[Music] thank you welcome to ATC the emergency medicine Channel today let us discuss about management of hypovolemia in emergency room we see our body water you can see here in our body around 40 to 45 percent is solids and 60 percent is fluid in that two-third is intra cellular fluid one there is extra cellular fluid in that extracellular fluid 80 percent of the fluid is industrial fluid and 20 percent of the fluid is plasma fluid and in emergence room we mainly Target this 20 percent because any patient who is admitted with hypovolemia hypotension shock all these things we have to correct the intravascular volume first if you don't correct the intravascular volume the circulation will be reduced and that will lead to anaerobic metabolism lactic acidosis like that now if you see the ah compartment in a 70 kg adult man you can see here total volume may be somewhere around 42 liters that is 60 percent of the body weight in that intravascular fluid will be around 3 liters that is very important this knowledge is very important because when we are managing a case in emergency room for hypovolemia we may have to give around three liters to correct the intravascular volume depletion in a person who is eyeing weight of 70 kg but you also should know that there will be a reduction the extra vascular volume also like industrial fluid extracellular ah fluid also we have to correct sometimes for that we have to give additional fluid after correcting the intravascular volume now we can see the causes for hypovolemia ah extracellular fluid or ah reduced extracellular volume reduced conditions like renal loss and extra renal loss vomiting diarrhea sweat Burns heat hemorrhagic shock renal loss mainly diuretics osmotic diuresis diabetes insipidus hypoaldosterone some salt wasting nephroposis diabetic ketocerosis all these things are very common in that DK is one of the most common condition we we manage in emergency room where there is severe hypovolemia other conditions in extraordinary it is vomiting and diarrhea extra cylinder volume increased that means total volume is increased but intravascular volume alone is reduced that conditions are cardiac failure liver failure kidney failure hypoal Dominion ah nephrotic syndrome capillary leaks and drums ah sepsis all these things volume is there in the body volume is not completely reduced but intravascular volume is reduced now you can see here the symptoms of hypovolemia one is due to volume depletion itself first fatigue weakness muscle cramps postural hypotension confusion comma oliguria concentrated urine all are due to reduced volume in our body second thing it is related to the cause of the illness whether it is diarrhea vomiting or Burns infections like that that symptoms also will be there third one will be electrolyte imbalance in that most important electrolyte will be potassium so potassium is required for muscle activity muscle weakness is the classical feature of any type of hypokalemia and you can see alkylosis also metabolic alcohols also in ABG but many patients who is having severe dehydration can also develop metabolic acidosis that is due to lactic acidosis now inadequate perfusion can lead to so so many complications it can reduce the perforation to internal circulation anaerobic metabolism and lactic acidosis so many abnormalities can occur due to inadequate perforation so inadequate perfusion ultimately lead to clinical findings like hypotension tachycardia cold calming skin tachypnea drowsiness confusion irritability reduced urine output jvp will be either reduced or elevated that depends on the fluid status ah patients who is in cardiac failure jvp will be elevated but circulation will not occur multi organ dysfunction poor altered cerebral perfusion lead to low GCS when there is an index called as shock index you can ah you can see the mortality rate by this shock index in severe types of shock it is defined as the heart rate divided by systolic blood pressure it has been suggested as a as such a marker that can be used to predict the severity of hypovolemic shock so shock index no shock less than 0. 6 mild shock 0. 621 moderate shock one to one point for severe shock more than 1.
4 the mortality in severe shock is 39 to 39. 8 percent or 40 percent mortalities there now one one important clinical finding which can be done in emergency room ah to find out whether the patient's perfusion is good or not that is capillary refill time this is a very simple test you can just press the finger tip like this and release it normally capillary refill time that means the white part will become red in less than two seconds but in a patient who is eyeing delayed circulation that capillary refill time is delayed and the whiteness will remain the white finger you can see that remain as such for some more time so capillary refill time less than two seconds indicates there is a good perforation of the ah peripherals if it is ready if it is delayed then that indicates a bad perfusion passive leg tracing test is another important investigation can be done in emergency room to see whether the patient is having volume responsiveness or not we always check the BP postural BP tachycardia all these things in patient who is having severe dehydration you can see postural BP will be initially itself it will be dropping there will be significant reduction in the standing BP if the patient is dehydrated but capillary refill time ah sorry passive leg raising test is a test which will tell you that whether the patient will improve with fluid or not for that you have to keep the patient in semi recommended position and suddenly passively raise the legs to 45 degree angle the effects occur in 30 to 90 seconds you can see ah the fluid from the lower leg the legs from the legs lower limbs it will drain to the central circulation when you are lifting the lower limb if the patient shows any significant Improvement in the systolic BP then that is a good indicator for fluid response units if you have a central line or if you have a arterial BP all these things will add to your ah clinical judgment arterial BP will be one of the simplest thing which can tell you that BP is improving or not but even otherwise you can check patients BP on passively erasing their leg you can check the BP if there is a significant Improvement in systolic BP then that indicates patient can receive more fluid so the procedure will be like this patient will be lying down like this suddenly raise the leg so that the fluid from the limbs lower limbs will drain to the central circulation BP can be slightly increased if the BP increases then that shows patient can take more fluid patient may not develop any adverse effects due to fluid so fluid challenge can be given without any fear in this type of patient so passive leg raising test is a very simple ah and effective method to find out whether the patient will be fluid responsive or not now IVC diameter little more expertise is required in this area ah you need to have a ultrasound Mission you you have to know how to do ultrasound for inferior vena cava and there we are seeing two important thing one is the diameter of uh IVC second one is ah collapsibility more than 50 percent in simple words IVC on USC's collapse patient can be treated with fruits IVC collapsibility is there means you can give more fluids if the IVC is distended even when there is hypotension that means patient is having volume overload the hypotension is due to something else so a collapsible ah IVC that indicates patient can receive more fluid so you can see here IVC is collapsible second ah ultrasound shows IBC is distended and if the collapsibility is ah not there in Inspiration expression change if the collapsibility is not there then that indicates ah patient is volume overloaded if the collapsibility is more than 50 percent that indicates patient can receive some more fluid now another important investigation or ah parameter is central venous pressure CVP for that you need to put a central line and the normal value of central line ah CVP will be eight to ten centimeter of water if it is low you can give more water if it is high then flow water should be restricted in this type of patients so hypotension with loss uvp you can give fluids hypertension with high CBP do not try to give fluids the problem for hypertension the the the cause for hypertension may be something else like cardiac failure or something else in Ventilator patients that may slightly alter I am not going to the details of that but in a patient who is having low CVP not on ventilator you can safely give fluids and improve the CBP to ah K to 10 or more than 10 initially itself so this is CBP monitoring now whenever you have a patient who is having a hypovolemia we suspect hypovolemia you have some lab investigation which which can tell you that patient is dehydrated that one is most important is hemoglobin percentage Whenever there is severe dehydration water loss you can see hemoglobin percentage increases that's a relative increase in the hemoglobin percentage because of the dehydration that will be corrected once you give fluid then blood durian nitrogen will be elevated creatine also be will be elevated but urea will be disproportionately elevated from than creatinine suppose in a patient who is saying ah normal creatinine urea ratio may be one is to 20 here it will be more than that for example patient who is having severe diarrhea admitted with urea 90. creatinine is only one that means there is a disproportionate elevation of the urea that indicates a pre-renal cause for kidney disease so pre-renal kidney diseases are due to hypo bulimia or severe dehydration no serum sodium most of the condition where there is hypovolemia alone you can see sodium will be high hypernatremia is a modern finding you can see in ah volume depletion now other way other investigations like you have to see lactate because patient who is having severe dehydration hypoperation anaerobic metabolism lactate can be produced in lactic acidosis can be ah seen in ABG values other investigations you have to see the electrolytes blood sugars infection screens because all these things can contribute to hypoally mean like krishnuism severe sepsis the dehydration or may be due to vascular leak Dengue shock syndrome dehydration may be due to vascular leak hypo or albuminmia the volume depletion may be due to intravascular collapse due to hypoalbuminum so you do some more investigation to find out what is the reason for the hypovolemia or hypotension now if a patient who is saying dehydration alone like a patient who is saying diarrhea vomiting or volume loss ah heat a heat stroke all these things we have to give ah fluid replacement ah normally if the patient is not sick we have to give fluids in a physiological way we have to ask the patient to take plenty of water through oral root itself if the patient is having diarrhea vomiting and all we have to give or oral rehydration salt that has to be given if you see the who or this one ah packet you can see here it contains sodium chloride glucose potassium chloride trisodium citrate dehydrate all these things are there in the orus pack so that has to be dissolved one pack has to be dissolved in one liter of clean drinking water and it should be prepared for uh 24 hours it should discard after 24 hours so it is only a freshly prepared solution should be used you should not use this for a longer period so prepare it in one liter water or whatever is ah advised in the packet and that should be diluted and given to the patient some patients May vomit after taking this horse they may not like the taste or smell of the aura so in that type of patients don't try this you can give salt water with salt and sugar solution to them or ah any other ah mild Solutions like oral drinks also can be even in a patient who is having severe dehydration whatever it is oral replacement of fluid is better than IV replacement in a patient who is ah normal clinical features now if the patient is having ah severe dehydration patient is ah not able to take water through oral root or vomiting after taking oral efforts you have to give ah IV fluids that better best IV fluid will be normal saline if the patient is having severe dehydration alone ah normal saline will be a better choice than any other fruit but if the patient designs severe diarrhea vomiting electrolyte imbalance is there then wrinkle lactate is better than normal saline in most of these type of conditions because that is most physiological solution available at present there is one more solution there is plasmolite that is a bit costly comparing with ringer lactate ringer lactate is available everywhere and it is less costly comparing with plasma light so wrinkle lactate will be a better choice in patient who is saying water with electrolyte loss but whereas in only water loss if the like patient is having diabetic ketosis you have to give normal saline only problem with normal certain is massive normal saline infusion can produce ah type of of acidosis that is hyperchloramic acidosis clinically it is not a big problem so you can continue that so normal serine will be a better choice if the sodium is very high then you can go for ah half normal saline or ah dextrose solution in hypotension if the volume depletion leads to hypotension and early shock then you have to put two IV lines that is very important to large gauge IV lines are important then you have to give fluids in a rate of 30 ml per kg body weight as a ballers in one hour you have to give 30 ml per kg body weight IV fluid has a ballast after the Ballers you can see the patient responds how is the patient improving in BP whether the patient urine output is improving whether the patient is developing any complication like permanent edema all these things can be looked into and you can continue the fluid administration crystalloids are like sludge like ringer lactate is equally effective like normal certain ah it has got no contraindication only contraindication is severe liver failure ah ringer lactate should not be used even in lactic acidosis finger lactate can be given plasmolite is another solution that also can be given in almost all type of hypovolemia it's the most physiological solution phospholite is the most physiological solution second one is ringer lactate third one only normal sign but comparing with all these three normal saline is less costly ah ringer lacted more costly and plasmolized is costlier than ringer lactate now when we are giving ah one liter of normal saline ringer lactate or plasma light or dextrose we have to see how much amount is remaining in the intravascular compartment if we are giving one liter of normal cell in around 300 mL of fluid will remain in the intravascular compartment after some time so whatever we give it will not remain in the international commandment it will shift to the extra vascular compartment also but it will not go to the intracellular compartment that is an advantage when we are giving ah crystalloids so if we are giving one liter a normal saline in a patient who is dying diary around 300 ml remain in the endovascular compartment for a long time but initially all the Thousand ml will remain in the intravascular compartment BP will improve circulation will improve then it will shift to the extra vascular compartment but if you are giving colloids like carbon only albumin should be used as a colloid in emergency room other colloids which was used previously are not indicated nowadays because it has got adverse effects so albumin ah 100 ml if you are giving 100 ml will remain in the intravascular compartment another 30 ml May draw from the extra vascular compartment to the Indra vascular compartment but it is not ah feasible to give albumin ah in emergency room because of the cost of the product cost around three thousand to five thousand rupees for 100 ml whereas normal selling costs only ah 90 Rupees to 100 rupees for 500 mL so that is a there is a major difference but after correcting the intravascular volume with normal cell and ringer lactate plasmite then if you want you can give album otherwise in a routine case albumin is not indicated in numbers and zero this chart will tell you that ah how much will remain in the intro escular compartment after giving each type of fluid so here we can see the ah normal saline around 300 ml will remain the intravascular compartment five percent extras around 100 ml remain in the intravascular compartment collides 1000 ml will remain the inrosical Commandment after giving thousand ml so that is the difference but uh unfortunately we cannot use colloids because it is very costly albumin is very costly normal saline ringerly acted plasma light these are the fluids should be used in hypovolemia or hypovolemic shock and most physiological IV fluid in emergency room is ah actually it is plasma right but plasmolite is not available in every emergency room so ringer lactate will be the most physiological IV fluid you can use ah ringer lactate in almost all types of hypovolemic conditions especially when there is diarrhea this is one ah IV fluid should be started in Diary operations because we can see many patients who is dying diarrhea unknowingly many start DNS that is not a good choice in diarrhea we have to give we have to replace the electrolytes so we have to give ah ringer lactate that is the best choice either normal Serene or ringer lactate not ah DNS once you correct intravascular volume by regular lactate normal Serene or plasmite then you can give ah DNS or five percent extra to improve the calorie requirement of the patient so to give the calorie requirement of the patient you have to give dextrose and to fill the extra vascular compartment also you have to give ah dextrose you can see here in a patient who is having severe diarrhea for many days his intravascular volume will be depleted is extra vascular volume also will be depleted so initially you have to correct the intravascular volume by crystalloids like normal cylindrical acid plasma light then you have to start DNS or five percent dextrose even to fill the extra vascular compartment albumin we already discussed albumin is very costly it is available as 20 100 ml it improves the intravascular volume by 100 and also draws some amount of fluid from the extra vascular compartment so it will increase the intravascular volume by 130 percent that is a important ah feature of albumin so if ah needed we have to give that otherwise unnecessarily albumin should not be given in patient over saying hypovolemia another important problem is hemorrhagic shock I am not going to discuss about hemologic shock here but you can see here the chart there are four major classes of hemorrhagic shock depending on the clinical feature we can classify into four major groups in that why we are classifying this is because ah from this itself we can understand that whether the patient require blood transfusion or not and the class for require massive transfusion protocol massive transfusion protocol means this patient require large amount of blood so when we are treating a patient with trauma with severe blood loss initially we will be treating the patient with normal serine or ringer lactate and patient volume will be diluted the blood will be diluted there loss of RBC with more fluid will be dilution so that will lead to dilution of the coagulation factors and dilution coagulopathy it can produce to prevent that when we are giving massive blood transfusion you have to give one is to one is to one ratio of RBC platelets and plasma that is massive transfusion protocol we will discuss massive transfusion protocol ah afterwards so when there is requirement of massive transfusion you need to give one point of RBC one point of ah platelets and one point of ffp that is ah massive transfusion protocol transition so when there is a severe ah shock due to bleed we had to give blood transfusion in patient suicide ah hemorrhagic shock it can be due to ah trauma it can be due to GI bleed or during surgeries all these things patient can develop ah hemorrhagic shock so blood transition should be ideally given when there is ah hemoglobin less than seven per seven gram per deciliter but in a patient who is a coronary artery disease stroke control uh ah dilute this protocol we have to give blood transfusion early itself suppose somebody is saying coronary artery disease we will not wait the patient to develop persevere anemia because anemia itself can produce ah severe angina or cardiac failure all these things so in a cardiac pain in a patient who is a cardiac disease severe anemia is not an acceptable problem in emergency room so that type of patients we made trans is faster than this level now once you transfuse the patient whether it is a wrinkle acted normal cell and plasma light album in blood whatever it is we should know whether the patient is improving or not for that some parameters we have to check that is clinical findings for good perforation main artery depression is one important factor that is more than 65 your notebook is very very important if the kidneys are normal your output should be more than 0.
