Hypovolemia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]

Synonyms and keywords: hypovolaemia; hypovolemic.

Overview

Hypovolemia is a state of decreased blood volume; more specifically, decrease in volume of blood plasma.

Causes

Common Causes

• Bleeding
• Sepsis
• Severe burns
• Dehydration
• Drugs such as diuretics or vasodilators typically used to treat hypertensive individuals

Causes by Organ System

Cardiovascular	Obstruction of a major venous system, Dissecting aortic aneurysm, Abdominal aortic aneurysm rupture, Iliac artery aneurysm dissection, Blood vessel trauma
Chemical/Poisoning	No underlying causes
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	ACE inhibitors, Diuretics, Ixabepilone, Vasodilators
Ear Nose Throat	No underlying causes
Endocrine	Hypoaldosteronism, Diabetes insipidus
Environmental	Heat stroke, Excessive Sweating
Gastroenterologic	Gastric volvulus, Gastric ulcer, Acute pancreatitis, Cirrhosis, Splenic rupture, Small bowel obstruction, Paralytic Ileus, Nausea and vomiting, Gastric volvulus, Duodenal ulcer, Diarrhoea, Bleeding Oesophageal varices
Genetic	No underlying causes
Hematologic	No underlying causes
Iatrogenic	External drainage
Infectious Disease	No underlying causes
Musculoskeletal/Orthopedic	Fracture of bone
Neurologic	No underlying causes
Nutritional/Metabolic	Protein energy malnutrition, Marasmus
Obstetric/Gynecologic	Uterine rupture, Phlegmasia alba dolens, Ovarian hyperstimulation syndrome, Ectopic pregnancy rupture
Oncologic	No underlying causes
Ophthalmologic	No underlying causes
Overdose/Toxicity	Alcohol consumption
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal/Electrolyte	Salt-wasting nephropathies
Rheumatology/Immunology/Allergy	No underlying causes
Sexual	No underlying causes
Trauma	Crush injury, Blood vessel trauma
Urologic	No underlying causes
Miscellaneous	Osmotic diuresis, Extreme weight loss, Bleeding, Severe burns, Retroperitoneal haemorrhage, Postpartum haemorrhage, Dehydration, Blood donation

Causes in Alphabetical Order

Abdominal aortic aneurysm rupture Cirrhosis ACE inhibitors Acute pancreatitis Alcohol consumption Bleeding Oesophageal varices Bleeding Blood donation(rare) Blood vessel trauma Burns Cholera Crush injury Dehydration Diabetes insipidus Diarrhoea Dissecting aortic aneurysm Diuretics Duodenal ulcer Ectopic pregnancy rupture Excessive Sweating External drainage Extreme weight loss Fracture of bone

Gastric ulcer Gastric volvulus Heat stroke Hypoaldosteronism Iliac artery aneurysm dissection Ixabepilone Lassa fever Marasmus Nausea and vomiting Obstruction of a major venous system Osmotic diuresis Ovarian hyperstimulation syndrome Paralytic Ileus Peritonitis Phlegmasia alba dolens Postpartum haemorrhage Protein energy malnutrition Retroperitoneal haemorrhage Salt-wasting nephropathies Severe burns Small bowel obstruction Splenic rupture Uterine rupture Vasodilators

Natural History, Complications and Prognosis

Severe hypovolemia may lead to hypovolemic shock which in turn can be associated with multiple organ failure, renal failure, brain damage, coma and death (desanguination).Note that in children, compensation can result in an artificially high blood pressure despite hypovolemia.This is another reason (aside from initial lower blood volume) that even the possibility of internal bleeding in children should always be treated aggressively.People can bleed to death internally without any external blood loss.

Diagnosis

Clinical symptoms may not present until 10-20% of total whole-blood volume is lost. Also consider possible mechanisms of injury (especially the steering wheel and/or use/non-use of seat belt in motor vehicle accidents) that may have caused internal bleeding such as ruptured or bruised internal organs.If trained to do so and the situation permits, conduct a secondary survey and check the chest and abdominal cavities for pain, deformity, guarding or swelling.(Injuries to the pelvis and bleeding into the thigh from the femoral artery can also be life-threatening.)

Symptoms

The patient may feel :

• Dizzy

• Faint

• Nausea

• Very thirsty

Physical Examination

• Elevated pulse

• Low blood pressure and the absence of perfusion

• Pale skin

• Reduced capillary refill assessed on forehead, lips and nail beds

Treatment

Minor hypovolemia from a known cause that has been completely controlled (such as a blood transfusion from a healthy patient who is not anemic) may be countered with initial rest for up to half an hour, oral fluids including moderate sugars (apple juice is good) and the advice to the donor to eat good solid meals with proteins for the next few days.Typically, this would involve a fluid volume of less than one liter (1000 ml), although this is highly dependent on body weight.Larger people can tolerate slightly more blood loss than smaller people.More serious hypovolemia should be assessed by a nurse or doctor.When in doubt, treat hypovolemia aggressively.Note that in children, compensation can result in an artificially high blood pressure despite hypovolemia.

First Aid

External bleeding should be controlled by direct pressure. If direct pressure fails, other techniques such as elevation and pressure points should be considered. The tourniquet should be used in the case of massive hemorrhage i.e. arterial bleeds, such as the femoral artery. If a first-aider recognizes internal bleeding, the life-saving measure to take is to immediately call for emergency assistance.

Field Care

Emergency oxygen should be immediately employed to increase the efficiency of the patient's remaining blood supply.This intervention can be life-saving.

The use of intravenous fluids(IVs) may help compensate for lost fluid volume, but IV fluids cannot carry oxygen in the way that blood can.See also emergency medical services for a discussion of techniques used in IV fluid management of hypovolemia.

Hospital Treatment

If the hypovolemia was caused by medication, the administration of antidotes may be appropriate but should be carefully monitored to avoid shock or the emergence of other pre-existing conditions.

Blood transfusions coupled with surgical repair are the definitive treatment for hypovolemia caused by trauma.See also the discussion of shock and the importance of treating reversible shock while it can still be countered.

References

Related Chapters

• Volume status
• Hypervolemia

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