Assessment

HISTORY. If the patient is actively bleeding or is severely compromised, the history, assessment, and early management merge together into the primary survey. The primary survey is a rapid (30 to 60 seconds) head-to-toe assessment that encompasses the emergency management of threats to airway, breathing, and circulation (ABCs) or life. If the patient's condition is stable enough to warrant a separate history, ask questions about allergies, current medications, preexisting medical conditions, and the factors that surround the hypovolemic/hemorrhagic condition.

Generally, patients who are experiencing hypovolemia because of trauma have either obvious bleeding or a history of injury to a vascularized area. Elicit information from the patient, emergency medical personnel, or the family as to how much blood was lost or how long the bleeding has continued. In the case of traumatic blood loss, it is important to remember that the most obvious injury site may not be the cause of the evolving hypovolemic shock.

Explore the possibility of a mechanism of injury, such as a burn or crush injury, leading to plasma fluid shifts extravascularly. Likewise, a history of either recent alterations in fluid volume intake or excessive loss—as in vomiting, diarrhea, excessive diaphoresis, or diuresis—is a potential indicator. In addition, obtain a subjective history of thirst, lethargy, and decreased urinary output.

PHYSICAL EXAMINATION. The patient may appear either stable and alert or critically ill, depending on the phase of hypovolemic shock. If the patient can maintain the ABCs, assess the patient's level of consciousness. Restlessness, anxiety, agitation, and confusion may be indicators of diminished cerebral perfusion and are among the early signs of hypovolemic shock. Other early indicators include a decreased urinary output of less than 30 mL/hr, delayed capillary blanching, and signs of sympathetic nervous system stimulation (tachycardia, piloerection [gooseflesh]). Monitor vital signs, including heart and respiratory rate, blood pressure, and temperature. Changes in blood pressure (particularly hypotension) are a late rather than an early sign; pulse pressure, however, does initially widen and then narrow in the first two stages of shock. Orthostatic blood pressure changes also indicate hypovolemia. Inspect the patient's neck veins and palpate them for the quality of carotid pulse and neck vein appearance. Inspect the patient's abdomen for possible sites of fluid loss or compartmenting.

Percuss the chest and lung fields for the presence of fluid. Auscultate the patient's bilateral breathing, and note the patient's respiratory effort. Auscultate the patient's heart, and note any new murmurs or other adventitious heart sounds. When you auscultate the patient's abdomen, note the absence of bowel sounds, which may indicate a paralytic ileus, internal gastrointestinal bleeding, or peritonitis. If bowel sounds are hypoactive, bleeding may be causing blood to shunt to other more vital organs. Palpate the patient's peripheral pulses and note signs of decreased blood flow and inadequate tissue perfusion (cold, clammy skin; weak, rapid pulses; delayed capillary refill), but remember that these signs are late indicators of hypovolemic shock and may not be present until the patient reaches stage III.

Four areas are considered to be life threatening: (1) chest (auscultate for decreased breath sounds); (2) abdomen (examine for tenderness or distension); (3) thighs (check for deformities and bleeding into soft tissues; and (4) external bleeding.

PSYCHOSOCIAL. If the patient has a decreased level of consciousness, attempt to identify a family member or significant other to discuss the patient's psychosocial history. Expect family members to be frightened, anxious, and in need of support. Of particular concern are the parents of young trauma patients who have to deal with a sudden, life-threatening event that may lead to the death of a child. Spouses of critically injured patients deal with role reversals, economic crises, and the fear of loss. Expect the family and partner of critically injured patients to express a range of emotions from fear and anxiety to grief and guilt.

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