Acute Medicine: Shock

Definition – inadequate tissue and organ perfusion leading to a hypoperfusion state & eventual
cellular hypoxia and its attendant sequelae.
S/S: Hypotension, urine output, tachycardia, diaphoresis, AMS
Types of Shock
Types
Causes

S/S

Invxs

‘White’ shock
Hypovolaemic
Cardiogenic
Haemorrhage
AMI
Burns
Dysrhythmia
Ruptured ectopic
pregnancy
Severe GE
Acute pancreatitis
Pallor
Pallor
Cold clammy skin
Cold clammy
skin
peri vas 
peri vas 
Cardiac
 Hct (late)
enzymes
ECG

‘Red’ shock
Anaphylactic

Neurogenic
Spinal injury

Septic
Infxns

Warm skin
N/ heart
rate
Neuro deficit

Fever, rigors
Warm skin

Fever, rigors
Warm skin

FBC
Bld C/S

Also, Obstructive Shock due to tension pneumothorax, cardiac tamponade or pulmonary
embolism
Management
General Mx
Airway
Breathing
Circulation

Monitoring








Hypovolaemic Shock
Invxs

FBC - Hct in acute alcoholic binge due to diuresis. Hct is an Inaccurate
marker of bld loss acutely.

GXM 6 units

U/E/Cr

Troponin T & Cardiac enzymes

Coagulation profile with DIVC screen (PT/PTT, pltlet, D-dimer)

ABG – metab acidosis, lactate, base deficits are poor Px factors

UPT - ?ectopic pregnancy? Ask for LMP

Examine abdomen for pulsatile AAA
Fluid Rx

1 L crystalloid fast infusion w/in 1 hr

Assess response

Subsequent colloid or whole blood infusion

Used to guide fluid Rx, esp in CCF patients
 CVP line

Maintain airway – consider intubation if necessary
100% O2 via non-rebreather mask
2 large bore (14-16G) cannulae
 Inotropic support
o
IV dopamine 5-10g/kg/min
o
IV dobutamine 5-10g/kg/min (esp for cardiogenic shock)
o
IV norepinephrine 5-20g/kg/min (esp for septic shock)
Pulse oximetry
ECG
BP
Heart rate
Urine output – catheterize patient

Cardiogenic Shock
ECG
Trop T & cardiac enzymes

Neurogenic Shock
Hx/PE


Immobilize

Invxs

Fluid Rx
 IV methyl
prednisolone

Disposition








Manage accordingly – refer acute coronary syndrome &
ACLS notes

Trauma – site, mechanism, force
Neuro exam, DRE – document initial neurological deficits
Immobilize spine in neutral position
C-spine X-ray (AP & lat) – ensure visualization up to C7/T1 junction
 Swimmer’s view (visualize C7/T1 jn) & open mouth view (visualize C1/2
injury)
Thoracic & lumbar spine X-ray (AP & lat)
 CT scan
 MRI later
Titrate fluid resus with urine output
 vasopressors if BP does not respond to fluid challenge
30 mg/kg over 15mins, followed by 5.4mg/kg/h for nxt 23 hrs
Indications – non-penetrating spinal cord injury & w/in 8 hrs of injury
Contraindications
o
<13YO
o
pregnancy
o
mild injury of the cauda equina / nerve root
o
abdominal trauma present
o
major life-threatening morbidity
Refer Ortho / NeuroSx

Or penicillin allergy Rx Anaerobic source (intra-abdo. pulmonary angiogram (gold std) present)  IV vancomycin 1g if hx of IVDA.  DIVC screen (D-dimer) pneumonia.  IV metronidazole 500mg + ceftriazone  Pain relieve – use Opioids with caution biliary.5ml if 50-65kg. MRI. 1g + IV gentamicin 80mg  Fluid Rx & inotropic support if haemodynamically unstable aspiration pneumonia)  Anticoagulation Rx: o IV heparin 5000U bolus or SC fraxiparine (0. immunocompromised state  ABG Invx  FBC . appendicitis. <4000/mm3. pltlet. indwelling cath. pericarditis  if no response to fluid Rx  CXR (may be normal)  Inotropic o Westermark sign – oligaemic lung fields support  Noradrenaline (drug of choice) .4ml if <50kg. peritonitis.or >10% immature forms  U/E/Cr Hx / PE  Identify site of infxn – UTI (indwelling cathether). lung scintigraphy. female genital tract. D-dimer  ECG (may be normal)  Bld C/S (2 different sites) o non-specific ST depression & T wave inversion  Capillary bld glucose o Sinus tachycardia  ABG o Right heart strain  CXR – pneumonia.6ml if >65kg) o Convert to Oral warfarin later  Thrombolysis o Intra pul. fibrinogen. DGIM – Last updated March 2005 . arterial urokinase fro 12-24 hrs Surgical o Complete IVC ligation or partial caval interruption Obstructive Shock  Tension  Decompression: insert 14G cannula over 2nd intercostals space in midPneumothorax clav. massive pleural effusion.1g/kg/min OR o Pul infarcts – wedge shape opacities w apex pointing  Dopamin 5-20g/kg/min towards the hilum Empirical ABx Immunocompetent w/o obvious  3rd gen cephalosporin (IV ceftriaxone o Atelectasis source 1g) OR o Pleural effusions  Quinolones (ciprofloxacin 200mg) o Raised diaphragm Immunocompromised w/o  Anti-pseudomonal ABx (IV ceftazidime o Consolidation obvious source 1g) OR o ‘Plump’ pul. gallbladder dz. ARDS  Right axis deviation  ECG  Transient RBBB  Urine dipstick – UTI  T wave inversion in V1-3  Urine C/S  P pulmonale Fluid Rx  Rapid infusion 1-2L crystalloids  S1Q3T3   CVP line insertion o Exclude DDxes – MI. pneumonia. lobar 80mg) collapse Gram-positive (burns. 0. Line Cardiac  IV fluid bolus 500ml N/S DGIM – Last updated March 2005 Septic Shock tamponade   IV dopamine infusion 5g/kg/min Sepsis =  2 of the following present:  Prepare for pericardiocentesis o Temp >38 or <36oC Pul Embolism Invx o HR > 90bpm  FBC o RR > 20 breaths/min OR PaCO2<32mmHg  GXM 6 units o WCC>12000/mm3. tumour. Echo. rib #. FB / lines  IV cefazolin 2g   Spiral CT. L heart  PLUS aminoglycoside (Gentamicin failure. arteries  Quinolone o Exclude DDxes – pneumothorax. TW o  PaO2 & N/ PaCO2  U/E/Cr o widened alveolo-arterial P02 gradient (AaPO2 >20mmHg)  DIVC screen – PT/PTT. 0.

wasps. Non-pruritic. TCM. -blocker use  0. hornets  Environment – dust. coxsackie virus. sulpha drugs  Food – shellfish. May be a/w numbness & pain  Anaphylaxis – severe systemic allergic rxn to an Ag. egg white. aspirin.5-1. Ppt by abrupt release of chemical mediators in a previously sensitized patient  Anaphylactoid rxn – resembles anaphylactic rxn. parasites Stop Pptant  Stop administration of suspected agent / flick out insect stinger with tongue blade  Gastric lavage & activated charcoal if drug was ingested Airway  Prepare for intubation or cricothyroidectomy – ENT/Anaesthesia consult Fluid Rx  2L Hartman’s or N/S bolus Drug Rx Adrenaline  Normotensive – 0.Anaphylactic Shock Definitions  Urticaria – oedematous & pruritic plaques w pale centre & raised edges  Angioedema – oedema of deeper layers of the skin. but due to direct histamine release from mast cells w/o need for prior sensitization Common causes  Drugs – penicililns & NSAIDS commonest. pregnancy. Can be repeated once after 30mins Antihistamines  Diphenhydramine 25mg IM/IV  Chlorpheniramine 10mg IM/IV  Promethazine 25mg IM/IV Cimetidine  For persistent symptoms unresponsive to above Rx  200-400mg IV bolus Nebulised  for persistent bronchospasm bronchodilator  Salbutamol 2:2 q20-30mins Corticosteroids  Hydrocortisone 200-300mg IV bolus. peanuts  Venoms – bees.0mg IV/IM.01ml/kg (max 0.1ml/kg (max 5ml) 1:10.000 dilution IV over 5 mins Glucagon  Indications: failure of adrenaline Rx OR if adrenaline is contraindicated eg IHD. severe HPT.5ml) 1:1000 dilution SC/IM  Hypotensive – 0. pollen  Infections – EBV. q 6hr DGIM – Last updated March 2005 . HBV.