Hypovolemia is a condition where you could lose blood due to various reasons. Hypovolemia in the secondary and serious condition such as a hypovolemia shock, when untreated immediately could cause death.
Blood is the most essential fluid in the body and any loss of it causes severe damage to all the bodily parts. This is because blood circulates the oxygen and nutrients to all parts of the body.
Hypovolemia or Oligemia is the intravascular component of volume contraction. This is nothing but the loss of the blood plasma which is the intravascular part of the blood due to bleeding because of cut or an injury.
Approximately a human body consists of 5 liters of blood and loss of more than 30 % without treatment could lead to death. And to know more about hypovolemia and blood losses and the ways to control it keep reading.
Hemorraghic shock or Hypovolemia shock is due to the sudden burst of a blood vessel causing huge loss of blood instantaneously. This could be in the form of injuries or during pregnancies where sudden internal bleeding could occur.
Hypovolemic shock is an emergency life-threatening condition which is more common in young children and older people. The loss of bodily fluids including blood is very fast in this case and should be replaced immediately.
More than 10 million cases of Hypovolemia and hypovolemic shock are reported in India every year.  Hypovolemia is only due to the loss of blood in the human body by an injury or dehydration. To know more about hypovolemia it is pertinent to know more about blood.
BLOOD:
Blood is the lifeline of the human body. It is because it connects to all parts of the body to supply them with the necessary oxygen and nutrients to function properly.
Blood consists of blood cells suspended in the blood plasma. Blood plasma consists of 55 % of blood fluid which is 92 % water along  with proteins, mineral ions, glucose, hormones, and carbon dioxide.
Waste management in the form of removing carbon dioxide as bicarbonate ion and the metabolic waste of the cells are also removed by the blood plasma.
Apart from the two kinds of blood cells the red and white, there are two kinds of proteins in the blood which are responsible for the oxygen circulation.
Albumin:
This is the main protein in the plasma. It regulates the osmotic pressure of blood.
Hemoglobin:
This is an iron-containing protein which is responsible for the facilitation of oxygen transport by reversibly binding to the respiratory gas and greatly increasing its solubility in blood.
Blood is very important to the human body and any loss of it could cause huge damage because of its following functions:
- Supply of oxygen to tissues
- Removal of wastes such as carbon dioxide, urea, and lactic acid
- Supply of nutrients such as glucose, amino acids, and fatty acids
- Hydraulic functions
- Regulation of core body temperature
- Transport of hormones and functioning as a messenger for signaling tissue damage.
CAUSES OF HYPOVOLEMIA:
The main cause of hypovolemia is lack of blood to pump the heart. This results in the stopping of blood supply to the vital and other organs.
When not treated immediately this causes the organs to stop functioning and blood pressure plummets causing death. Hence care should be taken to loss of blood from any part of the body, whether external or internal.
Common causes for hypovolemia:
Hypovolemia could be caused by trauma and other causes which could be on the external part of the body. The outflow of the blood is visible and care could be taken immediately.
There are cases like GI or endometriosis, or ectopic pregnancy where the blood is internal.
External causes for hypovolemia:
- Bleeding from serious cuts or wounds
- Internal bleeding from abdominal organs
- Bleeding from blunt traumatic injuries due to accidents
- Significant vaginal bleeding
- Bleeding from vaginal bleeding
- Broken bones around the hips
- Cuts on your head
- Damage to spleen, liver, and kidneys because of trauma
- A torn heart because of a large blood vessel
- Excessive or prolonged diarrhea
- Protracted and excessive vomiting
- Severe burns
- Excessive sweating
Internal causes for hypovolemia:
GI:
GI or the gastrointestinal disorders could cause damage to the digestion system and their organs. When untreated for a prolonged time could lead to internal hemorrhage and loss of blood. Some of the GI disorders which could lose in blood and cause hypovolemia are listed below:
MWS:
MWS or Mallory-Weiss Syndrome is a condition formed by a tear of the mucous membrane of the esophagus. The esophagus is the tube that connects the throat to the stomach.
Severe and continuous vomiting for a considerable period of time can result in the tears of the mucous membrane or the inner lining where the esophagus meets the stomach.
This tear could be healed when medications are taken for the vomiting and the underlying disease failing which could lead to heavy bleeding. A surgery should be performed in such case or could e life-threatening.
Bleeding ulcers:
Open sores in the digestive tract are called peptic ulcers. The ulcers depending on their position in the stomach are called according to the parts.
Ulcers become very serious if they perforate into the gut and start bleeding heavily. This needs emergency medical treatment.
Bleeding esophageal varices:
The tiny veins in the muscular esophageal tube connecting the mouth to the stomach become swollen when blood flow to the liver is reduced. This occurs due to scar tissue or a blood clot within the liver.
Once the blood flow is obstructed the blood builds up in the other vessels nearby including those in the lower esophagus. The veins which are smaller and incapable of carrying a large amount of blood gets dilated and swells as a result of the increased blood flow.
These swollen veins are known as esophageal varices and may leak blood and eventually rupture. This can cause severe bleeding and life-threatening complications including death.
Aorto-intestinal fistulas:
Aorto is the largest and main artery in the human body originating from the left ventricle of the heart and extending to the abdomen. An aorto-enteric fistula is a connection between the aorta and the stomach.
Aorto-intestinal fistulas are usually secondary to an AAA repair or the abdominal aortic aneurysm repair. This is because the walls of the aorta grow to a size of a balloon and produce heavy bleeding when ruptured.
Pregnancy:
It is true even in this scientific world in the saying that “pregnancy is second birth to the mother”. The number of complications that can be had with pregnancy confirms this. One of them is hypovolemia.
There are several possibilities for hypovolemia during the different stages of pregnancy. This is because of the vulnerability of the pregnant woman.
It is normal for a few quantities of blood to be accompanied with the pregnancy progress. But it exceeds in some cases which leads to hypovolemia. This may occur during pregnancy in the following cases.
Ectopic Pregnancy:
During normal pregnancy, the fertilized egg travels to the uterus and attaches with it. But due to various causes, the fertilized egg does not attach with the uterus but gets attached with the fallopian tube, cervix or the abdominal cavity.
This kind of pregnancy is called ectopic pregnancy and occurs in 1 out of 50 pregnant women. The fertilized grows best in the uterus only and any other place causes complications to other organs because of its size which includes hypovolemia.
Placenta previa:
A placenta is a structure that develops along with the baby in the uterus to help the baby. Normally this is attached to the uterus at the top or the side but when it covers the mother’s cervix partially or totally it is called placenta previa.
Since the mother’s cervix is the outlet for the uterus it can cause severe bleeding during pregnancy and in the delivery time.
AVM:
AVM or arteriovenous malformation is an abnormal tangle of blood vessels connecting arteries and veins. This disrupts normal blood flow and oxygen circulation among the arteries and veins.
During the critical process of AVM, the surrounding tissues may not get enough oxygen and the affected arteries and veins can weaken and rupture.
If this happens in the brain it causes a stroke or brain damage. Apart from the brain, it may occur in any part of the body and mainly in the spine.
SYMPTOMS OF HYPOVOLEMIA:
Symptoms of hypovolemia depend on the condition or the cause of the blood loss. Some symptoms are more urgent than the others. It could be external and internal.
External symptoms:
External symptoms are due to the cuts and injuries due to accidents. The amount of blood loss is visible though could not be measured for accurate quantity.
The more the loss of blood due to the external injuries to the bodily parts and mainly the brain and in the bone fractures should be immediately taken to the hospital for emergency treatment to save the part affected or in worse cases life.
Internal symptoms:
The blood loss in case of the internal symptoms could depend on the underlying damage of the organs. Depending on the age and the body conditions it could be mild and severe.
Mild symptoms:
- A headache
- Nausea
- Lightheadedness
- Profuse sweating
- Fatigue
- Dizziness
Severe symptoms:
- Rapid or shallow breathing
- Rapid heart rate or high or low blood pressure
- Cold or clammy or pale skin
- Little or no urine output
- Weak pulse
- Blue lips and fingernails
- Loss of consciousness
In case of internal hemorrhaging the following symptoms could be found:
- Vomiting blood
- Blood in the urine and stool
- Severe abdominal pain
- Black and tarry stool
- Severe chest pain
- Abnormal abdominal swelling
It is most important when more than one of these symptoms occur at once in groups to seek emergency treatment.
Blood loss quantity and their effects on the body:
Hypovolemia is all about blood loss. The loss of blood quantity is categorized into four types as to their seriousness of causing danger.
Type -1:
Losing up to 15 % of the total blood volume which approximately calculates to 750 ml does not have any serious symptoms.
Type -2:
Losing between 15 – 30 % will make the remaining blood to be pulled away from your skin, muscles, and guts to be sent to the vital organs like heart and brain.
This causes a faster heartbeat, blood vomiting, weak pulse, and pale, cool and clammy skin.
Type -3:
Losing between 30 – 40 % of the total blood volume may account to nearly 2 liters of blood or half a gallon will cause serious complications.
Blood pressure will drop drastically and breathing will be fast and there will be a confusion of all kinds with diaphoresis.
Type -4:
When losing of total blood volume increases the bodily organs stop functioning and the symptoms will get worse. There will be any pee at all. There will be total unconsciousness.
If not treated emergently in this type, death is for sure.
DIAGNOSIS OF HYPOVOLEMIA:
Hypovolemia in the external conditions could be easily diagnosed by the blood loss. But in cases of internal bleeding, it cannot be diagnosed until hypovolemia shock or hemorrhagic shock signs are found.
A doctor will check the temperature, pulse, breathing, and blood pressure along with the color and feel of the skin.
The doctor may ask a few questions if the patient is in a conscious state. This may include a medical history and the cause of the blood loss.
In case of hypovolemia shock or hemorrhage shock the following tests can be conducted based on the symptoms:
Blood tests:
Blood tests are done to check the electrolyte imbalances. The electrolytes checked are sodium, potassium, chloride, bicarbonate ion, creatin, BUN or blood urea nitrogen, and glucose levels.
A blood test also confirms kidney and liver functions.
CBC tests or complete blood count test should be done to detect disorders like anemia, leukemia, and infection.
- CSF test or cerebrospinal fluid test is done to check the lactate quantity in the blood and the cerebrospinal fluid.
- PTT or Prothrombin test is conducted to check the bleeding problems including the time for the blood to clot.
- ABG test or arterial blood gas test is conducted to check the levels of oxygen and carbon dioxide in the blood
- Urinalysis is conducted to check various disorders like diabetes, urinary tract infections, kidney diseases and also pregnancy.
- CT Scan or Ultrasound to visualize body organs
- Echocardiogram an ultrasound of the heart
- Electrocardiogram to assess the heart condition
- Endoscopy to examine the esophagus and other GI organs
- Right heart catheterization to check how effectively the heart is pumping blood
- Urinary catheter to measure the amount of urine in the bladder
- Pregnancy test in case of a woman
TREATMENT OF HYPOVOLEMIA:
Treatment to hypovolemia depends on the cause and symptoms of hypovolemia. In the case of eternal symptoms of hypovolemia due to an accident or other causes of grievous injuries, the following emergency care and first aid are given.
Emergency care and first aid:
Immediate emergency care should be given even before reaching hospitals in the cause of profuse and unstoppable blood drain. The following are the simple methods to save a life:
- The person should lie flat with their feet elevated about 12 inches
- Keep the patient warm to avoid hypothermia
- Refrain from moving the person if there is any suspicion of head, neck, or back injury.
- Do not give the person any fluids by mouth
- Do not elevate their head
- Remove any visible dirt or debris from the injury site but do not remove any knife, stick, arrow, glass or any other objects embedded in the wound.
- If the injury site is clear of any debris tie the wound site with a towel or shirt to minimize blood loss.
Hospital treatment for a hypovolemic shock:
Once in the hospital, the objective of the emergency department is to stabilize the hypovolemic patient, determine the cause of blood loss and provide definitive care as quickly as possible.
The main areas in which life-threatening hemorrhage can occur should be taken care of immediately.
The chest and abdomen should be auscultated for any altered sounds of the heart and bowels.
The thighs should be examined for deformities or enlargement and also for fracture.
The patient’s entire body should be examined for another external bleeding. In the case of a patient without trauma, the majority of the hemorrhage is in the abdomen. And hence the tenderness or distension of the abdomen can indicate intra-abdominal injury.
After the basic examinations are over it is time for three major steps of emergency treatment done to the patient.
- Maximizing oxygen delivery
- Resuscitation
- Control further blood loss
Also, the disposition of the patient should be rapidly and appropriately determined.
Maximizing oxygen delivery:
The patient’s airway should be checked and stabilized if necessary. High flow supplemental oxygen should be administered to all patients. Two large –bore IV lines should be started.
Resuscitation:
Resuscitation is a process of correcting the physiological disorders. This includes the breathing and fluid loss.
The most common resuscitation for breathing is the cardiopulmonary resuscitation and mouth to mouth resuscitation.
Fluid resuscitation should be started through the IV access. This includes the following:
- Blood plasma transfusion
- Platelet transfusion
- Red blood cell transfusion
- Intravenous crystalloids
Controlling further blood loss:
Control of blood loss depends on the source of bleeding. Mostly it requires surgical intervention.
In the external cases it could be controlled with direct pressure but with internal hemorrhage, surgery is the only option. Long-bone fractures should be treated with traction to decrease the blood loss.
Doctors may also give medications that increase the heart’s pumping strength to improve blood circulation and get the blood where it is needed. Some of the medicines include:
- Dobutamine
- Dopamine
- Epinephrine
- Norepinephrine
Also, antibiotics are administered to prevent septic shock and bacterial infections.
Coagulopathies or blood clot impairment may occur due to the excessive volume of resuscitation. This is because of the dilution of the platelets and clotting factors.
But coagulopathy does not occur within the first hour of hypovolemic shock. But baseline coagulation studies should be drawn and the administration of platelets and fresh frozen plasma should be guided.
Recovery from hypovolemia:
Recovery from hypovolemic shock depends on the degree of the shock and the patient’s prior medical condition.
In the case of mild shock, it is easy for recovery. If it is severe with a grievous injury and also the amount of blood loss is more it could have various complications.
Some common complications of hypovolemia and hypovolemic shock include
- Kidney damage
- Major organs damage
- Gangrene development with a decrease in circulation of blood to the limbs
- The affected limbs may have to be amputated.
A study was performed to investigate the prevalence of hypovolemia and hypovolemic shock in the acute nephritic stage. It emphasized the fact that both primary peritonitis and hypovolemic episodes should be considered when managing abdominal pain in children with nephrotic syndrome.
Chronic medical conditions such as diabetes, previous stroke, heart, lung or kidney disease could increase the likelihood of experiencing more complications from hypovolemic shock.
Hypovolemia or hypovolemic shock is unavoidable in certain situations. Proper care and concern with awareness in lifestyle could prevent these situations.
Blood is as important as it is the carrier of all nutrients and especially the oxygen to all parts of the body. Hence to preserve it and take care of not losing it is the best way to prevent hypovolemia.
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