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'{{Technical|date=June 2009}} {{Infobox medical condition (new) | name = Hypovolemia | synonyms = Oligemia, hypovolaemia, oligaemia, hypovolæmia, volume depletion | image = | caption = | field = [[Emergency medicine]] | symptoms = headache, fatigue, nausea, profuse sweating, dizziness | complications = | onset = | duration = | types = | causes = | risks = | diagnosis = | differential = | prevention = | treatment = | medication = | prognosis = | frequency = | deaths = }} '''Hypovolemia''' also known as '''volume depletion''' is a state of decreased [[blood volume]] or diminished body fluid;<ref name="McGee 2018 p. ">{{cite book | last=McGee | first=Steven | title=Evidence-based physical diagnosis | publisher=Elsevier | publication-place=Philadelphia, PA | year=2018 | isbn=978-0-323-39276-1 | oclc=959371826 | page= | 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> more specifically, decrease in volume of [[blood plasma]].<ref>{{cite web|url=http://www.medterms.com/script/main/art.asp?articlekey=3871 |title=Hypovolemia definition - MedicineNet - Health and Medical Information Produced by Doctors |publisher=Medterms.com |date=2012-03-19 |accessdate=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 |date= |accessdate=2015-11-01}}</ref> It is thus the intravascular component of [[volume contraction]] (or loss of blood volume due to things such as [[hemorrhaging|bleeding]] or [[dehydration]]), but, as it also is the most essential one, ''hypovolemia'' and '''''volume contraction''''' are sometimes used synonymously. Hypovolemia is characterized by sodium depletion, and thus is distinct from (although often overlapping with) [[dehydration]], excessive loss of [[body water]].<ref>{{cite web|url=http://www.medterms.com/script/main/art.asp?articlekey=2933 |title=Dehydration definition - MedicineNet - Health and Medical Information Produced by Doctors |publisher=Medterms.com |date=2013-10-30 |accessdate=2015-11-01}}</ref> ==Causes== Common causes of hypovolemia are:<ref>Sircar, S. Principles of Medical Physiology. Thieme Medical Pub. {{ISBN|9781588905727}}</ref> * 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=French |journal=Transfus Clin Biol |volume=12 |issue=2 |pages=153–9 |date=June 2005 |pmid=15894504 |doi=10.1016/j.tracli.2005.04.003 |url=}}</ref>) * Loss of plasma (severe [[Burn (injury)|burns]]<ref>{{cite web|url=http://www.totalburncare.com/orientation_burn_shock.htm |title=Burn Shock / House Staff Manual |publisher=Total Burn Care |date= |accessdate=2015-11-01}}</ref><ref>{{cite web|url=http://www.patient.info/doctor/Resuscitation-in-Hypovolaemic-Shock.htm |title=Resuscitation in Hypovolaemic Shock. Information page &#124; Patient |publisher=Patient.info |date= |accessdate=2015-11-01}}</ref> and [[lesions]] discharging fluid) * Loss of body sodium and consequent intravascular water; e.g. diarrhea or vomiting certain drugs ex-diuretics \ ==Signs and symptoms== Symptoms may not be present until 10–20% of total whole-blood volume is lost. Headache, fatigue, nausea, profuse sweating, dizziness may occur as the condition develops. ==Diagnosis== {{see also|Shock index}} Hypovolemia can be recognized by [[tachycardia]], diminished blood pressure,<ref>{{cite web|url=http://www.stagesofshock.com/stage3/index.html |title=Stage 3: Compensated Shock|archiveurl=https://web.archive.org/web/20100611035541/http://www.stagesofshock.com/stage3/index.html |archivedate=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|author1=Joseph S. Alpert|author2=Gordon A. Ewy|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> Note that in children compensation can result in an artificially high blood pressure despite hypovolemia. Children typically compensate (maintain blood pressure despite loss of blood volume) for a longer period than adults (until their blood is depleted by more than half), but deteriorate rapidly and severely once they do begin to decompensate.<ref name="Stapleton">{{cite book|author1=Henry|author2=Edward R. Stapleton|title=EMT Prehospital Care|url=https://books.google.com/books?id=LPoXkd4yN1AC&pg=PA471|date=26 July 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|date=31 August 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|author1=Clement|author2=I|title=Textbook on First Aid and Emergency Nursing|url=https://books.google.com/books?id=AC__AwAAQBAJ&pg=PA113|date=20 May 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|author1=Blaber, Amanda|author2=Harris, Graham|title=Assessment Skills For Paramedics|url=https://books.google.com/books?id=jfPbQbvP1yAC&pg=PA83|date=1 October 2011|publisher=McGraw-Hill Education|isbn=978-0-335-24199-6|pages=83–}}</ref> ===Stages=== Usually referred to as a "class" of shock. Most sources state that there are 4 stages of [[hypovolemic 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|archiveurl=https://web.archive.org/web/20090606044910/http://dynamicnursingeducation.com/class.php?class_id=47&pid=18 |archivedate=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)|archiveurl=https://web.archive.org/web/20100116055045/http://www.stagesofshock.com/stage1/index.html|archivedate=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|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 signs and symptoms of the major stages of hypovolemic shock include:<ref name=agabegi2nd>{{cite book |author1=Elizabeth D Agabegi |author2=Agabegi, Steven S. |title=Step-Up to Medicine (Step-Up Series) |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2008 |pages= |isbn=978-0-7817-7153-5 |oclc= |doi= |accessdate=}}</ref> {| class="wikitable" style="margin: 1em auto 1em auto;" ! scope="col" | ! scope="col" | '''Stage 1''' ! scope="col" | '''Stage 2''' ! scope="col" | '''Stage 3''' ! scope="col" | '''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<br/>by [[vasoconstriction]]) || Increased [[diastolic blood pressure|diastolic BP]] || [[Systolic blood pressure|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) || [[Tachypnea|Tachypneic]] (> 30) || Extreme [[tachypnea]] |- | '''Mental status''' || Normal || Slight anxiety, restless || [[Altered mental status|Altered]], confused || Decreased [[level of consciousness|LOC]], [[lethargy]], [[coma]] |- | '''Skin''' || [[Pallor]] || 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 |} ===Investigation=== In a hospital, physicians respond to a case of hypovolemic shock by conducting these investigations: * Blood tests: [[Basic metabolic panel|U+Es/Chem7]], full blood count, glucose, blood type and screen * [[Central venous catheter]] * [[Arterial line]] * Urine output measurements (via [[urinary catheterization|urinary catheter]]) * Blood pressure * SpO2 oxygen saturation monitoring ==Treatment== ===Field care=== The most important step in treatment of hypovolemic shock is to identify and control the source of bleeding.<ref>Bulger, E. M., Snyder, D., Schoelles, K., Gotschall, C., Dawson, D., Lang, E., ... & White, L. (2014). An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care, 18(2), 163-173.</ref> Medical personnel should immediately supply emergency oxygen to increase efficiency of the patient's remaining blood supply. This intervention can be life-saving.<ref>Takasu A, Prueckner S, Tisherman SA, Stezoski SW, Stezoski J, Safar P. (2000), ''Effects of increased oxygen breathing in a volume controlled hemorrhagic shock outcome model in rats.'', {{PMID|10959021}}</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 |accessdate=2015-11-01}}</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|author1=American Academy of Orthopaedic Surgeons (AAOS)|author2=AAOS|author3=Mike Kennamer|title=Intravenous Therapy for Prehospital Providers|url=https://books.google.com/books?id=YB2VAgAAQBAJ&pg=PA63|date=30 September 2013|publisher=Jones & Bartlett Publishers|isbn=978-1-4496-4204-4|pages=63–}}</ref><ref name="Franchis Dell'Era">{{cite book|author1=Roberto de Franchis|author2=Alessandra Dell'Era|title=Variceal Hemorrhage|url=https://books.google.com/books?id=YrW9BAAAQBAJ&pg=PA113|date=25 January 2014|publisher=Springer Science & Business Media|isbn=978-1-4939-0002-2|pages=113–}}</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. The following interventions are carried out: * IV access * Oxygen as required * Fresh frozen plasma or [[blood transfusion]] * Surgical repair at sites of bleeding Vasopressors (like ([[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 web|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|publisher=Pubmed-NCBI |date=1996-08-31 |accessdate=2017-11-21}}</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 |author1=L. Geeraedts Jr. |author2=H. Kaasjager |author3=A. van Vugt |author4=J. Frölke | year = 2009| title = Exsanguination in trauma: A review of diagnostics and treatment options | url = | journal = Injury | volume = 40 | issue = 1| pages = 11–20 | doi=10.1016/j.injury.2008.10.007|pmid=19135193 }}</ref> ==See also== * [[Exsanguination]] * [[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 * [[Volume status]] ==References== {{Reflist|colwidth=30em}} == External links == {{Medical resources | DiseasesDB = 29217 | 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 }} {{shock types}} {{Water-electrolyte imbalance and acid-base imbalance}} {{Cardiovascular system symptoms and signs}} [[Category:Blood disorders]] [[Category:Medical emergencies]]'