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El examen clínico racional. ¿Es este paciente hipovolémico?
S McGee1, W B Abernethy, D L Simel
1Department of Medicine, University of Washington, Seattle-Puget Sound VA Health Care System, 98108, USA.
JAMA
|March 23, 1999
Resumen
El diagnóstico de la hipovolemia en adultos se basa en cambios significativos en el pulso postural o mareos severos por pérdida de sangre. Por otras razones, pocos signos físicos son confiables, lo que requiere pruebas de laboratorio para tener certeza.
Área de la Ciencia:
- Medicina de emergencia Medicina de emergencia.
- Medicina interna es la medicina interna de las enfermedades.
- Diagnóstico Clínico El diagnóstico clínico.
Sus antecedentes:
- La hipovolemia, un estado de disminución del volumen sanguíneo, presenta desafíos de diagnóstico en los adultos.
- El diagnóstico físico preciso es crucial para el manejo oportuno y eficaz del paciente.
Objetivo del estudio:
- Revisar sistemáticamente los hallazgos del examen físico para el diagnóstico de la hipovolemia en pacientes adultos.
- Evaluar la utilidad diagnóstica de varios signos físicos en diferentes etiologías de hipovolemia.
Principales métodos:
- Búsqueda sistemática de la literatura de MEDLINE y otras fuentes (1966-1997).
- La inclusión de 10 estudios sobre los signos vitales posturales y el tiempo de recarga capilar en voluntarios sanos después de la flebotomía.
- La inclusión de 4 estudios en pacientes que se presentan en los departamentos de emergencia con sospecha de hipovolemia.
Principales resultados:
- El mareo postural severo o un aumento del pulso de ≥30 latidos/min son indicadores clave para una pérdida de sangre significativa (sensibilidad del 97% para una gran pérdida).
- La hipotensión supina y la taquicardia a menudo están ausentes incluso con una pérdida de sangre sustancial (sensibilidad del 33%).
- En la hipovolemia no hemorrágica, la axila seca apoya el diagnóstico, mientras que las membranas mucosas húmedas y una lengua lisa argumentan en contra.
Conclusiones:
- El diagnóstico clínico de hipovolemia por pérdida de sangre requiere cambios significativos en los signos vitales posturales, que pueden estar ausentes en casos moderados.
- Para la hipovolemia debida a vómitos, diarrea o mala ingesta, los hallazgos físicos tienen una utilidad limitada.
- Los electrolitos séricos, el BUN y la creatinina son esenciales para la certeza diagnóstica en la hipovolemia no hemorrágica.
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