How is hemorrhagic shock assessed in patients with upper gastrointestinal bleeding (UGIB)?

Updated: Aug 12, 2019
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
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Answer

As previously mentioned, patients who present in hemorrhagic shock have a mortality rate of up to 30%. Hemorrhage may be classified based on the amount of blood loss, as noted in the following table. [30]

Table 2. Estimated Fluid and Blood Losses in Shock (Open Table in a new window)

 

Class 1

Class 2

Class 3

Class 4

Blood Loss, mL

Up to 750

750-1500

1500-2000

>2000

Blood Loss, % blood volume

Up to 15

15-30

30-40

>40

Pulse Rate, bpm

< 100

>100

>120

>140

Blood Pressure

Normal

Normal

Decreased

Decreased

Respiratory Rate

Normal or Increased

Decreased

Decreased

Decreased

Urine Output, mL/h

>35

30-40

20-30

14-20

CNS/Mental Status

Slightly

anxious

Mildly

anxious

Anxious,

confused

Confused,

lethargic

Fluid Replacement, 3-for-1 rule

Crystalloid

Crystalloid

Crystalloid and blood

Crystalloid and blood

bpm = beats per minute; CNS = central nervous system

This classification scheme aids in understanding the clinical manifestations of hemorrhagic shock. In early class 1 shock, the patient may have normal vital signs, even with a 15% loss of total blood volume. As the percentage of blood volume loss increases, pertinent clinical signs, symptoms, and findings become more apparent.

Although early cardiovascular changes occur as blood loss continues, urine output, as a sign of end organ renal perfusion, is only mildly affected until class 3 hemorrhage has occurred.

Bornman et al correlated the presence of shock (defined as a pulse rate >100 bpm or systolic blood pressure [SBP] < 100 mm Hg) with the incidence of rebleeding rates after initial nonsurgical intervention. [30] They found that rebleeding (a marker for increased mortality and need for surgery) occurred in 2% of patients without shock, in 18% with isolated tachycardia, and in 48% with shock.

Schiller et al determined that SBP is a sensitive clinical marker for helping to predict mortality. They correlated mortality rates based on the patient's SBP at the time of bleeding and found mortality rates of 8% for patients with SBP more than 100 mm Hg, rates of 17% for SBP of 80-90 mm Hg, and rates of more than 30% for SBP less than 80 mm Hg.

Unless the patient has evidence of shock, orthostatic testing should be performed to assess and document a hypovolemic state. A positive tilt test finding is defined as an SBP decrease of 10 mm Hg and a pulse rate increase of 20 bpm with standing compared to the supine position. The American Society for Gastrointestinal Endoscopy (ASGE) survey was able to correlate orthostatic changes with the incidence of mortality. [31] The mortality rate when orthostatic changes are present is 13.6%, compared to 8.7% when they are absent.

Knopp et al studied the use of the tilt test in phlebotomized healthy volunteers and found that a positive tilt test result consistently correlated with a blood loss of 1000 mL. This becomes extremely useful when evaluating patients with class 1 hemorrhagic shock.


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