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A well-placed and well-calibrated arterial line would be the most helpful clinical tool for determining when this patient is out of shock
3%
119/3826
The hematocrit well within normal limits means the patient is not in hemodynamic shock
1%
32/3826
A combination of heart rate greater than 120 and MAP less than 65 equates to poor tissue perfusion levels
10%
364/3826
Normal lactate levels and base excess are markers of adequate tissue perfusion
67%
2555/3826
His orthopaedic injury alone cannot explain his vital sign derangements and an exploratory laparotomy is indicated
19%
730/3826
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Normal lactate levels or base excess indicate adequate tissue perfusion. Hypovolemic shock leads to poor tissue perfusion due to inadequate flow or oxygenation. If a patient is in compensated shock (i.e. normal vital signs), there may be ongoing inadequate perfusion of some end-organs. Elevated lactate or a base deficit are markers of poor end-organ perfusion, thus when normalized indicate appropriate end-organ perfusion even if vital sign derangements persist. Rossaint et al. wrote a comprehensive review article in 2006 in which they discuss principles of fluid management, coagulopathy, hypothermia and tissue oxygenation in hypovolemic shock. In addition to prolonged elevated lactate levels correlating to mortality, lactate levels (or base deficits) can be used to evaluate for compensated shock in the setting of normal hemodynamic status. Illustration A shows the classification of hypovolemic shock. Note the percent of blood loss required for vital sign abnormalities. Incorrect Answers: Answer 1: While an arterial line is often helpful in the setting of uncompensated hemodynamic shock, it would not be as important as measures of adequate tissue perfusion for ruling out compensated shock. Answer 2: The hematocrit is expected to stay normal for a short time even in the setting of massive blood loss. The hematocrit only changes once the patient has physiologic or iatrogenic fluid shifts in response to the blood loss. Answer 3: Vital sign derangements indicate uncompensated shock, but do not directly measure tissue perfusion or end-organ damage Answer 5: Though uncommon, bleeding from isolated femur fractures can lead to Class II shock (blood loss 15-30%)
2.6
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