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Referral and warning signs
When to refer
All cases of suspected Class 2 or higher hypovolaemic shock require immediate resuscitation and urgent referral to HC3/HC4 or Hospital. Patients with ongoing bleeding, poor response to initial fluid resuscitation, or requiring blood transfusion need specialist (surgical/medical/obstetric) intervention.
Red flags
- Absent peripheral pulses
- Unrecordable or very low blood pressure
- Confusion, lethargy or unconsciousness
- Absent capillary refill or significantly prolonged (> 3 seconds)
- Gasping respirations or apnoea
- Minimal or no urine output
Signs and symptoms
- High heart rate (tachycardia)
- Fast breathing rate (tachypnoea)
- Thin or absent pulse (peripheral)
- Cold, clammy extremities
- Slow capillary refill (>2 seconds)
- Low blood pressure (hypotension) - may be a late sign, especially in children
- Altered mental status (agitation, anxiety, confusion, lethargy, coma)
- Reduced urine output (oliguria/anuria)
Risk factors
- External haemorrhage (e.g., trauma, postpartum haemorrhage)
- Internal haemorrhage (e.g., ruptured spleen, ectopic pregnancy, GI bleed, PPH)
- Severe gastroenteritis (diarrhoea, vomiting)
- Extensive burns
- Severe dehydration from other causes
Diagnosis
Clinical assessment
Based on history of significant fluid or blood loss combined with clinical signs of inadequate perfusion (tachycardia, hypotension, poor capillary refill, altered mental status, low urine output). Classification (Class 1-4) helps gauge severity.
Investigations
- Vital signs monitoring (HR, BP, RR, Temp)
- Capillary refill time assessment
- Mental status assessment (e.g., AVPU, GCS)
- Urine output measurement
- Haemoglobin/Hematocrit (if bleeding suspected)
- Blood group and cross-match (essential if transfusion likely)
- Consider bedside ultrasound (e.g., FAST scan) if internal bleeding suspected
Diagnostic criteria
Classified by severity (Class 1-4) based on estimated blood/fluid loss percentage and physiological parameters (pulse, BP, pulse pressure, RR, mental status, urine output). Refer to UCG 2023 Tables for specific adult and child criteria (p. 4 & 6).
Management
Non-pharmacological management
- Call for help
- Follow ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure)
- Control obvious external bleeding with direct pressure
- Keep patient lying flat with legs raised (if no spinal injury/breathing difficulty)
- Keep patient warm (prevent hypothermia)
- Administer high-flow oxygen
Pharmacological treatment
- Establish large-bore IV access (preferably x2 lines)
- IV Fluid Resuscitation: Rapid infusion of warmed isotonic crystalloid (Normal Saline 0.9% or Ringer’s lactate). Adults: Initial bolus of 1-2 Litres (or 20-30 ml/kg). Children: Initial bolus of 20 ml/kg, repeat up to 3 times (total 60 ml/kg) based on response.
- Assess response to fluid challenge (improvement in HR, BP, mental status, urine output, capillary refill).
- Blood Transfusion: If haemorrhage is the cause, ongoing bleeding, or poor response to initial fluid resuscitation. Give cross-matched blood if possible. If urgent, consider Group O negative blood. Children: Transfuse 20 ml/kg whole blood or 10 ml/kg packed red cells.
- Follow specific Ugandan treatment algorithms/guidelines.
Monitoring
Continuously monitor vital signs (HR, BP, RR, SpO2), capillary refill, mental status, and urine output frequently (e.g., every 5-15 minutes initially) to guide resuscitation efforts. Regular reassessment is crucial.
Complications
- Multi-organ dysfunction/failure (kidney, liver, brain, lungs)
- Cardiac arrest
- Coagulopathy (especially in trauma/massive transfusion)
- Hypothermia
- Acidosis
- Death
Prevention
- Prompt identification and control of bleeding sources
- Adequate fluid replacement for conditions causing fluid loss (e.g., gastroenteritis, burns)
- Active Management of Third Stage of Labour (AMTSL) to prevent PPH
- Early recognition and management of conditions causing internal bleeding
Patient education
- Explain the need for rapid fluid or blood replacement
- If applicable, explain the underlying cause and planned interventions
- Emphasize importance of seeking care early for conditions with risk of significant fluid/blood loss (severe diarrhoea, vomiting, bleeding)
Uganda-specific notes
Tachycardia is often the first sign but can also be caused by fear or pain. Children may compensate well initially, and hypotension can be a late sign of severe shock. Do not use glucose solutions or plain water for initial resuscitation. PPH is a very common cause in obstetric settings. Consider underlying causes like ruptured ectopic or spleen in relevant patients.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 1, Sections 1.1.2, 1.1.2.1 (including classification tables)