CBL Emergency:

Fluid Resuscitation
in Hypovolemic
Shock.
Supervised by : Dr. Mohd Hazman Kamaruzaman
 Outline

1 2 3
Types of shock Definition & Positive relevant history
pathophysiology of shock and clinical features of
hypovolemic shock

4 5 6
Types of fluid
available, IV cannula APLS approach child Use of fluids in
sizes, microchamber in shock resuscitation
1. TYPE OF SHOCK
2. Definition & pathophysiology of shock
Imbalance between oxygen delivery and oxygen demand resulting on cell dysfunction and ultimately cell death and
multiple organ failure (Principle and Practice of Surgery, 7th Edition)
2. Definition of hypovolemic shock
Decreased preload due to decrease in intravascular volume

Examples:
● Reduced fluid intake (eg: dehydration)
● Cutaneous fluid loss ( eg burns)
● GIT fluid loss (eg: diarrhea and vomiting)
● Renal loss (eg: eg DM and DI, adrenal insufficiency)
● Third space loss (eg: acute pancreatitis)
● Blood loss (hemorrhagic shock)
2. Pathophysiology of Hypovolemic Shock
 3. Positive relevant history
Hemorrhagic shock Non hemorrhagic shock

● History of trauma ● History of GI losses

- Determine the mechanism of injury - Diarrhoea, vomiting
- Recent unhygienic food intake/taking outside
food (AGE)
- Sick contact at home
- Recent travelling history

● Recent surgery ● History of skin losses

- Burns, heat stroke
- Mechanism of injury (timing and cause of burn)

● History of overt bleeding ● History of renal losses

- melena,hematemesis - Any symptoms of fluid depletion (oliguria, thirst,
lightheadedness)
- Excessive drug induced

● Excessive nonsteroidal anti-inflammatory drug ● History of third space fluid losses

use - TRO GI bleeding - Any symptoms of vomiting, abdominal pain and
constipation (TRO bowel obstruction)
- Any symptoms of vomiting, abdominal pain and
fever (TRO pancreatitis)
- Recent surgery or trauma
 3. Clinical features of hypovolemic shock

● Fatigue or weakness
● Lightheadedness
● Increased thirst
● Muscle cramps
● Sweating (diaphoresis)
● Decreased urinary output
● Confusion
● Difficulty breathing or rapid breathing
● Reduced level of consciousness
● Low blood pressure
 Clinical features of hypovolemic shock

● Fatigue or weakness
● Lightheadedness
● Increased thirst
● Muscle cramps
● Sweating (diaphoresis)
● Decreased urinary output
● Confusion
● Difficulty breathing or rapid breathing
● Reduced level of consciousness
● Low blood pressure
 Clinical features of hypovolemic shock

● Fatigue or weakness
● Lightheadedness
● Increased thirst
● Muscle cramps - SHOCK
● Sweating (diaphoresis)
● Decreased urinary output
● Confusion
● Difficulty breathing or rapid breathing
● Reduced level of consciousness
● Low blood pressure
 Clinical features of hypovolemic shock

● Fatigue or weakness
● Lightheadedness
● Increased thirst
● Muscle cramps
● Sweating (diaphoresis)
● Decreased urinary output
● Confusion
● Difficulty breathing or rapid breathing
● Reduced level of consciousness
● Low blood pressure
4. Types of IV fluids
Crystalloid fluid
■1. Normal saline or
0.9% NaCl
■2. Hartmann’s solution
or Ringer’s lactate
solution
■3. Dextrose 5%
 Crystalloid fluid
● Aqueous solutions with varying concentrations of electrolytes (hypotonic, isotonic and
hypertonic)
● Also known as volume expander
● More commonly used fluids in hospital setting
● Crystalloids increase intravascular volume. The extent to which they do this depends on the
effect on fluid compartments

● Indications of crystalloid fluids

1. Hypertonic (3% NaCl): acute severe hyponatremia (reduce intracellular volume, increase
extracellular fluid)
2. Hypotonic (0.45% NaCl): replacing free water deficit (increase intracellular volume, increase
extracellular volume)
3. Isotonic (0.9% NaCl): fluid resuscitation and maintenance fluid therapy (increase extracellular
volume, no change to intracellular volume)
Colloid fluid
■1. Albumin
■2. Gelofusine
(gelatin-based)
■3. Hydroxyethyl starch
■4. Dextran
 Colloid fluid
● A colloid is a high molecular weight substance; that mostly remains confined to the
intravascular compartment and thus generates oncotic pressure
● Volume holder as the generated oncotic pressure increase extracellular volume
● Their use is controversial, but they may be indicated in combination with crystalloids
● Indications of colloid fluid
1. Albumin: cute management of severe burns
2. Gelatin: acute management of hemorrhagic hypovolemia, volume preloading before
regional anesthesia
3. Hydroxyethyl starch: acute management of hemorrhagic hypovolemia
4. Dextran: to improve micro-circulatory flow in microsurgical implantations
 Colloids vs Crystalloids
■Colloids are better than crystalloids in expanding the intravascular volume due to
oncotic pressure generated by the larger colloid molecules that are retained more
easily in the intravascular compartment compared to the crystalloids
■However, excessive use can precipitate cardiac failure, peripheral and pulmonary
edema. Even though onset of pulmonary edema may be delayed compared to
crystalloid solution, it is more sustained
■Besides, colloid solution such as albumin and gelatins might cause anaphylactic
shock in some patients
❖Hence, the selection of the type of fluid to use depends on the primary origin
of the exact kind of fluid loss (intracellular or intravascular dehydration), the
condition of the patient and the availability of fluids
 4. IV catheter sizes and flow rates
❖ 2 Large bore catheter 22/24 gauge
•

in newborn and infant, 18/20 gauge

for older children
❖ If unsuccessful, may attempt central
venous catheter by skilled provider
or intraosseous catheter.
➢ Particularly useful when peripheral
•

vessels are very small or collapsed.

➢ Vessels in the bone are supported
by a rigid matrix.
In infant, 1-2cm below tibial tuberosity
•

(Lower limb)
● Stable, large cannula perpendicularly
•

Adult /older children, proximal humerus

•

● • Might cause fracture in small child.

❏ After vascular access is confirmed, perform

a bedside glucose determination.
❏ -Correct hypoglycaemia via rapid IV
infusion of dextrose.
 Infusion rate : resuscitation
● 20 ml/kg of 0.9% Normal Saline
(NS) or Hartmann’s solution as a
rapid ( 5-10 minutes) IV bolus.

❖ Eg. 10kg child:

- 10 X 20 = 200 ml of 0.9% Normal
Saline (NS) or Hartmann’s solution
as a rapid IV bolus
Repeat as needed up to 3 times in patient without improvement and no sign of
fluid overload

Correct hypoglycaemia via rapid IV infusion of dextrose with 2mls/kg of 10%

dextrose solution
 Infusion rate : resuscitation
● 20 ml/kg of 0.9% Normal Saline
(NS) or Hartmann’s solution as a
rapid ( 5-10 minutes) IV bolus.

❖ Eg. 10kg child:

- 10 X 20 = 200 ml of 0.9% Normal
Saline (NS) or Hartmann’s solution
as a rapid IV bolus
 Infusion rate : maintenance
Holliday- Segar method
for 1-12 year old (max
weight of 60kg)
- If counted for adults,
high risk of fluid overload
A child of 15kg
10 x 4 = 40
10x 100 = 1000ml/day
5 x 2 = 10
5 x 50 = 250 50ml/h
1250/24= 52ml/h

Isotonic solution : 0.9 % NS or Hartmann’s solution (0.45% NS in neonate)

With dextrose; because risk of hypoglycaemia in paediatrics
 Infusion rate : maintenance
Holliday- Segar method
for 1-12 year old (max
weight of 60kg)
- If counted for adults,
high risk of fluid overload
A child of 15kg
10x 100 = 1000ml/day
10 x 4 = 40 Adult: 35-45 ml/kg/day
5 x 2 = 10
5 x 50 = 250 50ml/h
1250/24= 52ml/h

Isotonic solution : 0.9 % NS or Hartmann’s solution (0.45% NS in neonate)

 Infusion rate : deficit

•Estimation of the degree of dehydration

expressed as % of body weight
•Use an isotonic solution for replacement of
the deficit, e.g. 0.9% saline.
•Reassess clinical status and weight at 4-6
hours, and if satisfactory continue. If child is
losing weight, increase the fluid and if weight
gain is excessive decrease the fluid rate.
 Infusion rate : replacement
•Replacement may be rapid in most cases of gastroenteritis (best achieved by oral or nasogastric fluids)

•Any fluid losses > 0.5ml/kg/hr needs to be replaced

•Replace ongoing diarrhoea/vomiting losses orally whenever possible: 5- 10 ml /kg for each episode.

1 sachet in 250
ORS CALCULATION
ml water
•Give frequent small sips from cup or spoon.
•If the child vomits, wait 10 minutes, then
continue but more slowly (i.e. 1 spoonful
every 2 - 3 minutes).
• Continue breastfeeding whenever the child
wants
•Reassess back after 4 hr, Select the
appropriate plan to continue
treatment (Plan A, B or C)
 Cont..
Depends on Hydration Status:
Mild Dehydration
•Total ORS: 50 ml/kg over 4 hours by syringe, spoon or cup.
•How to give?
•Give 1 ml/kg of ORS by syringe every 5 minutes for 4 hours
•Give 3 ml/kg of ORS every 15 minutes for 4 hours
Moderate Dehydration
•Total ORS: 100 ml/kg over 4 hours or According to WHO age and weight specific recommendations.

Weight Age How to Give

<5kg <4m 200-400 ml in 4hours (50-100 ml/h)

•for ongoing Losses:
•It is given per purge or per emesis.
5-8kg <12m 400-600 ml in 4hours (100-150 ml/h) •10 mL/kg body weight for each stool
•2 mL/kg body weight for each episode of
8-11kg 12-24m 600-800 ml in 4hours (15-200 ml/h) emesis

11-16kg 2-5y 800-1200 ml in 4hours (200-300 ml/h)

 Cont..
Depends on Hydration Status:
Mild Dehydration
•Total ORS: 50 ml/kg over 4 hours by syringe, spoon or cup.
•How to give?
•Give 1 ml/kg of ORS by syringe every 5 minutes for 4 hours
•Give 3 ml/kg of ORS every 15 minutes for 4 hours
Moderate Dehydration
•Total ORS: 100 ml/kg over 4 hours or According to WHO age and weight specific recommendations.

Weight Age How to Give

<5kg <4m 200-400 ml in 4hours (50-100 ml/h)

•for ongoing Losses:
•It is given per purge or per emesis.
5-8kg <12m 400-600 ml in 4hours (100-150 ml/h) •10 mL/kg body weight for each stool
•2 mL/kg body weight for each episode of
8-11kg 12-24m 600-800 ml in 4hours (15-200 ml/h) emesis

11-16kg 2-5y 800-1200 ml in 4hours (200-300 ml/h)

 Primary assessment
Specific Features of Shock:
1. Tachypnea/ Acidotic breathing
ABC
2. HR, BP, CRT, toe-core temp & urine output
3. Perform ECG if HR; >200bpm (infants), >150 bpm (child) ABCD
A- AIRWAY
or if irregular rhythm
4. ABG airway is open
Ensure
5. Mental Status (AVPU); agitation -> obtundation/coma
6. Hypotonic posture (Consider manuvers, adjunct or intubation)
B-BREATHING
7. Rash in hemorrhagic purpura, meninggococal sepsis,
Adequate airway
toxic shock and hypoventilating
syndrome (generalised erythema,
conjunctivitis & mucositis (Consider BVM, tracheal intubation or mech ventilation)
8. Fever dt infective cause
C-CIRCULATION
Gain IV / IO access and run blood test
(ABG, Lactate, Hb, Ca+, Glu) & Lab test if available ( FBC
etc)
D- Disability
AVPU - increased ICP
Titrated to:
-reverse hypotension
-increase urine output (>1 ml/kg/hr)- CBD
-attain normal CRT , peripheral pulses and level of consciousness

-Reassess after each bolus for sign of improvement

• if no response consider inotropes
In case of non-hemorraghic fluid loss,
Large volume: >40 ml/kg in first hour • how to assess fluid needed?