CURRENT Essentials of Critical Care.pdf

76 Current Essentials of Critical Care■■■Hypovolemic ShockEssentials of Diagnosis• Hypotension, cool extremities, collapsed neck veins, poor capillaryrefill• Orthostatic hypotension and oliguria• Elevated BUN to creatinine ratio, concentrated hematocrit; anemiaif blood loss is cause• Rapid correction of signs occurs with adequate fluid resuscitation• Trauma most common cause• Other etiologies: gastrointestinal bleeding, fistulas, diarrhea, excessivediuresis, diabetes insipidus, burns, disruption of suturelinesDifferential Diagnosis• Cardiogenic shock• Septic Shock• Neurogenic shock• Anaphylactic shockTreatment• Establish intravenous access with two large bore catheters• Rapid fluid resuscitation; infuse at rate adequate to correct calculatedor estimated fluid deficit• Fluid for resuscitation can be crystalloid (normal saline, lactatedRinger’s), colloid (albumin, hetastarch, dextran), blood products(packed red blood cells, plasma)• Transfusion of platelets and coagulation factors may be necessaryif large volume of packed red blood cells given• Continue rapid fluid resuscitation until reversal of abnormalsigns such as improved blood pressure, decreased heart rate, increasedurine output; avoid excessive volume leading to pulmonaryedema• Evaluate patient for source of blood loss to tailor additional therapeuticinterventions■ PearlIf oliguria is not present in the face of clinical hypovolemic shock,evaluate the urine for the presence of osmotically active substancessuch as glucose, radiographic dyes, or toxinsReferenceOrlinsky M et al: Current controversies in shock and resuscitation. Surg ClinNorth Am 2001;81:1217. [PMID: 11766174]