Hypovolemic shock

Hypovolemic shock

1. Patients' background

   • Mrs.Muna
     • 45 years old
     • Housewife
     • Got into an accident

2. Physical examination

   • Pale
   • Dehydrated
   • Disoriented
   • Obese woman
   • Abdomen and right lower limb bruised and wounded
     • Multiple abrasions and ecchymosis of abdomen
   • Vital signs
     • Temperature 36.8 C
     • Pulse rate 110 bpm
     • BP of 56/38 mmHg
     • Respiratory rate 25/min
   • Marked tenderness in right hypochondrium. Mild tenderness all over
   • Diminished bowel sounds
   • Unable to move right leg
   • A large ecchymotic area is seen on the right thigh with marked tendernes

3. Diagnostic/lab tests

   • X-ray shows gas under diaphragm
   • Diagnostic peritoneal lavage
     • Presence of blood and intestinal contents in the peritoneal cavity.
   • Portable X-ray shows fracture of the right femur.
     • Thoracic and cerebral injuries are excluded

4. Pre-operative preparations

   • Put on I/V fluids through a central venous line
   • Her CVP is recorded as 2mmHg
   • Bladder catheterized
     • 200 ml of amber colored urine is drained
   • Immediately transfused with two units of O-ve blood

5. Lab investigations

   • Hb 6 g/dL,
   • PCV 15%
   • Blood group A –ve
   • Urine microscopy shows
     • (heme) granular casts (Muddy casts)
       • Erythrocytes and cellular debris.

6. Surgery

   • Laparotomy,
     • lacerated liver
     • perforated ileum with hemoperitoneum
   • abdominal surgery and fixation of femur fracture lasted for about 6 hours.

7. Postoperative, Shifted to the surgical ICU

   • given I/V fluids and monitored continuously for vital signs
   • Urine output recorded as 10ml/hour in the first four hours
     • Her urine output increases to 20 ml/hour in the next 24 hours
       • Next day, her urine output declines to 10 ml/hour
         • The output continues to decline despite I/V infusion of fluids
   • Urine and blood samples sent for urgent laboratory investigations show
   • Hemoglobin 2nd P0 day rises to 7 g/dL with a hematocrit of 25%.
   • during transfusion she develops a transfusion reaction
   • Transfusion is stopped and replaced by plasma expanders
   • Blood and urine specimens sent for urgent investigations show

8. Final diagnosis

   • acute renal failure as a result of acute tubular necrosis
     • plasma creatinine, urea and potassium show a rise leading to ECG changes
   • Nephrologist advises urgent hemodialysis using an external cannula.

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