/books?id=LPoXkd4yN1AC&pg=PA471 |title=EMT Prehospital Care |last2=Stapleton |first2=Edward R |last3=Edgerly |first3=Dennis |publisher=Jones & Bartlett Publishers |year=2011 |isbn=978-0-323-08533-5 |pages=471– |name-list-style=vanc}}</ref> Consequently, any possibility of [[internal bleeding]] in children should be treated aggressively.<ref name="Beevi">{{cite book|author=Assuma Beevi|title=Pediatric Nursing Care Plans|url=https://books.google.com/books?id=2pQGoymRB9YC&pg=PT47|year=2012|publisher=JP Medical Ltd|isbn=978-93-5025-868-2|pages=47–}}</ref><ref name="Clement" />
 Signs of external bleeding should be assessed, noting that individuals can bleed internally without external blood loss or otherwise apparent signs.<ref name="Clement">{{cite book| vauthors = Clement I |title=Textbook on First Aid and Emergency Nursing|url=https://books.google.com/books?id=AC__AwAAQBAJ&pg=PA113|year= 2013|publisher=Jaypee Brothers Publishers|isbn=978-93-5025-987-0|pages=113–}}</ref>
-There should be considered possible mechanisms of injury that may have caused internal bleeding, such as ruptured or bruised internal organs. If trained to do so and if the situation permits, there should be conducted a [[Advanced Trauma Life Support#Secondary survey|secondary survey]] and checked the chest and abdomen for pain, deformity, guarding, discoloration or swelling.  Bleeding into the abdominal cavity can cause the classical bruising patterns of [[Grey Turner's sign]] (bruising along the sides) or [[Cullen's sign]] (around the navel).<ref name="Amanda Graham">{{cite book| last1 = Blaber | first1 = Amanda | last2 = Harris | first2 = Graham | name-list-style = vanc |title=Assessment Skills For Paramedics|url=https://books.google.com/books?id=jfPbQbvP1yAC&pg=PA83|year=2011|publisher=McGraw-Hill Education|isbn=978-0-335-24199-6|pages=83–}}</ref>
+There should be considered possible mechanisms of injury that may have caused internal bleeding, such as ruptured or bruised internal organs. If trained to do so and if the situation permits, there should be conducted a [[Advanced Trauma Life Support#Secondary survey|secondary survey]] and checked the chest and abdomen for pain, deformity, guarding, discoloration or swelling.  Bleeding into the abdominal cavity can cause the classical bruising patterns of [[Grey Turner's sign]] (bruising along the sides) or [[Cullen's sign]] (around the navel).<ref name="Amanda Graham">{{Cite book |last1=Blaber |first1=Amanda |url=https://books.google.com/books?id=jfPbQbvP1yAC&pg=PA83 |title=Assessment Skills For Paramedics |last2=Harris |first2=Graham |publisher=McGraw-Hill Education |year=2011 |isbn=978-0-335-24199-6 |pages=83– |name-list-style=vanc}}</ref>
-===Investigation===
+===Examination===
-In a hospital, physicians respond to a case of hypovolemic shock by conducting these investigations:{{cn|date=November 2021}}
+In a hospital, physicians respond to a case of hypovolemic shock by conducting these examinations:{{citation needed|date=November 2021}}
 * Blood tests: [[Basic metabolic panel|U+Es/Chem7]], full blood count, glucose, blood type and screen
 * [[Central venous catheter]]
@@ Line 84: / Line 86: @@
 Untreated hypovolemia can lead to shock (see also: [[hypovolemic shock]]). Most sources state that there are 4 stages of hypovolemia and subsequent shock;<ref name="dynamicnursingeducation.com">{{cite web|author=Hudson, Kristi|url=http://dynamicnursingeducation.com/class.php?class_id=47&pid=18|title=Hypovolemic Shock – 1 Nursing CE|archive-url=https://web.archive.org/web/20090606044910/http://dynamicnursingeducation.com/class.php?class_id=47&pid=18 |archive-date=2009-06-06}}</ref> however, a number of other systems exist with as many as 6 stages.<ref>{{cite web|url=http://www.stagesofshock.com/stage1/index.html|title=Stage 1: Anticipation stage (a new paradigm)|archive-url=https://web.archive.org/web/20100116055045/http://www.stagesofshock.com/stage1/index.html|archive-date=2010-01-16}}</ref>
-The 4 stages are sometimes known as the "Tennis" staging of hypovolemic shock, as the stages of blood loss (under 15% of volume, 15–30% of volume, 30–40% of volume and above 40% of volume) mimic the scores in a game of tennis: 15, 15–30, 30–40 and 40.<ref name=emergencycare>{{cite book|editor1-last=Greaves|editor1-first=Ian|editor2-last=Porter|editor2-first=Keith|editor3-last=Hodgetts|editor3-first=Timothy|display-editors = 3 |editor4-last=Woollard|editor4-first=Malcolm| name-list-style = vanc |title=Emergency Care: A Textbook for Paramedics|date=2006|publisher=Elsevier Health Sciences|isbn=9780702025860|page=229}}</ref> It is basically the same as used in classifying [[bleeding]] by blood loss.
+The 4 stages are sometimes known as the "Tennis" staging of hypovolemic shock, as the stages of blood loss (under 15% of volume, 15–30% of volume, 30–40% of volume and above 40% of volume) mimic the scores in a game of [[tennis]]: 15, 15–30, 30–40 and 40.<ref name=emergencycare>{{cite book|editor1-last=Greaves|editor1-first=Ian|editor2-last=Porter|editor2-first=Keith|editor3-last=Hodgetts|editor3-first=Timothy|display-editors = 3 |editor4-last=Woollard|editor4-first=Malcolm| name-list-style = vanc |title=Emergency Care: A Textbook for Paramedics|date=2006|publisher=Elsevier Health Sciences|isbn=9780702025860|page=229}}</ref> It is basically the same as used in classifying [[bleeding]] by blood loss.{{cn|date=December 2023}}
-The signs and symptoms of the major stages of hypovolemic shock include:<ref name=agabegi2nd>{{cite book | first1 = Elizabeth D | last1 = Agabegi | first2 = Agabegi | last2 = Steven S. | name-list-style = vanc | title = Step-Up to Medicine (Step-Up Series) | publisher = Lippincott Williams & Wilkins | location = Hagerstwon, MD | year = 2008 | isbn = 978-0-7817-7153-5 | url-access = registration | url = https://archive.org/details/stepuptomedicine0000agab }}</ref><ref>{{Cite book|title=Robbins and Cotran pathologic basis of disease|editor-last1=Kumar|editor-first1=Vinay|editor-last2=Abbas|editor-first2=Abul K.|editor-last3=Aster|editor-first3=Jon C.|others=Illustrated by Perkins, James A.|date=2015|isbn=9781455726134|edition=9th|location=Philadelphia, PA|publisher=[[Saunders (imprint)|Saunders]]|oclc=879416939}}</ref>
+The signs and symptoms of the major stages of hypovolemic shock include:<ref name="agabegi2nd">{{Cite book |last1=Agabegi |first1=Elizabeth D |url=https://archive.org/details/stepuptomedicine0000agab |title=Step-Up to Medicine (Step-Up Series) |last2=Steven S. |first2=Agabegi |publisher=Lippincott Williams & Wilkins |year=2008 |isbn=978-0-7817-7153-5 |location=Hagerstwon, MD |url-access=registration |name-list-style=vanc}}</ref><ref>{{Cite book|title=Robbins and Cotran pathologic basis of disease|editor-last1=Kumar|editor-first1=Vinay|editor-last2=Abbas|editor-first2=Abul K.|editor-last3=Aster|editor-first3=Jon C.|others=Illustrated by Perkins, James A.|date=2015|isbn=9781455726134|edition=9th|location=Philadelphia, PA|publisher=[[Saunders (imprint)|Saunders]]|oclc=879416939}}</ref>
 {| class="wikitable" style="margin: 1em auto 1em auto;"
@@ Line 119: / Line 121: @@
 Medical personnel should immediately supply emergency oxygen to increase efficiency of the patient's remaining blood supply. This intervention can be life-saving.<ref>{{cite journal |last1=Takasu |first1=A. |last2=Prueckner |first2=S. |last3=Tisherman |first3=S. A. |last4=Stezoski |first4=S. W. |last5=Stezoski |first5=J. |last6=Safar |first6=P. |year=2000 |title=Effects of increased oxygen breathing in a volume controlled hemorrhagic shock outcome model in rats |journal=Resuscitation |volume=45 |issue=3 |pages=209–220 |pmid=10959021 |doi=10.1016/s0300-9572(00)00183-0 }}</ref>
+Also, the respiratory pump is especially important during hypovolemia as spontaneous breathing may help reduce the effect of this loss of blood pressure on stroke volume by increasing venous return.<ref name="pmid29494288">{{cite journal | vauthors = Skytioti M, Søvik S, Elstad M | title = Respiratory pump maintains cardiac stroke volume during hypovolemia in young, healthy volunteers | journal = J Appl Physiol | volume = 124 | issue = 5 | pages = 1319–1325 | date = May 2018 | pmid = 29494288 | doi = 10.1152/japplphysiol.01009.2017 | s2cid = 3626450 | hdl = 10852/72205 | hdl-access = free }}</ref>
-The use of [[intravenous drip|intravenous fluids]] (IVs) may help compensate for lost fluid volume, but IV fluids cannot carry oxygen the way blood does—however, researchers are developing [[blood substitutes]] that can. Infusing [[colloid fluids|colloid]] or [[crystalloid fluid|crystalloid]] IV fluids also dilutes [[clotting factor]]s in the blood, increasing the risk of bleeding. Current best practice allow [[permissive hypotension]] in patients suffering from hypovolemic shock,<ref>{{cite web |url=http://www.trauma.org/archive/resus/permissivehypotension.html |title=Permissive Hypotension |publisher=Trauma.Org |date=1997-08-31 |access-date=2015-11-01 |archive-url=https://web.archive.org/web/20131127011402/http://www.trauma.org/archive/resus/permissivehypotension.html |archive-date=2013-11-27 |url-status=dead }}</ref> both avoid overly diluting clotting factors and avoid artificially raising blood pressure to a point where it "blows off" clots that have formed.<ref name="AAOS">{{cite book | first = Mike | last = Kennamer | author2 = American Academy of Orthopaedic Surgeons (AAOS) | name-list-style = vanc |title=Intravenous Therapy for Prehospital Providers|url=https://books.google.com/books?id=YB2VAgAAQBAJ&pg=PA63|year=2013|publisher=Jones & Bartlett Publishers|isbn=978-1-4496-4204-4|pages=63–}}</ref><ref name="Franchis Dell'Era">{{cite book| first1 = Roberto | last1 = de Franchis | first2 = Alessandra | last2 = Dell'Era | name-list-style = vanc |title=Variceal Hemorrhage|url=https://books.google.com/books?id=YrW9BAAAQBAJ&pg=PA113|year= 2014|publisher=Springer Science & Business Media|isbn=978-1-4939-0002-2|pages=113–}}</ref>
+The use of [[intravenous drip|intravenous fluids]] (IVs) may help compensate for lost fluid volume, but IV fluids cannot carry oxygen the way blood does—however, researchers are developing [[blood substitutes]] that can. Infusing [[colloid fluids|colloid]] or [[crystalloid fluid|crystalloid]] IV fluids also dilutes [[clotting factor]]s in the blood, increasing the risk of bleeding. Current best practice allow [[permissive hypotension]] in patients with hypovolemic shock,<ref>{{cite web |url=http://www.trauma.org/archive/resus/permissivehypotension.html |title=Permissive Hypotension |publisher=Trauma.Org |date=1997-08-31 |access-date=2015-11-01 |archive-url=https://web.archive.org/web/20131127011402/http://www.trauma.org/archive/resus/permissivehypotension.html |archive-date=2013-11-27 |url-status=dead }}</ref> both avoid overly diluting clotting factors and avoid artificially raising blood pressure to a point where it "blows off" clots that have formed.<ref name="AAOS">{{Cite book |last1=Kennamer |first1=Mike |url=https://books.google.com/books?id=YB2VAgAAQBAJ&pg=PA63 |title=Intravenous Therapy for Prehospital Providers |last2=American Academy of Orthopaedic Surgeons (AAOS) |publisher=Jones & Bartlett Publishers |year=2013 |isbn=978-1-4496-4204-4 |pages=63– |name-list-style=vanc}}</ref><ref name="Franchis Dell'Era">{{Cite book |last1=de Franchis |first1=Roberto |url=https://books.google.com/books?id=YrW9BAAAQBAJ&pg=PA113 |title=Variceal Hemorrhage |last2=Dell'Era |first2=Alessandra |publisher=Springer Science & Business Media |year=2014 |isbn=978-1-4939-0002-2 |pages=113– |name-list-style=vanc}}</ref>
 ===Hospital treatment===
-[[Fluid replacement]] is beneficial in hypovolemia of stage 2, and is necessary in stage 3 and 4.<ref name=agabegi2nd /> See also the discussion of [[Shock (circulatory)|shock]] and the importance of treating reversible shock while it can still be countered.
+[[Fluid replacement]] is beneficial in hypovolemia of stage 2, and is necessary in stage 3 and 4.<ref name="agabegi2nd" /> See also the discussion of [[Shock (circulatory)|shock]] and the importance of treating reversible shock while it can still be countered.
-The following interventions are carried out:
+The following interventions are carried out:{{cn|date=November 2024}}
 * IV access
 * Oxygen as required
-* Fresh frozen plasma or [[blood transfusion]]
+* Fresh frozen [[Blood plasma|plasma]] or [[blood transfusion]]
 * Surgical repair at sites of bleeding
-Vasopressors (such as [[dopamine (medicine)|dopamine]] and [[Norepinephrine (drug)|noradrenaline]]) should generally be avoided, as they may result in further tissue ischemia and don't correct the primary problem.  Fluids are the preferred choice of therapy.<ref>{{cite journal|url=https://www.ncbi.nlm.nih.gov/pubmed?term=9001880 |title=Failure of dobutamine to improve liver oxygenation during resuscitation with a crystalloid solution after experimental haemorrhagic shock|journal=The European Journal of Surgery = Acta Chirurgica|volume=162|issue=12|pages=973–979|publisher=Pubmed-NCBI |date=1996-08-31 |access-date=2017-11-21|last1=Nordin|first1=A. J.|last2=Mäkisalo|first2=H.|last3=Höckerstedt|first3=K. A.}}</ref>
+[[Vasopressor]]s (such as [[dopamine (medicine)|dopamine]] and [[Norepinephrine (drug)|noradrenaline]]) should generally be avoided, as they may result in further tissue [[ischemia]] and don't correct the primary problem. Fluids are the preferred choice of therapy.<ref>{{cite journal|url=https://pubmed.ncbi.nlm.nih.gov/9001880/ |title=Failure of dobutamine to improve liver oxygenation during resuscitation with a crystalloid solution after experimental haemorrhagic shock|journal=The European Journal of Surgery = Acta Chirurgica|volume=162|issue=12|pages=973–979|publisher=Pubmed-NCBI |date=1996-08-31 |access-date=2017-11-21|last1=Nordin|first1=A. J.|last2=Mäkisalo|first2=H.|last3=Höckerstedt|first3=K. A.|pmid=9001880 }}</ref>
 ==History==
-In cases where loss of blood volume is clearly attributable to bleeding (as opposed to, e.g., dehydration), most medical practitioners prefer the term ''[[exsanguination]]'' for its greater specificity and descriptiveness, with the effect that the latter term is now more common in the relevant context.<ref>{{cite journal | vauthors = Geeraedts LM, Kaasjager HA, van Vugt AB, Frölke JP | title = Exsanguination in trauma: A review of diagnostics and treatment options | journal = Injury | volume = 40 | issue = 1 | pages = 11–20 | date = January 2009 | pmid = 19135193 | doi = 10.1016/j.injury.2008.10.007 }}</ref>
+In cases where loss of blood volume is clearly attributable to bleeding (as opposed to, e.g., dehydration), most medical practitioners prefer the term ''[[exsanguination]]'' for its greater specificity and descriptiveness, with the effect that the latter term is now more common in the relevant context.<ref>{{Cite journal |vauthors=Geeraedts LM, Kaasjager HA, van Vugt AB, Frölke JP |date=January 2009 |title=Exsanguination in trauma: A review of diagnostics and treatment options |journal=Injury |volume=40 |issue=1 |pages=11–20 |doi=10.1016/j.injury.2008.10.007 |pmid=19135193}}</ref>
 == See also ==
 * [[Hypervolemia]]
 * [[Non-pneumatic anti-shock garment]]
-* [[Polycythemia]], an increase of the hematocrit level, with the "relative polycythemia" being a decrease in the volume of plasma
+* [[Polycythemia]], an increase of the [[hematocrit]] level, with the "relative polycythemia" being a decrease in the volume of plasma
 * [[Volume status]]
@@ Line 148: / Line 152: @@
 |  ICD10           = {{ICD10|E|86||e|70}}, {{ICD10|R|57|1|r|50}}, {{ICD10|T|81|1|t|80}}
 |  ICD9            = {{ICD9|276.52}}
 |  ICDO            =
 |  OMIM            =
 |  MedlinePlus     = 000167
 |  eMedicineSubj   =
 |  eMedicineTopic  =
 |  MeshID          = D020896
 }}
+{{Electrolyte abnormalities}}
 {{shock types}}
 {{Disorders of volume state}}

Classification	D ICD-10: E86, R57.1, T81.1 ICD-9-CM: 276.52 MeSH: D020896 DiseasesDB: 29217
External resources	MedlinePlus: 000167

v t e Electrolyte imbalances
Calcium	High Low Symptoms and signs Chvostek sign Trousseau sign Milk-alkali syndrome Disorders of calcium metabolism Hypercalcemia of malignancy Calcinosis (Calciphylaxis, Calcinosis cutis) Calcification (Metastatic calcification, Dystrophic calcification) Familial hypocalciuric hypercalcemia
Chloride	High Low
Magnesium	High Low
Phosphate	High Low
Potassium	High Hyperkalemic periodic paralysis equine Low Hypokalemic periodic paralysis Hypokalemic sensory overstimulation
Sodium	High Salt poisoning Low Hypotonic Isotonic Cerebral salt-wasting syndrome

v t e Shock
Distributive	Septic shock Neurogenic shock Anaphylactic shock Toxic shock syndrome
Obstructive	Abdominal compartment syndrome
Low-volume	Hemorrhage Hypovolemia Osmotic shock
Other	Cardiogenic Spinal shock Cryptic shock Vasodilatory shock

v t e Disorders of volume state
Volume contraction	Dehydration Hypovolemia
Hypervolemia	Edema Anasarca cerebral edema pulmonary edema Angioedema Lymphedema
Other	Cause of fluid collection exudate transudate By site hydrothorax ascites hydrosalpinx hyperaemia