title: Passport stamp

text: Both entry and exit stamps do not name the point of entry/exit but indicate them by the use of letters of the alphabet – "A" is used for entry by air, namely through Changi Airport or Seletar Airport; "S" by sea though the Singapore Cruiseship Terminal or Tanah Merah Ferry Terminal; "T" by land via the Tuas Checkpoint; and "W" by land via the Woodlands Checkpoint. The entry stamp has the letter running along the border of the stamp together with a code number while the exit stamp has a single letter marked in the center of the stamp. From 22 April 2019, foreign travellers no longer get their passports stamped when they depart from Singapore. As of 21 October 2021, foreign travellers no longer get their passports stamped on arrival. This has been replaced by a record of entry email sent to the passenger.


title: Passport stamp

text: Entry stamp is applied in square and magenta ink, while exit stamp is applied in circle and cyan ink. Exit stamp is omitted to every passenger since 1 November 2016, unless specifically requested. Entry stamp is only omitted to Republic of Korea travel document holder since 10 February 2011. Beginning January 2018, landing slips are issued to visitors on arrival in South Korea instead of passport stamps, and on departure from South Korea no slips or passport stamps are issued (being unable to present the landing slip on departure does not affect a traveller's ability to clear immigration). Starting from June 2022 in Incheon International Airport, the landing slip is changed to an entry confirmation sticker pasted in the passport.


title: Passport stamp

text: On 1 January 2021, a new set of stamps were issued, replacing the plum flower with an outline of the island of Taiwan, but keeping the calligraphic characters created by Dong Yang-zi (a renowned calligrapher in Taiwan).


title: Passport stamp

text: Immigration officer applies stamp on all passports upon arrival at or departure from Thailand. Since August 2020, entry stamps are in the shape of a waving flag applied in red ink, and exit stamps are ovals applied in blue ink. Stamps bear the date and point of entry/exit, as well as an identification code running along the border of the stamps. Entry stamps for foreigners also state expiry date.


title: Passport stamp

text: The automated passport control (APC) system has been available for Thai nationals since 2012 and more than 20 million have used it, whereas Suvarnabhumi Airport opened 8 automated immigration lanes for foreigners, Singaporeans and Hong Kongers have been allowed to use the system also. Once processed, the foreign travelers can leave the automatic channel and present their passport to a Thai immigration officer to be stamped.


title: Passport stamp

text: Timor-Leste applies a full-page blue stamp along with a red entry stamp. Exit stamps are a black oval.


title: Passport stamp

text: UAE applies blue oval stamps on entry, along with a smaller blue rectangular stamp showing the valid length of stay. Exit stamps are green oval. However residents and UAE passport holders can pass without passport stamping through e-gates at Abu Dhabi International Airport , Dubai International Airport , Al Maktoum International Airport and Sharjah International Airport.


title: Passport stamp

text: Vietnam passport stamps are rectangle and name the point of entry, date of entry and whether the person is exiting or entering the country by using an arrow out of or into a box similar to the Schengen passport stamps. Mode of entry is indicated by an icon and also differentiated by the colour of the stamp – blue for air, red for land crossings. The permitted length of stay is printed with a separate stamp and the final date handwritten.


title: Passport stamp

text: When arriving in and departing from the French overseas departments of Mayotte and Réunion, French Border Police officers stamp travelers' travel documents according to the following rules:


title: Passport stamp

text: Travellers flying directly from metropolitan France to Mayotte or Réunion only undergo border checks by the French Border Police at the departure airport in metropolitan France and not on arrival at Dzaoudzi–Pamandzi International Airport in Mayotte or Roland Garros Airport in Réunion. However, as third-country nationals (who do not benefit from one of the exemptions in the right-hand column above) are required to receive a passport stamp, the French Border Police will give them an information sheet when they leave metropolitan France informing them that they should present themselves to the French Border Police at the arrival airport to receive a passport stamp. On the other hand, travellers flying directly from Mayotte or Réunion to metropolitan France undergo border checks by the French Border Police both on departure and on arrival, when their travel documents will be stamped accordingly.


title: Passport stamp

text: Tunisia stamps passports upon both entry and exit. In the photo below, the red stamp indicates the entry date, while the black stamp indicates the exit date.


title: Passport stamp

text: All 26 European countries within the Schengen Area have entry and exit stamps of a uniform design. As of April 2016, at a national level, 11 Schengen countries (Estonia, Finland, Greece, Hungary, Latvia, Lithuania, Malta, Poland, Portugal, Slovakia and Spain) have developed computer databases recording entries and exits of third-country nationals (i.e. travellers who are not EU, EEA or Swiss citizens) at external border crossing points. However, on a Schengen-wide level, there is no centralised computer database that tracks entries and exits at all of the external border crossing points of the 26 Schengen countries, nor are entry and exit records from national databases shared between countries. As a result, law enforcement officials continue to rely on checking passport stamps as the primary way to check that travellers who do not have the right of free movement have not exceeded their length of permitted stay in the Schengen Area.


title: Passport stamp

text: Regulation (EU) 2017/2226 envisages the establishment of an Entry-Exit System (EES) which will record third-country nationals' entries and exits when they cross the external borders of the Schengen Area in a central database, replacing passport stamps. As of August 2022, EES is expected to enter into operation at the end of May 2023.


title: Passport stamp

text: There are no systematic immigration checks when travelling between Schengen countries (i.e. crossing the internal borders of the Schengen Area). Passport stamps are never issued when travelling between Schengen countries, even when immigration checks between Schengen countries are temporarily re-introduced.


title: Passport stamp

text: When travelling to/from a non-Schengen country (i.e. crossing the external borders of the Schengen Area), the rules on stamping travel documents are as follows:


title: Passport stamp

text: Border officials are required, by law, to stamp the travel documents of third country nationals who do not qualify for one of the exemptions listed in the right hand column, even when border controls have been relaxed. Exceptionally, if stamping a person's travel document would cause serious difficulties (such as political persecution), border officials can instead issue a sheet of paper detailing the person's name, travel document number and entry date and location. However, in practice, border officials do not always stamp the travel documents of travellers as legally required. If a person who should have received an entry stamp cannot show one either upon request by a law enforcement officer or upon leaving the Schengen Area to a border official, the officer can presume that the person has been staying illegally in the Schengen Area and can expel him/her, unless the person can demonstrate using credible evidence (such as transport tickets and accommodation receipts) that he/she has not exceeded his/her permitted length of stay in the Schengen Area.


title: Passport stamp

text: Also, whilst by law persons enjoying the right of freedom of movement are not to receive a passport stamp, in practice, upon request, a stamp may be given – see the gallery below for an example of an entry stamp being issued upon request by an EU citizen. Similarly, although by law heads of state are not to receive a passport stamp, in practice, this is not always followed. For example, when arriving for the 37th G8 summit in Deauville, United States President Barack Obama had his passport stamped at Deauville – Saint-Gatien Airport. Similarly, when President Obama attended the 2009 Strasbourg–Kehl summit, his diplomatic passport was stamped on arrival at Strasbourg Airport on 3 April 2009, and after visiting Prague, Czech Republic, his diplomatic passport was stamped on departure from Prague Ruzyně Airport on 5 April 2009.


title: Passport stamp

text: Although, according to EU rules, third country nationals who hold residence permits should not have their travel documents stamped, France nevertheless requires third country nationals holding a "visa de long séjour valant titre de séjour" (a long-stay visa serving additionally as a residence permit for up to one year) to receive a passport stamp upon their first entry to the Schengen Area as a part of the process to validate the visa as a residence permit; without an entry stamp, the process cannot be completed.


title: Passport stamp

text: Third-country nationals who otherwise fulfil all the criteria for admission into the Schengen area must not be denied entry for the sole reason that there is no remaining empty space in their travel document to affix a stamp; instead, the stamp should be affixed on a separate sheet of paper.


title: Passport stamp

text: Entry and exit stamps are applied in black ink, except for the red date stamp and a two-digit security code in the middle. The two-digit security code must be changed at least once a month, although some Schengen countries (such as Greece) change security codes every day. The stamps bear the country abbreviation within a circle of stars in the top left hand corner, the name of the entry/exit border crossing point in Latin alphabet at the bottom, and an icon in the top right hand corner to denote the mode of entry/exit. Below the name of the border crossing point is an identifying number – a record is kept of the identity of the border officer to whom a given stamp is assigned at any given time. Entry stamps are rectangular and have an arrow into a square, while exit stamps are rectangular with rounded corners and have an arrow out of a square. The stamps do not indicate any maximum permitted duration of stay.


title: Passport stamp

text: Border guards are required to ensure the secure storage of passport stamps in locked safes between shifts. Border posts are advised to set out clear responsibilities and instructions for the distribution and use of passport stamps.


title: Passport stamp

text: According to European Commission recommendations and guidelines, stamps should be affixed in travel documents by border officials in the following manner:


title: Passport stamp

text: If a third-country national is refused entry to the Schengen Area, the border official is required to affix an entry stamp in the travel document, cancel the stamp by an indelible cross in blank ink and write the letter corresponding to the reason for the refusal of entry to the right-hand side of the cancelled stamp.


title: Passport stamp

text: By contrast, if a border official has affixed a stamp in a travel document by mistake (as opposed to a refusal of entry), the stamp can be annulled by drawing two parallel lines through the top left-hand corner.


title: Passport stamp

text: In view of the coronavirus pandemic, starting from 16 March 2020 there is a temporary restriction on the entry of third-country nationals (i.e. travellers who are not EU/EEA/Swiss/British citizens and family members with the right of free movement) to the Schengen Area for non-essential travel. However, third-country nationals who are holders of long-term visas or residence permits or are family members of EU/EEA/Swiss/British citizens are exempt from this restriction. Further, third-country nationals 'with an essential function or need' (such as healthcare workers, transport personnel, aid workers, military personnel, seasonal agricultural workers), passengers in transit, those travelling 'for imperative family reasons' and those 'in need of international protection or for other humanitarian reasons' are exempt from this restriction. Citizens of the European micro-states (Andorra, the Holy See, Monaco and San Marino) are also exempt from this restriction. In addition, citizens of Serbia, North Macedonia, Montenegro and Turkey are exempt from this restriction if they are stranded abroad and are repatriated to their country of origin.


title: Passport stamp

text: Third-country nationals (not covered by one of the exemptions from the temporary restriction of entry for non-essential reasons) who seek to enter the Schengen Area will be refused entry at the border crossing point and will receive a refusal of entry form (with the reason of refusal marked as "I", i.e. a threat to public health), as well as a passport stamp cancelled by an indelible cross in black ink and the letter "I" on the right hand side.


title: Passport stamp

text: The obligation imposed by European law on national border authorities to stamp travel documents of certain travellers should not prevent the development of automated border control systems which are then made available to those who are required to have their travel documents stamped when crossing the external border of the Schengen Area. One solution is to dedicate separate lanes to third-country nationals and to have a border guard physically positioned next to the automated border gates used by these lanes who can stamp travel documents where required: this has been adopted by the Finnish Border Guard at the automated border gates in Helsinki Airport, where eligible users (who are required to receive a passport stamp) include holders of Canadian, Japanese, South Korean and United States biometric passports, and in the Port of Helsinki, where eligible users (who are required to receive a passport stamp) include Russian citizens, as well as by the Portuguese Serviço de Estrangeiros e Fronteiras at the automated border gates in Lisbon Airport where eligible users (who are required to receive a passport stamp) include holders of Angolan and Brazilian passports and holders of diplomatic/service passports. This approach has also been adopted in Italy, where eligible users of eGates include holders of Australian, Canadian, Israeli, Japanese, New Zealand, Singaporean, South Korean, United States and Vatican biometric passports. A similar but slightly different solution has been adopted by the Dutch Royal Marechaussee at the Privium iris recognition automated border gates at Amsterdam Airport Schiphol, where eligible users include registered EU/EEA/Swiss citizens, US citizens who are Global Entry members, and all nationals who are holders of diplomatic passports, as well as by the German Federal Police at the ABG Plus iris recognition automated border gates at Frankfurt Airport where eligible users include registered EU/EEA/Swiss citizens and US citizens who are Global Entry members: when eligible third-country nationals use Privium/ABG Plus, after their iris is scanned and verified, a different gate/door/turnstile opens to that for EU/EEA/Swiss citizens and the third-country national user is directed to a lane which leads them to the front of the queue for manual passport checks at immigration desks, where the border guard stamps the user's passport. Another possible solution would be to design the automated border gates to print a paper slip with an entry or exit stamp on it, as well as the user's name and travel document number, whenever the user is a traveller who is subject to the requirement to have his/her travel document stamped.


title: Passport stamp

text: Although Albania is not a European Union or Schengen Area member state, and is outside the EU freedom of movement area, it has adopted the common Schengen design for passport stamps. In addition, passports of EU/EFTA countries, Andorra, Monaco and San Marino are not stamped.


title: Passport stamp

text: Entry from France or Spain requires no formalities. However, a souvenir stamp is issued on request at the border.


title: Passport stamp

text: Belarus is a member of the Union State of Russia and Belarus but, like Russia, still has its own passport stamps. Belarus passport stamps have the state's name in the Belarusian language: Republic of Belarus, a chevron (facing to the left for entry, to the right for exit), date and name of the checkpoint.


title: Passport stamp

text: Although Bulgaria is a European Union member state, it has not yet joined the Schengen Area. Nonetheless, it has adopted the common Schengen design for passport stamps.


title: Passport stamp

text: After joining the European Union on 1 July 2013, Croatia adopted the common Schengen design for passport stamps, even though Croatia is still not a member of the Schengen passport-free area.


title: Passport stamp

text: Although Cyprus is a European Union member state, it has not yet joined the Schengen Area. Nonetheless, it has adopted the common Schengen design for passport stamps.


title: Passport stamp

text: Liechtenstein is a member of the Schengen area with no borders with non-Schengen countries; thus, no passport stamps are issued. However, for a nominal fee, a souvenir stamp can be issued at the Liechtenstein Center tourist office.


title: Passport stamp

text: The border with France is completely open. However, a souvenir stamp is given on request at the tourist office.


title: Passport stamp

text: Although North Macedonia is not a European Union or Schengen Area member state, and is outside the EU freedom of movement area, it has adopted the common Schengen design for passport stamps. In addition, passports of EU/EFTA countries and UK are not stamped.


title: Passport stamp

text: Romania is not currently a member of the Schengen Area, however, being in the European Union since 2007, Romanian entry and exit stamps have been harmonised with the format of the stamps issued by Schengen states.


title: Passport stamp

text: Entry and exit stamps are placed in passports regardless of citizenship; Russian passports are stamped as well as foreign ones, except the Internal Passports, with which Russian citizens may travel to a few countries of the CIS. The stamp shows the name of the country (КПП below the country name stands for checkpoint – контрольно-пропускной пункт), the date, the name of the checkpoint and the personal code of the immigration official applying the stamp. Stamp colours and series (the last number following the date) change every time in few years, currently the color of the stamps is red of 9 series, but it can be blue or crimson as well. Entry or exit is designated by a direction of an angle bracket in the stamp: if it points to the right, that denotes exit. Exit stamp placed left, and entrance stamp placed right on the passport page.


title: Passport stamp

text: Even though there is an open border agreement with Italy, visitors can have their passport stamped by the San Marino authority at the passport office in the city centre for a small fee.


title: Passport stamp

text: Serbia stamps both Serbian and foreign passports on exit, and foreign passports also on entry (until March 2018, foreign passports were not stamped on exit).


title: Passport stamp

text: Although Switzerland is not a European Union member state, it is part of the Schengen Area and so it has adopted the common Schengen design for passport stamps.


title: Passport stamp

text: Turkey, as a candidate member of the European Union, has adopted a design for passport stamps similar to that of the Schengen area.


title: Passport stamp

text: Ukrainian passport stamps bear the country's name (since 2020 only country code UA), mode of travel (ship, train, vehicle, plane), code of the immigration officer, chevron (facing to the right for entry, to the left for exit), date, serial code (probably periodic), name of the checkpoint and its code. All are written in the Ukrainian language.


title: Passport stamp

text: The UK Border Force only stamps the travel documents of travellers "entering" the UK from outside the Common Travel Area who do not have the right of abode in the UK. When such travellers are granted leave to enter the UK, a stamp will generally be endorsed in their travel document, as the general rule laid down by section 4(1) of the Immigration Act 1971 is that power to give leave to enter the UK 'shall be exercised by notice in writing'. Passport stamps are in black ink and bear the name of the entry point, as well as the immigration officer's identification number.


title: Passport stamp

text: Non-visa nationals entering as a visitor (except Australian, Canadian, Japanese, New Zealand, Singaporean, South Korean and United States citizens) receive a passport stamp with the endorsement 'Leave to enter for six months: employment and recourse to public funds prohibited'.


title: Passport stamp

text: EU, EEA and Swiss citizens (regardless of whether they hold settled or pre-settled status under the EU Settlement Scheme in the UK) entering the UK on their passport or national identity card do not receive a stamp.


title: Passport stamp

text: If the traveller is the holder of a visa/entry clearance or a person exempt from immigration control (e.g. a diplomat), he/she receives an open date passport stamp (i.e. a stamp that does not contain any leave conditions). Moreover, this entry passport stamp is stamped on the right edge of the visa/entry clearance (if the traveller has one) on the traveller's first entry to indicate that the document has been used, even if the document is valid for multiple entries.


title: Passport stamp

text: The following table shows which travellers arriving in the UK from outside the Common Travel Area receive a passport stamp:


title: Passport stamp

text: As a derogation from the general requirement to grant leave to enter the UK 'by notice in writing' in the form of a passport stamp (where a person without the right of abode and the right to free movement arrives in the UK from outside the Common Travel Area), UK Border Force officers are permitted by law to grant leave to enter by fax or e-mail, and may also grant leave to enter orally (including by telephone) if the traveller seeks to enter the UK as a visitor for up to 6 months.


title: Passport stamp

text: All travellers from outside the Common Travel Area entering the UK using the ePassport gates (including those without the right of abode) do not receive a passport stamp. Non-visa nationals entering the UK as a visitor who successfully use an ePassport gate are granted 6 months' leave to enter (subject to conditions prohibiting employment and recourse to public funds) without receiving any written notice/endorsement.


title: Passport stamp

text: Since 20 May 2019, Australian, Canadian, Japanese, New Zealand, Singaporean, South Korean and United States citizens who enter the UK as a visitor and are granted leave to enter for 6 months do not receive a passport stamp, regardless of whether they use an ePassport gate or a staffed counter. However, citizens of these countries who enter the UK with a Tier 5 (Temporary Worker – Creative and Sporting) Certificate of Sponsorship (for up to 3 months) or on a permitted paid engagement are not eligible to use the ePassport gates and must use a staffed counter, where they will receive a passport stamp.


title: Passport stamp

text: When the transition period of the UK's withdrawal from the EU came to an end on 31 December 2020, EU, EEA and Swiss citizens became subject to immigration control. However, regardless of whether they hold settled or pre-settled status under the EU Settlement Scheme in the UK, EU, EEA and Swiss citizens continue not to receive a stamp when entering the UK on their passport or national identity card.


title: Passport stamp

text: In the case of general aviation flights arriving in the UK from outside the Common Travel Area, travellers may not be inspected by the UK Border Force on arrival (depending on the risk assessment conducted on the basis of the travellers' information submitted in advance via the General Aviation Report (GAR) form) and may be 'remotely cleared' instead. In this case, no passport stamp is received.


title: Passport stamp

text: Previously, all travellers entering the UK using the Iris Recognition Immigration System (including non-UK/EU/EEA/Swiss citizens) did not receive a passport stamp.


title: Passport stamp

text: The UK Border Agency had a policy from 23 June 2008 until 4 November 2011 of conducting onboard clearance of some passengers travelling by coach at the juxtaposed controls at the Port of Calais and the Eurotunnel Calais Terminal. Passengers' travel documents were visually inspected by a UKBA officer on the coach, without the passengers having to disembark and pass through immigration control (where their travel documents would be scanned and, when required, stamped). This concession mainly applied to school groups travelling within the European Economic Area, though it was also extended to some other groups, such as elderly passengers, travellers with special needs, brownie and scout groups and sports teams. This policy meant that some passengers whose travel documents would usually be stamped did not receive a stamp on entering the UK.


title: Passport stamp

text: Travellers arriving in the UK directly from the Channel Islands, Ireland and the Isle of Man are not subject to immigration checks as they are travelling within the Common Travel Area. Accordingly, no passport stamp is received.


title: Passport stamp

text: There are no routine exit checks when departing from the UK for a destination outside the Common Travel Area by air, rail or sea. Instead, airline/rail/ferry companies obtain passengers' travel document information at check-in or on departure and transmit the information electronically to the UK Border Force. However, from time to time spot checks are carried out by the UK Border Force (in this case, travel documents are not stamped).


title: Passport stamp

text: Canada no longer routinely stamp passports upon entry. With effect from 2 April 2012, Border Services Officers of the Canada Border Services Agency will only stamp passports in the following circumstances:


title: Passport stamp

text: When arriving in and departing from the French overseas departments of Guadeloupe and Martinique and the French overseas collectivities of Saint Barthélemy, Saint Martin and Saint Pierre and Miquelon, French Border Police officers stamp travellers' travel documents according to the following rules:


title: Passport stamp

text: Travellers flying directly from metropolitan France to Guadeloupe, Martinique or Saint Pierre and Miquelon only undergo border checks by the French Border Police at the departure airport in metropolitan France and not on arrival in the French overseas department/collectivity. However, as third-country nationals (who do not benefit from one of the exemptions in the right-hand column above) are required to receive a passport stamp, the French Border Police will give them an information sheet when they leave metropolitan France informing them that they should present themselves to the French Border Police at the arrival airport to receive a passport stamp. On the other hand, travellers flying directly from Guadeloupe, Martinique or Saint Pierre and Miquelon to metropolitan France undergo border checks by the French Border Police both on departure and on arrival, when their travel documents will be stamped accordingly.


title: Passport stamp

text: Whilst the rules for stamping travel documents of travellers arriving in and departing from the French overseas departments/collectivities mentioned above are based upon the rules which apply in metropolitan France and the Schengen Area (see the section above), important differences exist between the two sets of rules. For example, when crossing the external border of the Schengen Area, only family members of EU/EEA/Swiss citizens who hold a residence card issued under Article 10 of Directive 2004/38/EC and who are accompanying or joining their EU, EEA and Swiss citizen family member exercising the right of freedom of movement are exempt from having their travel documents stamped, whereas in the French overseas departments/collectivities mentioned above, more generous rules apply — when entering/leaving Guadeloupe/Martinique/Saint Pierre and Miquelon, a family member of an EU/EEA/Swiss citizen who holds a residence card issued by an EU/EEA member state or Switzerland under Article 10 of Directive 2004/38/EC is exempt from having his/her travel document stamped regardless of whether he/she is accompanying/joining his/her EU/EEA/Swiss citizen family member; when entering/leaving Saint Barthélemy and Saint Martin, a family member of an EU/EEA/Swiss citizen who holds a residence card issued by an EU/EEA member state or Switzerland is exempt from having his/her travel document stamped regardless of whether he/she is accompanying/joining his/her EU/EEA/Swiss citizen family member and regardless of whether the residence card was issued under Article 10 of Directive 2004/38/EC. Another example relates to third-country nationals who hold a residence permit issued by a Schengen member state — when crossing the external border of the Schengen Area, his/her travel document should not be stamped, but when entering/leaving a French overseas department/collectivity, whilst he/she is not required to hold a visa for a short stay not exceeding 90 days in a 180-day period, his/her travel document will be stamped upon entry and exit.


title: Passport stamp

text: Another exception applies in the case of the French overseas collectivity of Saint Martin—travellers who in principle are subject to the obligation to have their travel documents stamped but who have cleared immigration control in Sint Maarten will not have their passport stamped when they enter/leave the French side of Saint Martin.


title: Passport stamp

text: The design of passport stamps issued in the French overseas departments/collectivities differs from those issued in metropolitan France/the Schengen Area. Previously, entry stamps issued in French overseas departments/collectivities were rectangular, whilst exit stamps were hexagonal. Under the current design, both entry and exit stamps issued in French overseas departments/collectivities are hexagonal and have a similar design to Schengen Area stamps. The top left corner states Outre-Mer and F, and indicates the 3-digit INSEE code for the overseas department/collectivity where the stamp was issued (971 for Guadeloupe, 972 for Martinique, 975 for Saint Pierre and Miquelon, 978 for Saint Martin).


title: Passport stamp

text: The three-letter Port of Entry code at the top of the entry stamp is assigned and maintained by the Department of State. It is different from the IATA airport code.


title: Passport stamp

text: The actual deadline to leave the U.S. for those admitted on a non-immigrant status is written at the bottom of the stamp, placed in the passport (when entering by air or sea) or on a green I-94W form stapled into the passport.


title: Passport stamp

text: With the introduction of Automated Passport Control (APC), entries are not always stamped into passports of travelers using the kiosks (especially US and Canadian passports). There are custom slips printed out from the machine, which are stamped by immigration and then handed over to customs. However, details of arrival and departure records are still made available at the website of US Customs and Border Protection.


title: Passport stamp

text: The Australian government no longer stamps travellers’ passports on arrival or departure from Australia as a matter of principle, regardless of whether travellers go through SmartGate or are processed manually at a counter.


title: Passport stamp

text: When arriving in and departing from the French overseas territories of French Polynesia, New Caledonia and Wallis and Futuna, French Border Police officers stamp travellers' travel documents according to the following rules:


title: Passport stamp

text: When travelling between the French overseas territories situated in the Pacific Ocean (for example, when travelling directly by plane from New Caledonia to French Polynesia), unless qualifying for one of the exemptions in the right hand column in the table above, a traveller will receive a passport stamp in his/her travel document upon departure from New Caledonia and another stamp upon arrival in French Polynesia.


title: Passport stamp

text: Whilst the rules for stamping travel documents of travellers arriving in and departing from the French overseas territories in the Pacific Ocean are based upon the rules which apply in metropolitan France and the Schengen Area (see the section above), important differences exist between the two sets of rules. For example, when crossing the external border of the Schengen Area, only family members of EU/EEA/Swiss citizens who hold a residence card issued under Article 10 of Directive 2004/38/EC and who are accompanying or joining their EU, EEA and Swiss citizen family member exercising the right of freedom of movement are exempt from having their travel documents stamped, whereas in the French overseas territories in the Pacific, more generous rules apply — a family member of an EU/EEA/Swiss citizen who holds a residence permit issued by an EU/EEA member state or Switzerland is exempt from having his/her travel document stamped regardless of whether he/she is accompanying/joining his/her EU/EEA/Swiss citizen family member and regardless of whether his/her residence permit was issued under Article 10 of Directive 2004/38/EC. Another example relates to third-country nationals who hold a residence permit issued by a Schengen member state – when crossing the external border of the Schengen Area, his/her travel document should not be stamped, but when entering/leaving a French overseas territory in the Pacific, whilst he/she is not required to hold a visa for a short stay not exceeding 90 days in a 180-day period, his/her travel document will be stamped upon entry and exit.


title: Passport stamp

text: The design of passport stamps issued in the French overseas territories in the Pacific differs from those issued in metropolitan France/the Schengen Area. Previously, entry stamps issued in French overseas territories in the Pacific were rectangular, whilst exit stamps were hexagonal. Under the current design, both entry and exit stamps issued in French overseas territories in the Pacific are hexagonal, and are similar in design to Schengen Area passport stamps. The top left corner states Outre-Mer and F, and indicates the 3-digit INSEE code for the overseas territory where the stamp was issued (988 for New Caledonia).


title: Passport stamp

text: Since March 2018, the New Zealand Customs Service ceased stamping passports for Australian permanent residents and New Zealand residents. General entry stamps continue to be used for temporary visa holders.


title: Passport stamp

text: On arrival in New Zealand, travellers who are neither New Zealand nor Australian citizens or permanent residents who are granted entry into the country will receive a 'Visitor Visa' rectangular stamp in their travel document.


title: Passport stamp

text: New Zealand and Australian citizens do not have their passports stamped on arrival in New Zealand unless specifically requested.


title: Passport stamp

text: Travellers using eGate (available to holders of a New Zealand, Australian, Chinese, Canadian, Dutch, French, German, Irish, Japanese, Singaporean, South Korean, United Kingdom or United States ePassport aged 12 years or over) will not have their passports stamped on arrival in New Zealand.


title: Passport stamp

text: For all travellers, passports are not stamped on departure from New Zealand regardless of nationality and whether using an immigration desk or eGate.


title: Passport stamp

text: Niue passport stamps bear the name of the country, a map outline of Niue, date and location of entry/departure.


title: Passport stamp

text: Holder of Brazilian passports entering or departing from Brazil will not receive a passport stamp. However, other nationals will go through customs and receive a stamp for both entry and exit. When entering Brazil by car from another country such as Argentina or Paraguay, few people go through customs and thus rarely receive stamps in their passport.


title: Passport stamp

text: When arriving in and departing from the French overseas department of French Guiana, French Border Police officers stamp travellers' travel documents according to the following rules:


title: Passport stamp

text: Travellers flying directly from metropolitan France to French Guiana only undergo border checks by the French Border Police at the departure airport in metropolitan France and not on arrival in French Guiana. However, as third-country nationals (who do not benefit from one of the exemptions in the right-hand column above) are required to receive a passport stamp, the French Border Police will give them an information sheet when they leave metropolitan France informing them that they should present themselves to the French Border Police at the arrival airport to receive a passport stamp. On the other hand, travellers flying directly from French Guiana to metropolitan France undergo border checks by the French Border Police both on departure and on arrival, when their travel documents will be stamped accordingly.


title: Passport stamp

text: Both entry and exit stamps issued in French Guiana are hexagonal, and are similar in design to Schengen Area passport stamps. The top left corner states Outre-Mer and F, and indicates the 3-digit INSEE code (973) for French Guiana.


title: Passport stamp

text: In some countries, there is no formal control by immigration officials of travel documents upon exit. Consequently, exit stamps are not placed in passports.


title: Passport stamp

text: Exit may be recorded by immigration authorities via information provided to them by carriers when the passenger departs from the country.


title: Montreux

text: Montreux (, , ; ) is a Swiss municipality and town on the shoreline of Lake Geneva at the foot of the Alps. It belongs to the district of Riviera-Pays-d'Enhaut in the canton of Vaud in Switzerland, and has a population of approximately 26,433, with about 85,000 in the agglomeration Vevey-Montreux as 2019.


title: Montreux

text: Located in the centre of a region named "Riviera" (), Montreux has been an important tourist destination since the 19th century due to its mild climate. The region includes numerous Belle Époque palaces and hotels near the shores of Lake Geneva. Montreux railway station is a stop on the Simplon Railway and is a mountain railway hub.


title: Montreux

text: The earliest settlement was a Late Bronze Age village at Baugy. Montreux lies on the north east shore of Lake Geneva at the fork in the Roman road from Italy over the Simplon Pass, where the roads to the Roman capital of Aventicum and the road into Gaul through Besançon separated. This made it an important settlement in the Roman era. A Roman villa from the 2nd-4th centuries and a 6th–7th century cemetery have been discovered.


title: Montreux

text: In the 12th century, viticulture was introduced to the region, and the sunny slopes of the lake from Lavaux to Montreux became an important wine-growing region. Montreux is first mentioned in 1215 as "Mustruel". In 1295, the Bishop of Sion sold the parish of Montreux to Girard of Oron. In 1317, it was split between the Lords of Oron (Le Châtelard) and the Counts of Savoy (Les Planches). A Brotherhood of the Holy Spirit administered estates and a hospital in Montreux starting in about 1309.


title: Montreux

text: The region was subject to various princes, most notably the princes of Savoy from the south side of the lake. They unified the territory which comprises the present canton of Vaud and were generally popular sovereigns.


title: Montreux

text: After the Burgundian Wars in the 15th century, the Swiss in Bern occupied the region without resistance, an indication of the weakness of the princes of Savoy. Under Bernese rule (1536–1798) it belonged to the Bailiwick of Chillon (renamed in 1735 into the Bailiwick of Vevey).


title: Montreux

text: The Reformation made the region around Montreux and Vevey an attractive haven for Huguenots from Italy, who brought their artisanal skills and set up workshops and businesses.


title: Montreux

text: In 1798, Napoleon liberated the region from the Bernese. In the 19th century, the tourist industry became a major commercial outlet, with the grand hotels of Montreux attracting the rich and cultured from Europe and America.


title: Montreux

text: Starting in the 19th century there were three independent municipalities that shared a central authority. This county council was made up of four deputies from Le Châtelard, two from Les Planches and one from Veytaux. The church, the market hall of La Rouvenaz, the secondary school (the building was from 1872 and 1897) and the slaughter-house (1912) were all owned by the county council. Each municipality had its own taxes and a mayor. In 1962, the municipalities of Le Châtelard and Les Planches merged, while Veytaux remained independent.


title: Montreux

text: Montreux has an area, , of . Of this area, or 25.0% is used for agricultural purposes, while or 50.3% is forested. Of the rest of the land, or 20.0% is settled (buildings or roads), or 0.3% is either rivers or lakes and or 4.6% is unproductive land.


title: Montreux

text: Of the built up area, housing and buildings made up 11.8% and transportation infrastructure made up 6.4%. Out of the forested land, 46.8% of the total land area is heavily forested and 2.9% is covered with orchards or small clusters of trees. Of the agricultural land, 1.5% is used for growing crops and 9.9% is pastures, while 1.2% is used for orchards or vine crops and 13.7% is used for alpine pastures. All the water in the municipality is flowing water.


title: Montreux

text: The municipality was part of the Vevey District until it was dissolved on 31 August 2006, and Montreux became part of the new district of Riviera-Pays-d'Enhaut.


title: Montreux

text: The municipality stretches from Lake Geneva to the foothills of the Swiss Alps (Rochers-de-Naye). It includes the former municipalities of Montreux-Les Planches (until 1952 Les Planches) and Montreux-Le Châtelard (until 1952 Le Châtelard). It was formed in 1962 with the merger of the two former municipalities.


title: Montreux

text: The Köppen Climate Classification subtype for Montreux's climate is "" (Marine West Coast Climate/Oceanic climate).


title: Montreux

text: Montreux has a population () of . , 44.2% of the population are resident foreign nationals. Over the last 10 years (1999–2009) the population has changed at a rate of 14.7%. It has changed at a rate of 22.3% due to migration and at a rate of -0.8% due to births and deaths.


title: Montreux

text: Most of the population () speaks French (16,695 or 74.4%) as their first language, with German being second most common (1,398 or 6.2%) and Italian being third (897 or 4.0%). There are 9 people who speak Romansh.


title: Montreux

text: The age distribution, , in Montreux is; 2,050 children or 8.3% of the population are between 0 and 9 years old and 3,021 teenagers or 12.2% are between 10 and 19. Of the adult population, 4,216 people or 17.0% of the population are between 20 and 29 years old. 3,016 people or 12.2% are between 30 and 39, 3,552 people or 14.4% are between 40 and 49, and 3,048 people or 12.3% are between 50 and 59. The senior population distribution is 2,565 people or 10.4% of the population are between 60 and 69 years old, 1,795 people or 7.3% are between 70 and 79, there are 1,206 people or 4.9% who are between 80 and 89, and there are 263 people or 1.1% who are 90 and older.


title: Montreux

text: , there were 9,380 people who were single and never married in the municipality. There were 9,758 married individuals, 1,631 widows or widowers and 1,685 individuals who are divorced.


title: Montreux

text: , there were 9,823 private households in the municipality, and an average of 2 persons per household. There were 4,198 households that consist of only one person and 402 households with five or more people. Out of a total of 10,236 households that answered this question, 41.0% were households made up of just one person and there were 53 adults who lived with their parents. Of the rest of the households, there are 2,563 married couples without children, 2,245 married couples with children. There were 605 single parents with a child or children. There were 159 households that were made up of unrelated people and 413 households that were made up of some sort of institution or another collective housing.


title: Montreux

text: , a total of 9,553 apartments (70.7% of the total) were permanently occupied, while 3,043 apartments (22.5%) were seasonally occupied and 916 apartments (6.8%) were empty. , the construction rate of new housing units was 1.6 new units per 1000 residents.


title: Montreux

text: The Audiorama, the Swiss National Audiovisual Museum, Crêtes Castle, Châtelard Castle, the Train Station, the Hôtel Montreux Palace, the Caux Palace Hotel, the Ile and Villa Salagnon, the Marché couvert, the Palace-Hôtel, the Grand Hôtel de Territet which was formerly the Grand-Hôtel/the Hôtel des Alpes, served as the recording studio for Deep Purple's record Machine Head, and the Villa Karma are listed as Swiss heritage site of national significance. The entire urban village of Territet / Veytaux as well as the Caux, Montreux and Villas Dubochet areas are all part of the Inventory of Swiss Heritage Sites.


title: Montreux

text: In the 2007 federal election the most popular party was the SP which received 22.11% of the vote. The next three most popular parties were the SVP (21.97%), the FDP (16.06%) and the Green Party (13.49%). In the federal election, a total of 4,473 votes were cast, and the voter turnout was 39.7%.


title: Montreux

text: , Montreux had an unemployment rate of 6.9%. , there were 70 people employed in the primary economic sector and about 27 businesses involved in this sector. 1,165 people were employed in the secondary sector and there were 174 businesses in this sector. 9,290 people were employed in the tertiary sector, with 999 businesses in this sector. There were 10,202 residents of the municipality who were employed in some capacity, of which females made up 46.1% of the workforce.


title: Montreux

text: , there were 4,949 workers who commuted into the municipality and 4,964 workers who commuted away. The municipality is a net exporter of workers, with about 1.0 workers leaving the municipality for every one entering. About 2.3% of the workforce coming into Montreux are coming from outside Switzerland, while 0.0% of the locals commute out of Switzerland for work. Of the working population, 22.5% used public transportation to get to work, and 50.9% used a private car.


title: Montreux

text: From the , 8,557 or 38.1% were Roman Catholic, while 6,438 or 28.7% belonged to the Swiss Reformed Church. Of the rest of the population, there were 745 members of an Orthodox church (or about 3.32% of the population), there were 18 individuals (or about 0.08% of the population) who belonged to the Christian Catholic Church, and there were 925 individuals (or about 4.12% of the population) who belonged to another Christian church. There were 73 individuals (or about 0.33% of the population) who were Jewish, and 1,031 (or about 4.59% of the population) who were Muslim. There were 80 individuals who were Buddhist, 171 individuals who were Hindu and 90 individuals who belonged to another church. 2,796 (or about 12.45% of the population) belonged to no church, are agnostic or atheist, and 1,941 individuals (or about 8.64% of the population) did not answer the question.


title: Montreux

text: In Montreux about 7,464 (33.2%) of the population have completed non-mandatory upper secondary education, and 3,171 or (14.1%) have completed additional higher education (either university or a "Fachhochschule"). Of the 3,171 who completed tertiary schooling, 39.8% were Swiss men, 25.3% were Swiss women, 19.8% were non-Swiss men and 15.1% were non-Swiss women.


title: Montreux

text: In the 2009/2010 school year there were a total of 2,106 students in the Montreux school district. In the Vaud cantonal school system, two years of non-obligatory pre-school are provided by the political districts. During the school year, the political district provided pre-school care for a total of 817 children of which 456 children (55.8%) received subsidized pre-school care. The canton's primary school program requires students to attend for four years. There were 1,056 students in the municipal primary school program. The obligatory lower secondary school program lasts for six years and there were 931 students in those schools. There were also 119 students who were home schooled or attended another non-traditional school.


title: Montreux

text: , there were 490 students in Montreux who came from another municipality, while 790 residents attended schools outside the municipality.


title: Montreux

text: Montreux is home to the "Bibliothèque municipale de Montreux et Veytaux" library. The library has () 48,948 books or other media, and loaned out 99,490 items in the same year. It was open a total of 274 days with average of 28 hours per week during that year.


title: Montreux

text: Other local schools include Surval Montreux (an international all girls boarding school) and St George's School in Switzerland (British international school, in Clarens).


title: Montreux

text: Private hospitality schools in the area include Swiss Hotel Management School (in Caux), Hotel Institute Montreux (Montreux), and Glion Institute of Higher Education (Glion).


title: Montreux

text: Montreux has three railway stations on the Simplon line, , , and . The latter is also the western terminus of the Montreux–Glion–Rochers-de-Naye and Montreux–Lenk im Simmental lines, both of which climb into the hills away from Lake Geneva and have several dozen stations within Montreux.


title: Montreux

text: Montreux was a haven for Catherine Barkley and Lt. Frederic Henry in Ernest Hemingway's classic novel "A Farewell to Arms".


title: Montreux

text: Montreux has a walking trail along the lake, stretching from Villeneuve to Vevey. The main square of the town, Place du Marché, features a statue of Freddie Mercury facing Lake Geneva. Some of the numerous small cities around Montreux include La Tour-de-Peilz, and Villeneuve. The Château of Chillon has views over Lake of Geneva and can be accessed via bus, train, walk or boat.


title: Montreux

text: Deep Purple traveled to Montreux in December 1971 to record "Machine Head". The band's song "Smoke on the Water" tells of the events of December 1971, when a Frank Zappa fan with a flare gun set the Montreux Casino on fire, destroying the casino where they had originally planned to record the album. Thanks to Claude Nobs, who eventually arranged alternate locations, the Grand Hôtel de Territet was where almost the entirety of the album was created and recorded, except for "Smoke on the Water" which had already been partly recorded at the "Le Petit Palais", formerly called "Le Pavilion". Deep Purple again returned in 1973 to record "Burn". The Montreux Casino was reopened in 1975, and later a monument commemorating Deep Purple and their song "Smoke on the Water" was built along the lake shore, with the band's name, the song title, and the riff in musical notes. However, the only other memorial dedicated to the band's song that can be found nowadays in Montreux, is a small plaque placed outside the back entrance of the former Grand Hôtel de Territet.


title: Montreux

text: The Dubliners's song "Montreux Monto" on their album "Live at Montreux" was recorded live at the Montreux Jazz Festival in 1976.


title: Montreux

text: Montreux is the home of Mountain Studios, the recording studio used by several artists. "Bonzo's Montreux" by Led Zeppelin is named after the city where the drums session of John Bonham was recorded in 1976. In 1978, the band Queen bought the studio. It was then sold to Queen producer David Richards. In 2002, the Mountain Studios was converted into a bar as part of a complete renovation of the studio. David Richards has left Montreux to settle down somewhere else. Queen also appeared in 1984 and in 1986 at the Golden Rose Festival and Queen guitarist Brian May appeared in 2001 at the Jazz Festival. Montreux was also the subject of the 1995 Queen single "A Winter's Tale" on the album "Made in Heaven", one of Freddie's last songs before his death on 24 November 1991. The album cover features the statue of Mercury beside the lake.


title: Montreux

text: In 1990, the Wakker Prize for the development and preservation of its architectural heritage was awarded to Montreux.


title: Montreux

text: The Fédération Internationale de Roller Sports was founded in Montreux in 1924. Montreux HC, the oldest roller hockey club in Switzerland (founded in 1911) is based in Montreux.


title: Brent Venables

text: Thomas Brent Venables (born December 18, 1970) is an American football coach who is the head coach at the University of Oklahoma. He previously served as the defensive coordinator and linebackers coach at Clemson University from 2012 to 2021.


title: Brent Venables

text: Venables played college football at Kansas State University as a linebacker from 1991 to 1992. Prior to his tenure at Oklahoma, he held various assistant coaching positions at Kansas State University, University of Oklahoma and Clemson University. Venables was awarded the Broyles Award in 2016.


title: Brent Venables

text: From 1989 to 1990, Venables played linebacker at Garden City Community College then at Kansas State University under head coach Bill Snyder from 1991 to 1992.


title: Brent Venables

text: In 1993, Venables began his coaching career at Kansas State University as a graduate assistant. In 1996, Venables was promoted to linebackers coach and served in that capacity until 1998.


title: Brent Venables

text: In 1999, Venables began coaching at the University of Oklahoma, where he served as co-defensive coordinator and linebackers coach for the Sooners under head coach Bob Stoops, with whom he previously worked at Kansas State. He shared oversight of the defense with Stoops’ younger brother, Mike Stoops, until Mike became head coach at Arizona in 2004. Venables then became sole defensive coordinator, and was also promoted to associate head coach.


title: Brent Venables

text: In January 2012, after it was announced that Mike Stoops would be returning to Oklahoma to resume the defensive coordinator position he had held until 2004, Venables accepted the position of defensive coordinator at Clemson, where his salary was expected to be between $750,000 and $1 million. Venables had been previously reported to be a candidate for the head coaching position at a number of schools including Miami, Kansas, Kansas State, and Texas Tech.


title: Brent Venables

text: On December 6, 2016, Venables was named the winner of the 2016 Broyles Award for the nation's top assistant coach.


title: Brent Venables

text: "Clemson Diehards" reported on December 6, 2017, that Venables was the second-highest paid assistant football coach in college football that year, receiving $1.7 million from Clemson. The only coach in this category receiving more money was Dave Aranda of LSU, who was paid $1.8 million.


title: Brent Venables

text: On December 5, 2021, Venables was named the 23rd head coach at the University of Oklahoma, replacing Lincoln Riley after his departure to become the head coach at the University of Southern California (USC).


title: Brent Venables

text: Venables and his wife, Julie, have four children: sons Jake and Tyler, who played football at Clemson, and daughters Laney and Addie.


title: Patrick O'Brian

text: Patrick O'Brian, CBE (12 December 1914 – 2 January 2000), born Richard Patrick Russ, was an English novelist and translator, best known for his Aubrey–Maturin series of sea novels set in the Royal Navy during the Napoleonic Wars, and centred on the friendship of the English naval captain Jack Aubrey and the Irish–Catalan physician Stephen Maturin. The 20-novel series, the first of which is "Master and Commander", is known for its well-researched and highly detailed portrayal of early 19th-century life, as well as its authentic and evocative language. A partially finished 21st novel in the series was published posthumously containing facing pages of handwriting and typescript.


title: Patrick O'Brian

text: O'Brian wrote a number of other novels and short stories, most of which were published before he achieved success with the Aubrey–Maturin series. He also translated works from French to English, and wrote biographies of and Picasso.


title: Patrick O'Brian

text: His major success as a writer came late in life, when the Aubrey-Maturin series caught the eye of an American publisher. The series drew more readers and favourable reviews when the author was in his seventies. Near the end of his life, and in the same year that he lost his wife, British media revealed details of O'Brian's early life, first marriage, and post-war change of name, causing distress to the very private author and to many of his readers at that time.


title: Patrick O'Brian

text: O'Brian was christened as Richard Patrick Russ, in Chalfont St Peter, Buckinghamshire, a son of Charles Russ, an English physician of German descent, and Jessie Russ (née Goddard), an English woman of Irish descent. The eighth of nine children, O'Brian lost his mother at the age of four, and his biographers describe a fairly isolated childhood, limited by poverty, with sporadic schooling, at St Marylebone Grammar School from 1924 to 1926, while living in Putney, and then at Lewes Grammar School, from September 1926 to July 1929, after the family moved to Lewes, East Sussex, but with intervals at home with his father and stepmother Zoe Center.


title: Patrick O'Brian

text: His literary career began in his childhood, with the publication of his earliest works, including several short stories. The book "Hussein, An Entertainment" published by Oxford University Press in 1938, and the short-story collection "Beasts Royal" brought considerable critical praise, especially considering his youth. He published his first novel at age 15, "Caesar: The Life Story of a Panda Leopard", with help from his father.


title: Patrick O'Brian

text: In 1927 he applied unsuccessfully to enter the Royal Naval College, Dartmouth. In 1934, he underwent a brief period of pilot training with the Royal Air Force, but that was not successful and he left the RAF. Prior to that, his application to join the Royal Navy had been rejected on health grounds. In 1935, he was living in London, where he married his first wife, Elizabeth Jones, in 1936. They had two children. The second was a daughter who suffered from spina bifida, and died in 1942, aged three, in a country village in Sussex. When the child died, O'Brian had already returned to London, where he worked throughout the war.


title: Patrick O'Brian

text: The details of his employment during the Second World War are murky. He worked as an ambulance driver, and he stated that he worked in intelligence in the Political Intelligence Department (PID). Dean King has said O'Brian was actively involved in intelligence work and perhaps special operations overseas during the war. Indeed, despite his usual extreme reticence about his past, O'Brian wrote in an essay, "Black, Choleric and Married?", included in the book "Patrick O'Brian: Critical Appreciations and a Bibliography" (1994) that: "Some time after the blitz had died away I joined one of those intelligence organisations that flourished during the War, perpetually changing their initials and competing with one another. Our work had to do with France, and more than that I shall not say, since disclosing methods and stratagems that have deceived the enemy once and that may deceive him again seems to me foolish. After the war we retired to Wales (I say we because my wife and I had driven ambulances and served in intelligence together) where we lived for a while in a high Welsh-speaking valley..." which confirms in first person the intelligence connection, as well as introducing his wife Mary Tolstoy, née Wicksteed, as a co-worker and fellow intelligence operative.


title: Patrick O'Brian

text: Nikolai Tolstoy, stepson through O'Brian's marriage to Mary, disputes that account, confirming only that O'Brian worked as a volunteer ambulance driver during the Blitz when he met Mary, the separated wife of Russian-born nobleman and lawyer Count Dimitri Tolstoy. They lived together through the latter part of the war and, after both were divorced from their previous spouses, they married in July 1945. The following month he changed his name by deed poll to Patrick O'Brian.


title: Patrick O'Brian

text: As background to his later sea-going novels, O'Brian did claim to have had limited experience on a square-rigged sailing vessel, as described within his previously-quoted 1994 essay:


title: Patrick O'Brian

text: However, in 1995, venture capitalist Thomas Perkins offered O'Brian a two-week cruise aboard his then sailing yacht, a ketch. In an article about the experience written after O'Brian's death, Perkins commented that "... his knowledge of the practical aspects of sailing seemed, amazingly, almost nil" and "... he seemed to have no feeling for the wind and the course, and frequently I had to intervene to prevent a full standing gybe. I began to suspect that his autobiographical references to his months at sea as a youth were fanciful."


title: Patrick O'Brian

text: Between 1946 and 1949 the O'Brians lived in Cwm Croesor, a remote valley in north Wales, where they initially rented a cottage from Clough Williams-Ellis. O'Brian pursued his interest in natural history; he fished, went birdwatching, and followed the local hunt. During this time they lived on Mary O'Brian's small income and the limited earnings from O'Brian's writings.


title: Patrick O'Brian

text: In 1949 O'Brian and Mary moved to Collioure, a Catalan town in southern France. He and Mary remained together in Collioure until her death in 1998. Mary's love and support were critical to O'Brian throughout his career. She worked with him in the British Library in the 1940s as he collected source material for his anthology "A Book of Voyages", which became the first book to bear his new name – the book was among his favourites, because of this close collaboration. The death of his wife in March 1998 was a tremendous blow to O'Brian. In the last two years of his life, particularly once the details of his early life were revealed to the world, he was a "lonely, tortured, and at the last possibly paranoid figure."


title: Patrick O'Brian

text: O'Brian protected his privacy fiercely and was usually reluctant to reveal any details about his private life or past, preferring to include no biographical details on his book jackets and supplying only a minimum of personal information when pressed to do so. For many years reviewers and journalists presumed he was Irish, and he took no steps to correct the impression. One interviewer, Mark Horowitz, described the man in his late seventies as "a compact, austere gentleman. ... his pale, watchful eyes are clear and alert." He is polite, formal, and erudite in conversation, an erudition that Horowitz said could be intimidating. He learned from those who worked with O'Brian that the erudition did not go unnoticed, while they remained friends.


title: Patrick O'Brian

text: Richard Ollard, a naval historian, calls this particular habit "blowing people out of the game." Ollard, who edited the early Aubrey–Maturin novels, urged O'Brian to tone down the most obscure allusions, though the books remain crammed with Latin tags, antiquated medical terminology and an endless stream of marvellous sounding but impenetrable naval jargon. "Like many who have struggled themselves", Ollard said of his friend, "he thought others should struggle, too." One longtime acquaintance put it more bluntly: "Patrick can be a bit of a snob, socially and intellectually."


title: Patrick O'Brian

text: In 1998, a BBC documentary and an exposé in "The Daily Telegraph" made public the facts of his ancestry, original name and first marriage, provoking considerable critical media comment. In his biography of O'Brian, Nikolai Tolstoy claims to give a more accurate and balanced account of his late stepfather's character, actions and motives, particularly in respect of his first marriage and family.


title: Patrick O'Brian

text: Lanchester, in reviewing Tolstoy's book, says "The last few years have been disheartening for Patrick O'Brian's many fans." He does not find the arguments altogether persuasive, and with access to documents that Dean King never saw, Tolstoy "gives a portrait of a man who is cold, bullying, isolated, snobbish and super-sensitive." Lanchester closes by saying "Let's agree, we O'Brianists, to read the novels and forget everything else." Veale, in reviewing King's book, says that "however judicious and well-grounded his [King's] speculation, he fails to crack his subject's protective shell. In the end, Aubrey and Maturin will have to thrive on their own—which is how the willfully enigmatic O'Brian most likely intended it."


title: Patrick O'Brian

text: As if anticipating 21st-century debates and disappointments once O'Brian's past was exposed, Horowitz interviewed O'Brian at his home in France in 1994: "Until recently, he refused all interviews. Those authors we know the least about, he says, are the ones we get in their purest form, like Homer. In "Clarissa Oakes" (published as "The Truelove" in the US), Stephen warns would-be interviewers that "question and answer is not a civilised form of conversation." O'Brian deflects direct inquiries about his private life, and when asked why he moved to the south of France after World War II, he stops and fixes his interrogator with a cold stare. "That seems to be getting rather close to a personal question," he says softly, walking on."


title: Patrick O'Brian

text: At his death, many obituaries were published evaluating his work, particularly in the Aubrey–Maturin series, and the too-recent revelations of his biography prior to his marriage to Mary Wicksteed Tolstoy. Playwright David Mamet wrote an appreciation. His American publisher, W W Norton, wrote an appreciation, mentioning their story with O'Brian, how pleased they were the three times he came to the US, in 1993, 1995 and in November 1999 only weeks before his death, and noting sales in the US alone of over three million copies.


title: Patrick O'Brian

text: He continued to work on his naval novels until his death and spent the winter of 1998–1999 at Trinity College Dublin. He died there on 2 January 2000. His body was returned to Collioure, where he is buried next to his wife.


title: Patrick O'Brian

text: The "Amis of Patrick O'Brian" association, based in Collioure, has been entrusted with the contents of his writing space, including his books and papers, as well as his writing desk, pens and ink.


title: Patrick O'Brian

text: O'Brian published two novels, a collection of stories and several uncollected stories under his original name, Richard Patrick Russ. His first novel, "Caesar: The Life Story of a Panda-Leopard", was written at the age of 12 and published three years later in 1930. It was a critical success, with a recommendation in the "New Statesman" and positive reviews in publications including the "New York Herald Tribune" and the "Saturday Review of Literature". Other stories followed, published in boys' magazines and annuals and incorporating themes of natural history and adventure, and a collection of these and other animal stories was published in 1934 under the title "Beasts Royal", with illustrations by the noted artist Charles Tunnicliffe, illustrator of "Tarka the Otter".


title: Patrick O'Brian

text: "Hussein: An entertainment", set in India, was published in 1938, when O'Brian was 23. It was notable for being the first book of contemporary fiction ever published by the Oxford University Press, to whose annuals for boys he had been a regular contributor for some years. O'Brian published very little under his original name of Russ during World War II, and nothing after 1940. His change of surname in 1945 necessarily meant abandoning the literary reputation he had built up as R P Russ.


title: Patrick O'Brian

text: O'Brian returned to writing after the war when he moved to rural Wales. His non-fiction anthology "A Book of Voyages" (1947) attracted little attention. A collection of short stories, "The Last Pool", was published in 1950 and was more widely and favourably reviewed, although sales were low. The countryside and people around his village in Wales provided inspiration for many of his short stories of the period, and also his novel "Testimonies" (1952), which is set in a thinly disguised Cwm Croesor, and which was well received by Delmore Schwartz in "Partisan Review" in 1952. His next novel was "The Catalans", published in 1953. The review in "The New York Times" noted O'Brian's accomplishments in "Testimonies"; "The Catalans" was viewed as a series of well-written scenes by an observant author, but the reviewer did not think it held together as a novel.


title: Patrick O'Brian

text: In the 1950s, O'Brian wrote three books aimed at a younger age group, "The Road to Samarcand", "The Golden Ocean", and "The Unknown Shore". Although written many years before the Aubrey–Maturin series, the two naval novels reveal literary antecedents of Aubrey and Maturin. In "The Golden Ocean" and "The Unknown Shore", based on events of George Anson's voyage around the world from 1740 to 1744, they can be clearly seen in the characters of Jack Byron and Tobias Barrow in the latter novel.


title: Patrick O'Brian

text: Over four decades he worked on his own writings, his British literary reputation growing slowly. He became an established translator of French works into English. His early novels and several of the translations were published by Rupert Hart-Davis from 1953 to 1974. O'Brian wrote the first of the Aubrey-Maturin series in 1969 at the suggestion of American publisher J B Lippincott, following the death of C. S. Forester in 1966, a writer of popular nautical novels. The Aubrey–Maturin books were quietly popular in Britain; after the first four volumes, they were not published in the United States.


title: Patrick O'Brian

text: In the early 1990s, the series was successfully relaunched into the American market by the interest of Starling Lawrence of W W Norton publishers, attracting critical acclaim and dramatically increasing O'Brian's sales and public profile in the UK and America. Paul D Colford notes that when O'Brian "visited the United States a few weeks ago [in December 1993], fans waiting to meet, lunch and have tea with him included Walter Cronkite, Sen. Dirk Kempthorne (R-Idaho) and Supreme Court Justice Anthony Kennedy, who invited O'Brian to attend a session of the high court. Hollywood also wants a piece of the press-shy storyteller."


title: Patrick O'Brian

text: The novels sold over three million copies in 20 languages. In its review of "21: The Final Unfinished Voyage of Jack Aubrey" (published in 2004), "Publishers Weekly" says that over six million copies have been sold. Thus O'Brian's greatest success in writing, gaining him fame, a following, and invitations to events and interviews came late in his life, when he was well into his seventies and accustomed to his private life.


title: Patrick O'Brian

text: Shortly before his last completed novel was published in October 1999, O'Brian wrote an article for a series of the best in the millennium ending, titled "Full Nelson", choosing for his topic Admiral Nelson's victory in the Battle of the Nile in 1798.


title: Patrick O'Brian

text: Beginning in 1969, O'Brian began writing what turned into the 20-volume Aubrey–Maturin series of novels. The books are set in the early 19th century and describe the lives and careers of Captain Jack Aubrey of the Royal Navy and his friend, naval physician and naturalist Dr Stephen Maturin, a man of Irish and Catalan parents. The books are distinguished by O'Brian's deliberate use and adaptation of actual historical events, either integrating his protagonists in the action without changing the outcome, or using adapted historical events as templates. In addition to this trait and to O'Brian's distinctive literary style, his sense of humour is prominent (see Humour in main article, "Aubrey–Maturin series").


title: Patrick O'Brian

text: The series employs technical sailing terminology throughout. Some critics consider the books a roman fleuve, which can be read as one long story; the books follow Aubrey and Maturin's professional and domestic lives continuously.


title: Patrick O'Brian

text: As well as his historical novels, O'Brian wrote three adult mainstream novels, six short-story collections, and a history of the Royal Navy aimed at young readers. He was also a respected translator, responsible for more than 30 translations from the French into English, including Henri Charrière's "Papillon" (UK) and "Banco: The further adventures of Papillon", Jean Lacouture's biography of Charles de Gaulle, as well as many of Simone de Beauvoir's later works.


title: Patrick O'Brian

text: O'Brian wrote detailed biographies of Sir Joseph Banks, an English naturalist who took part in Cook's first voyage (and who appears briefly in O'Brian's Aubrey-Maturin series), and Pablo Picasso. His biography of Picasso is a massive and comprehensive study of the artist. Picasso and O'Brian both lived in the French village of Collioure and became acquainted there.


title: Patrick O'Brian

text: Peter Weir's 2003 film, "" is loosely based on the novel "The Far Side of the World" from the Aubrey–Maturin series for its plot, but draws on a number of the novels for incidents within the film. The character of Jack Aubrey is drawn from the character in the novels.


title: Patrick O'Brian

text: In 1995 he was awarded the inaugural Heywood Hill Literary Prize, in the amount of 10,000 pounds, for his lifetime's writings. In his acceptance speech in July 1995, O'Brian, then age 80, said it was the first literary prize of his adult life. He received an honorary doctorate from Trinity College Dublin and a CBE in 1997.


title: Patrick O'Brian

text: On 21–23 September 2001, the National Museum of the Royal Navy, Portsmouth, organised a "The Patrick O'Brian Weekend" to celebrate O'Brian's achievement in depicting Nelson's Navy in his novels. The weekend featured lectures by some of Britain's leading naval historians on "how the novels closely reflect the insights of modern scholarship". There was a concert of contemporary music and readings from his books. The weekend concluded with a tour of Nelson's flagship HMS "Victory" followed by a dinner on her lower gundeck. The event was repeated one year later at the same venue.


title: Patrick O'Brian

text: O'Brian claimed that he wrote "like a Christian, with ink and quill"; Mary was his first reader and typed his manuscripts "pretty" for the publisher. O'Brian handwrote all his books and stories, shunning both typewriter and word processor. The handwritten manuscripts for 18 Aubrey-Maturin novels have been acquired by the Lilly Library at Indiana University. Only two, "The Letter of Marque" and "Blue at the Mizzen", owned by Stuart Bennet, remain in private hands. Bennet donated his correspondence from O'Brian to the Lilly Library; one letter recommends to Bennet that he donate the two manuscripts he holds to Indiana University, where the rest of the manuscripts reside. The O'Brian manuscript collection at the Lilly Library also includes the manuscripts for "Picasso" and "Joseph Banks" and detailed notes for six Aubrey/Maturin novels. The 2011 exhibit Blue at the Mizzen suggests that the manuscript was donated.


title: Patrick O'Brian

text: Nikolai Tolstoy also has an extensive collection of O'Brian manuscript material, including the second half of "Hussein", several short stories, much of the reportedly "lost" book on Bestiaries, letters, diaries, journals, notes, poems, book reviews, and several unpublished short stories.


title: Patrick O'Brian

text: Since O'Brian's death, two biographies have been published, though the first was well advanced when he died. The second is by O'Brian's stepson Nikolai Tolstoy.


title: Patrick O'Brian

text: Dean King's "Patrick O'Brian: A Life Revealed" was the first biography to document O'Brian's early life under his original name.


title: Patrick O'Brian

text: Tolstoy's two-volume biography, "Patrick O'Brian: The Making of the Novelist" (2004) and "Patrick O'Brian: A Very Private Life" (2019) make use of material from the Russ and Tolstoy families and sources, including O'Brian's personal papers and library which Tolstoy inherited on O'Brian's death.


title: Hypovolemic shock

text: Hypovolemic shock is a form of shock caused by severe hypovolemia (insufficient blood volume or extracellular fluid in the body). It could be the result of severe dehydration through a variety of mechanisms or blood loss. Hypovolemic shock is a medical emergency; if left untreated, the insufficient blood flow can cause damage to organs, leading to multiple organ failure.


title: Hypovolemic shock

text: In treating hypovolemic shock, it is important to determine the cause of the underlying hypovolemia, which may be the result of bleeding or other fluid losses. To minimize ischemic damage to tissues, treatment involves quickly replacing lost blood or fluids, with consideration of both rate and the type of fluids used.


title: Hypovolemic shock

text: Tachycardia, a fast heart rate, is typically the first abnormal vital sign. When resulting from blood loss, trauma is the most common root cause, but severe blood loss can also happen in various body systems without clear traumatic injury. The body in hypovolemic shock prioritizes getting oxygen to the brain and heart, which reduces blood flow to nonvital organs and extremities, causing them to grow cold, look mottled, and exhibit delayed capillary refill. The lack of adequate oxygen delivery ultimately leads to a worsening increase in the acidity of the blood (acidosis). The "lethal triad" of ways trauma can lead to death is acidosis, hypothermia, and coagulopathy. It is possible for trauma to cause clotting problems even without resuscitation efforts.


title: Hypovolemic shock

text: Symptoms of hypovolemic shock can be related to volume depletion, electrolyte imbalances, or acid–base disorders that accompany hypovolemic shock.


title: Hypovolemic shock

text: Patients with volume depletion may complain of thirst, muscle cramps, and/or orthostatic hypotension. Severe hypovolemic shock can result in mesenteric and coronary ischemia that can cause abdominal or chest pain. Agitation, lethargy, or confusion may characterize brain mal-perfusion.


title: Hypovolemic shock

text: Dry mucous membranes, decreased skin turgor, low jugular venous distention, tachycardia, and hypotension can be seen along with decreased urinary output. Patients in shock can appear cold, clammy, and cyanotic.


title: Hypovolemic shock

text: Early signs and symptoms include tachycardia given rise to by catecholamine release; skin pallor due to vasoconstriction triggered by catecholamine release; hypotension followed by hypovolaemia and perhaps arising after myocardial insufficiency; and confusion, aggression, drowsiness and coma caused by cerebral hypoxia or acidosis. Tachypnoea owing to hypoxia and acidosis, general weakness caused by hypoxia and acidosis, thirst induced by hypovolaemia, and oliguria caused by reduced perfusion may also arise.


title: Hypovolemic shock

text: Abnormal growing central venous pressure indicates either hypotension or hypovolemia. Tachycardia accompanied by declined urine outflow implies either tension pneumothorax, cardiac tamponade or cardiac failure which is thought secondary to cardiac contusion or ischaemic heart disease. Echocardiography in such case may be helpful to distinguish cardiac failure from other diseases. Cardiac failure manifests a weak contractibility myocardium; treatment with an inotropic drug such as dobutamine may be appropriate.


title: Hypovolemic shock

text: The annual incidence of shock of any etiology is 0.3 to 0.7 per 1000, with hemorrhagic shock being most common in the intensive care unit. Hypovolemic shock is the most common type of shock in children, most commonly due to diarrheal illness in the developing world.


title: Hypovolemic shock

text: Hemorrhagic shock is hypovolemic shock from blood loss. Traumatic injury is by far the most common cause of hemorrhagic shock, particularly blunt and penetrating trauma, followed by upper and lower gastrointestinal sources, such as gastrointestinal (GI) bleed. Other causes of hemorrhagic shock include bleed from an ectopic pregnancy, bleeding from surgical intervention, vaginal bleeding, and splenic rupture.


title: Hypovolemic shock

text: Obstetrical, vascular, iatrogenic, and even urological sources have all been described. Bleeding may be either external or internal. A substantial amount of blood loss to the point of hemodynamic compromise may occur in the chest, abdomen, or the retroperitoneum. The thigh itself can hold up to 1 L to 2 L of blood.


title: Hypovolemic shock

text: Localizing and controlling the source of bleeding is of utmost importance to the treatment of hemorrhagic shock.


title: Hypovolemic shock

text: The sequence of the most-commonly-seen causes that lead to hemorrhagic type of hypovolemic shock is given in order of frequencies: blunt or penetrating trauma including multiple fractures absent from vessel impairment, upper gastrointestinal bleeding e.g., variceal hemorrhage, peptic ulcer., or lower GI bleeding e.g., diverticular, and arteriovenous malformation.


title: Hypovolemic shock

text: Except for the two most common causes, the less common causes are intra-operative and post-operative bleeding, abdominal aortic rupture or left ventricle aneurysm rupture, aortic–enteric fistula, hemorrhagic pancreatitis, iatrogenic e.g., inadvertent biopsy of arteriovenous malformation, severed artery., tumors or abscess erosion into major vessels, post-partum hemorrhage, uterine or vaginal hemorrhage owing to infection, tumors, lacerations, spontaneous peritoneal hemorrhage caused by bleeding diathesis, and ruptured hematoma.


title: Hypovolemic shock

text: In spite of hemorrhage, the amount of circulating blood in the body may drop as well when one loses excessive body fluid owing to non-hemorrhagic reasons.


title: Hypovolemic shock

text: Gastrointestinal (GI) losses can occur via many different etiologies. The gastrointestinal tract usually secretes between 3 and 6 liters of fluid per day. However, most of this fluid is reabsorbed as only 100 to 200 mL are lost in the stool. Volume depletion occurs when the fluid ordinarily secreted by the GI tract cannot be reabsorbed. This occurs when there is retractable vomiting, diarrhea, or external drainage via stoma or fistulas.


title: Hypovolemic shock

text: Renal losses of salt and fluid can lead to hypovolemic shock. The kidneys usually excrete sodium and water in a manner that matches sodium intake and water intake.


title: Hypovolemic shock

text: Diuretic therapy and osmotic diuresis from hyperglycemia can lead to excessive renal sodium and volume loss. In addition, there are several tubular and interstitial diseases beyond the scope of this article that cause severe salt-wasting nephropathy.


title: Hypovolemic shock

text: Fluid loss also can occur from the skin. In a hot and dry climate, skin fluid losses can be as high as 1 to 2 liters/hour. Patients with a skin barrier interrupted by burns or other skin lesions also can experience large fluid losses that lead to hypovolemic shock.


title: Hypovolemic shock

text: Sequestration of fluid into a third space also can lead to volume loss and hypovolemic shock. Third-spacing of fluid can occur in intestinal obstruction, pancreatitis, obstruction of a major venous system, vascular endothelium or any other pathological condition that results in a massive inflammatory response.


title: Hypovolemic shock

text: Hemorrhagic shock is due to the depletion of intravascular volume through blood loss to the point of being unable to match the tissues demand for oxygen. As a result, mitochondria are no longer able to sustain aerobic metabolism for the production of oxygen and switch to the less efficient anaerobic metabolism to meet the cellular demand for adenosine triphosphate. In the latter process, pyruvate is produced and converted to lactic acid to regenerate nicotinamide adenine dinucleotide (NAD+) to maintain some degree of cellular respiration in the absence of oxygen.


title: Hypovolemic shock

text: The body compensates for volume loss by increasing heart rate and contractility, followed by baroreceptor activation resulting in sympathetic nervous system activation and peripheral vasoconstriction. Typically, there is a slight increase in the diastolic blood pressure with narrowing of the pulse pressure. As diastolic ventricular filling continues to decline and cardiac output decreases, systolic blood pressure drops.


title: Hypovolemic shock

text: Due to sympathetic nervous system activation, blood is diverted away from noncritical organs and tissues to preserve blood supply to vital organs such as the heart and brain. While prolonging heart and brain function, this also leads to other tissues being further deprived of oxygen causing more lactic acid production and worsening acidosis. This worsening acidosis along with hypoxemia, if left uncorrected, eventually causes the loss of peripheral vasoconstriction, worsening hemodynamic compromise, and death.


title: Hypovolemic shock

text: The body's compensation varies by cardiopulmonary comorbidities, age, and vasoactive medications. Due to these factors, heart rate and blood pressure responses are extremely variable and, therefore, cannot be relied upon as the sole means of diagnosis.


title: Hypovolemic shock

text: A key factor in the pathophysiology of hemorrhagic shock is the development of trauma-induced coagulopathy. Coagulopathy develops as a combination of several processes. The simultaneous loss of coagulation factors via hemorrhage, hemodilution with resuscitation fluids, and coagulation cascade dysfunction secondary to acidosis and hypothermia have been traditionally thought to be the cause of coagulopathy in trauma. However, this traditional model of trauma-induced coagulopathy may be too limited. Further studies have shown that a degree of coagulopathy begins in 25% to 56% of patients before initiation of the resuscitation. This has led to the recognition of trauma-induced coagulopathy as the sum of two distinct processes: "acute coagulopathy of trauma" and "resuscitation-induced coagulopathy".


title: Hypovolemic shock

text: Trauma-induced coagulopathy is acutely worsened by the presence of acidosis and hypothermia. The activity of coagulation factors, fibrinogen depletion, and platelet quantity are all adversely affected by acidosis. Hypothermia (less than 34 C) compounds coagulopathy by impairing coagulation and is an independent risk factor for death in hemorrhagic shock.


title: Hypovolemic shock

text: Hypovolemic shock results from depletion of intravascular volume, whether by extracellular fluid loss or blood loss. The body compensates with increased sympathetic tone resulting in increased heart rate, increased cardiac contractility, and peripheral vasoconstriction. The first changes in vital signs seen in hypovolemic shock include an increase in diastolic blood pressure with narrowed pulse pressure.


title: Hypovolemic shock

text: As volume status continues to decrease, systolic blood pressure drops. As a result, oxygen delivery to vital organs is unable to meet the oxygen needs of the cells. Cells switch from aerobic metabolism to anaerobic metabolism, resulting in lactic acidosis. As sympathetic drive increases, blood flow is diverted from other organs to preserve blood flow to the heart and brain. This propagates tissue ischemia and worsens lactic acidosis. If not corrected, there will be worsening hemodynamic compromise and, eventually, death.


title: Hypovolemic shock

text: Such ratio value is clinically employed to determine the scope or emergence of shock. The SI correlates with the extent of hypovolemia and thus may facilitate the early identification of severely injured patients threatened by complications due to blood loss and therefore need urgent treatment, i.e. blood transfusion.


title: Hypovolemic shock

text: Data presented as n (%), mean ± standard deviation or median (interquartile range (IQR)). n = 21,853; P <0.001 for all parameters. ED Emergency department, GCS Glasgow coma scale, HR Heart rate, SBP Systolic blood pressure, SI = Shock index.


title: Hypovolemic shock

text: Recognizing the degree of blood loss via vital sign and mental status abnormalities is important. The American College of Surgeons Advanced Trauma Life Support (ATLS) hemorrhagic shock classification links the amount of blood loss to expected physiologic responses in a healthy 70 kg patient. As total circulating blood volume accounts for approximately 7% of total body weight, this equals approximately five liters in the average 70 kg male patient.


title: Hypovolemic shock

text: Again, the above is outlined for a healthy 70 kg individual. Clinical factors must be taken into account when assessing patients. For example, elderly patients taking beta blockers can alter the patient's physiologic response to decreased blood volume by inhibiting mechanism to increase heart rate. As another, patients with baseline hypertension may be functionally hypotensive with a systolic blood pressure of 110 mmHg.


title: Hypovolemic shock

text: Various laboratory values can be abnormal in hypovolemic shock. Patients can have increased BUN and serum creatinine as a result of pre-renal kidney failure. Hypernatremia or hyponatremia can result, as can hyperkalemia or hypokalemia.


title: Hypovolemic shock

text: Lactic acidosis can result from increased anaerobic metabolism. However, the effect of acid–base balance can be variable as patients with large GI losses can become alkalotic.


title: Hypovolemic shock

text: In cases of hemorrhagic shock, hematocrit and hemoglobin can be severely decreased. However, with a reduction in plasma volume, hematocrit and hemoglobin can be increased due to hemoconcentration.


title: Hypovolemic shock

text: Low urinary sodium is commonly found in hypovolemic patients as the kidneys attempt to conserve sodium and water to expand the extracellular volume. However, sodium urine can be low in a euvolemic patient with heart failure, cirrhosis, or nephrotic syndrome. Fractional excretion of sodium under 1% is also suggestive of volume depletion. Elevated urine osmolality can also suggest hypovolemia. However, this number also can be elevated in the setting of impaired concentrating ability by the kidneys.


title: Hypovolemic shock

text: Central venous pressure (CVP) is often used to assess volume status. However, its usefulness in determining volume responsiveness has recently come into question. Ventilator settings, chest wall compliance, and right-sided heart failure can compromise CVPs accuracy as a measure of volume status. Measurements of pulse pressure variation via various commercial devices has also been postulated as a measure of volume responsiveness. However, pulse pressure variation as a measure of fluid responsiveness is only valid in patients without spontaneous breaths or arrhythmias. The accuracy of pulse pressure variation also can be compromised in right heart failure, decreased lung or chest wall compliance, and high respiratory rates.


title: Hypovolemic shock

text: Similar to examining pulse pressure variation, measuring respiratory variation in inferior vena cava diameter as a measure of volume responsiveness has only been validated in patients without spontaneous breaths or arrhythmias.


title: Hypovolemic shock

text: Measuring the effect of passive leg raises on cardiac contractility by echo appears to be the most accurate measurement of volume responsiveness, although it is also subject to limitations.


title: Hypovolemic shock

text: History and physical can often make the diagnosis of hypovolemic shock. For patients with hemorrhagic shock, a history of trauma or recent surgery is present. For hypovolemic shock due to fluid losses, history and physical should attempt to identify possible GI, renal, skin, or third-spacing as a cause of extracellular fluid loss.


title: Hypovolemic shock

text: Although relatively nonsensitive and nonspecific, physical exam can be helpful in determining the presence of hypovolemic shock. Physical findings suggestive of volume depletion include dry mucous membranes, decreased skin turgor, and low jugular venous distention. Tachycardia and hypotension can be seen along with decreased urinary output.


title: Hypovolemic shock

text: While hemorrhage is the most common cause of shock in the trauma patient, other causes of shock are to remain on the differential. Obstructive shock can occur in the setting of tension pneumothorax and cardiac tamponade. These etiologies should be uncovered in the primary survey. In the setting of head or neck trauma, an inadequate sympathetic response, or neurogenic shock, is a type of distributive shock that is caused by a decrease in peripheral vascular resistance. This is suggested by an inappropriately low heart rate in the setting of hypotension. Cardiac contusion and infarctions can result in cardiogenic shock. Finally, other causes should be considered that are not related to trauma or blood loss. In the undifferentiated patient with shock, septic shock and toxic causes are also on the differential.


title: Hypovolemic shock

text: The first step in managing hemorrhagic shock is recognition. Ideally, This should occur before the development of hypotension. Close attention should be paid to physiological responses to low-blood volume. Tachycardia, tachypnea, and narrowing pulse pressure may be the initial signs. Cool extremities and delayed capillary refill are signs of peripheral vasoconstriction.


title: Hypovolemic shock

text: In the setting of trauma, an algorithmic approach via the primary and secondary surveys is suggested by ATLS. Physical exam and radiological evaluations can help localize sources of bleeding. A trauma ultrasound, or Focused Assessment with Sonography for Trauma (FAST), has been incorporated in many circumstances into the initial surveys. The specificity of a FAST scan has been reported above 99%, but a negative ultrasound does not rule out intra-abdominal pathology.


title: Hypovolemic shock

text: With a broader understanding of the pathophysiology of hemorrhagic shock, treatment in trauma has expanded from a simple massive transfusion method to a more comprehensive management strategy of "damage control resuscitation". The concept of damage control resuscitation focuses on permissive hypotension, hemostatic resuscitation, and hemorrhage control to adequately treat the "lethal triad" of coagulopathy, acidosis, and hypothermia that occurs in trauma.


title: Hypovolemic shock

text: Hypotensive resuscitation has been suggested for the hemorrhagic shock patient without head trauma. The aim is to achieve a systolic blood pressure of 90 mmHg in order to maintain tissue perfusion without inducing re-bleeding from recently clotted vessels. Permissive hypotension is a means of restricting fluid administration until hemorrhage is controlled while accepting a short period of suboptimal end-organ perfusion. Studies regarding permissive hypotension have yielded conflicting results and must take into account type of injury (penetrating versus blunt), the likelihood of intracranial injury, the severity of the injury, as well as proximity to a trauma center and definitive hemorrhage control.


title: Hypovolemic shock

text: The quantity, type of fluids to be used, and endpoints of resuscitation remain topics of much study and debate. For crystalloid resuscitation, normal saline and lactated ringers are the most commonly used fluids. Normal saline has the drawback of causing a non-anion gap hyperchloremic metabolic acidosis due to the high chloride content, while lactated ringers can cause a metabolic alkalosis as lactate metabolism regenerates into bicarbonate.


title: Hypovolemic shock

text: Recent trends in damage control resuscitation focus on "hemostatic resuscitation" which pushes for early use of blood products rather than an abundance of crystalloids in order to minimize the metabolic derangement, resuscitation-induced coagulopathy, and the hemodilution that occurs with crystalloid resuscitation. The end goal of resuscitation and the ratios of blood products remain at the center of much study and debate. A recent study has shown no significant difference in mortality at 24 hours or 30 days between ratios of 1:1:1 and 1:1:2 of plasma to platelets to packed RBCs. However, patients that received the more balanced ratio of 1:1:1 were less likely to die as a result of exsanguination in 24 hours and were more likely to achieve hemostasis. Additionally, reduction in time to first plasma transfusion has shown a significant reduction in mortality in damage control resuscitation.


title: Hypovolemic shock

text: In addition to blood products, products that prevent the breakdown of fibrin in clots, or antifibrinolytics, have been studied for their utility in the treatment of hemorrhagic shock in the trauma patient. Several antifibrinolytics have been shown to be safe and effective in elective surgery. The CRASH-2 study was a randomized control trial of tranexamic acid versus placebo in trauma has been shown to decrease overall mortality when given in the first three hours of injury. Follow-up analysis shows additional benefit to tranexamic acid when given in the first three hours after surgery.