"hkJO extern !!!!!!

inuo 3 BP drop fi: 70/ 50 mmHg"

iwuoiirilnOuiriiu extern IhLinuHU 107 a: rioteirioiirilhunino:

'

ooxJ/ Tuuinurnou 00 U7 mid noanunuo

niiiuiuicrialiJu iiluuuu extern IdLiumou TuInandooDHuihOiarlouinmu licit! 5 nou u

nuinuolu ward uuumulnoluln nnooou:nou (aout) 4 rhwaofio naiulnnou)

riauau QhuimwiJouriauu:nou 01 cardiac arrest Uouo (idu air hunger) nai carotid
pulse nou Mduoiicioiuoiodniau ouaulUoinulu cardiac arrest Uuao auuuJauuosmo
onuiHuniauu:nou iwoiruululdiooo shock uao
> rinOu extern oonao loaiionoa notify BP drop nnnuiinuornaulnuwoauiwouonu
01 "Ondl " WOOUlQUUUHUlllJlTtJOd BP ThiUlOO 5555

0507 moon BP nuUo:inuu:nou Tnuictwiilunulunu arrhythmia ayinu idu AF > mo

deflate cuff niooinulU ormtolnm BP nninoinoiuiiluooo ii/nonuuudinoo deflate cuff
\J

nunou rate irillho > mnau rate 1-2 mmHg ciaouin

nuaaontiunaunoi07 oiioio:Uo:iQunuIduofon miOunuIun admit auuao

u I u

1. nooon tissue perfusion riounou > iwoi:niuuuiu shock = poor tissue perfusion

nouufhluu poor tissue perfusion unluld shock nou

nooooiomudiu7 nnoornna monaiUaiuuaiJaiuiifmiuuuu (cold clammy skin), n
capillary refill, n consciousness lOuuolo (drowsiness, agitation), urine output nwiuui
lOuuolo Miaino:mu record mn (keep urine output > 0.5 mL/kg/hr)
iwoiruionuluu sign of poor tissue perfusion Orloiau no BP drop HU0 U7 idu 85/ 50
mmHg iinuauno:nnirhn TV In wnoioioaon urine aann > ouiou nnalu shock

nou
mnuaou sign poor tissue perfusion tonnloriauiaudi shock
louamnonnoiaoiaudinao A-B-C managenent
Inu airway ua: breathing lOiunomaonnulU > mo: shock ii) umo:nu low 02
delivery nouuliiwoioaillii 02 lUiauoiliiuuInoiJiiuuuo (cannula, mask, kask with bag)
 impending respiratory failure idu respiratory paradox nbta ET tube IU
^iHSUfluIuncn
: -u
iauu n ammiianoiiaumuniwmurrbb NIV lUltbonurnau IWTI
l
: hemodynamic

instability

-
pm bunubn on ET tube auiiao u
nbrnfmiwu Fi02 lUiauUaiumj 0.6-1.0 iwaiwu 02
delivery

2. naoaaiomuiwaUanuuaiarbaisuibmaaTij

Unci shock u 4 Uannnna hypovolemic, cardiogenic, obstructive, distributive >

shock noHUCi uniau cardiogenic (left sided) niaiarluba iaihiiluauiian ninaanabais
'

UIHUCI > nouunniluwu wua: R /0 cardiogeneic shock aanlUriau

Q neck vein riauiau > rh neck vein aomn bnnfio cardiogenic shock riau (uci
obstructive shock niiluln arlcfnaiacialU)
numimla central line atiuaa nlucnaoTUwtntniJR neck vein u:n5u tccudumn lUn
VI VI VI

CVP line lau uaanan CVP Id > onnaumubaanan (rnmubiao b column thaoan
i v V# i

mmubbinSaodoumub fib column uicrnan)

Wo crepitation nauaiuSiUm fhurbriOucnan limit uiwanoa
iHaualUnnuIudnunyiu chest pain 5iUm ihbaiinncnaiSuinuwnnWSalU mubncnfio
acute coronary syndrome (ACS) riauiau thlUa ininSaomfn EKG fauwauiwahn
'

hangiuuao ACS (ST-T change, T wave inversion nonaiu) > bbo portable CXR
iGbuuIonau iwamMangiudaomainn acute pulmonary edema
aa uaamu pulmonary edema 0507 nauiacri lasix lucnauuumau ainnatnlayitnauu BP
drop ay aUiiwob lasix ai
nauufn BP drop nicbuutJU vasopressor Uiau n HR nub m HR th n dopamine fh HR
iSanb norepinephrine

3. nnOu shock nbrn

^uiln fb:cnn 3 naunia hypovolemic, distributive, obstructive
V'
1
JU
3.1 naunwuln common nanrTirbu ward med na septic shock iwyircuuuiaiauuaanm
^

nau
- rbuROOuaiWaouUoanmiMauiaudMtJuu nulumao chill uu > rhunRno septic
shock riauiau > toouni septic work up [Ruwau ORlUriauiau H/ C x II specimens
uarnaatnaium souce Tcnub touaomtb:mfuu
@ Pneumonia, VAP
@ UTI
@ central line infection
@ Skin, soft tissue infection (aau source Suninaa tJununoiuaimsrb'mHusiiJa'i)

bnuaul(7f uauu:n-5u auTsawaomhao lab naio iw5i:uionndilU (aou^a c/ s u

=> a:

nuTanouuMau) m5uaua:rn!MRuIdI(fimR5onuiani0u MOum^inououn douOaonu

m5incii3aRamlRu:R5u
R lab riauhUiURDUDiuolJmo infection uu idu CBC u leukocytosis, vacuolization, toxic
granulation hSa U/ A nao7 Tou pyuria HOalui wan culture RI07 idu sputum, drain n
laiui review ROU iW5 i:uuo:iiluuuomol!un i5to antibiotics In
' '

nnOu infection nldnaiuacnauO 4 tl 5 niouumtbruoayi infection ninuuiQu medical

u

disease U53 surgical disease idu fhihu necrotizing fasciitis ncnaoau:anQu surgical
disease

- nauu mluRRyi heart naa lung u0 fymuin7 to IV fluid riaulUiau rate tb:mai 500-

1,000 mL IV drip in 1/ 2 hr rh heart nao lung nuOfym nto rate ndiaonaiu idu 200 mL
IV drip in 10-15 min

- IV fluid arhOuarlanlcncmunaiunuR NSS, RLS, Acetar > laulaniiou chronic

liver disease IUROOHUU RLS (luaoomRuiJ defect nrn Cori' s cycle MR)

3.2 naunwulRoaoaomna hypovolemic shock donamunoaniQu hemorrhagic nuaun

Md hemorrhagic
auniOu hemorrhagic shock nno bleeding iuu:iina: aauRaauORiUaanRiRfiauaidR
HOOTU nidR tonRnoouuriau uaoUouuutolRdi source uao bleeding ayntou
lamuu common7 fiau n Gl bleed luuruna: > RlUiaufl5U NG , larvage, PR >
tb:DutoTaaiTHdaiaoa:iilu variceal hSa non variceal bleeding R > fhiClu bleed
uanomo:to IV fluid uao athauoaoiaaR R coagto PPI, consult med (Gl) hoanauRDu
(uaoiicin)
niHaamlciibrlb luidu hematuria, intraperitoneal bleeding, retroperitoneal bleeding
'

(5:00 rupture AAA BflOUUrFVSU UUTlOrOd ward med hOOHuIunlQ heparin/ warfarin n
incn retroperitoneal bleeding IQI50U7 R 5U)

da o lloomouo

uuorlu drop nauuonumou Qouuniihu
loan acute bleeding m Hct

bleeding nnocnoo resuscitate iauo omlUaufom initial Hct

naunMd hemorrhagic shock nauuunom source dniou idu diarrhea, polyuria, fistula
loss duunlhUicnuTUiau > uciorumonaunmn idu acute pancreatitis nauuanOu
fluid ooUIudoonoo nauuncnooMuiiMuounu (laan RLS iilunan)

3.3 naunwuIcvsooaolUon no distributive shock nluld septic shcok duuncnDoaonaiu

aiumlnub
1) Adrenal insufficiency [Runoldunorluldiiuo anorexia naula/ onouu cnoch > uciuu
a:(nniJ5:maihmcm Cushingoid appearance uaoFiuuooIuiHU uciiyiuooiKU (mWu)

0i5Ufua:ib:LnainfuiJi uMuonianuou uao BP drop douuUoBnUoRuuoiJonm UociMao

uaodoulUdomunUoRnuioonuaouwaiJuoo steriods
- on category uo unonoofu septic shock n5u dolnai'suiltjiiaoouiouou 30 ua./nn.
oounu vasopressor uao BP luuu nMnemo adrenal insuffiency looou
mid nonmlUiaucbu hydrocortisone 200 mg IV drip in 24 hr nooo:Id hydrocortisone
100 mg IV q 12 hrs

2) Anaphylactic shock norluld setting ER uuunnuinu iiniuooom ward med iQu ward n
famith lamaan Tnumiaonlijnauo (iwm:monncnaoaonuIuTiJ CT uio ultrasound uio w
dent HibunmiUauu order ouimluoioao) > mnoooyiomuuaoioa wheez oounu
wide pulse pressure nlnnonomoiulonounou

rhld nlmioonmnou epinephrine nou (Miunnfio vasopressor cnoaulu anaphylactic

shock)

3) Neurogenic shock > no:Iu!d setting uuu C-spine injury uuunulutu trauma uciOu
Orilluuuu spinal cord disease Ido med idu transverse myelitis hoaluniOuuuu disease lu
brain niauwu phase increase intracranial pressure Iiluao (wu phase Cushing's reflex III
uao)
Olid OIH IV 0 HR 01 HR dl 0 dopamine 01 HR 1530 norepinephrine
4) Drug and toxin rbulHfy 3:i0 uuini5iIa 7 ouiooBciauoaioau iia:ooucrnudocfiiuu:iiHa:
uci BP ui drop oaionu > nwulRuau 7 owao ACEI , ARB , nitrate , direct vasodilator
( hydralazine) > uuii5OQO 0 uu:n 5 u:)i shock ( poor tissue perfusion ) 5idai oildofiau
manage Id

3.4 lOunaunwulRuauaoIdan iiouoi 55ouiniawi:mo7 oauuiiluoau obstructive shock

R 5 u lai 3 Bnnwulouat > Bnoauu JVP aoHuo

1) Tension pneumothorax
^ > aauIhfyuoiOQOunun on ventilator Cold PEEP iua:7
cnaoncifiooia:ulhuio > orncnun 50 w. u . Id cn 5335iooiu Wo lung decrease breath
sound ini:UacilRiOu hyperresonance ( naiuuioa:0 dlu case COPD doo decrease breath
sound iia:o [ m:UaciI(nTU 500 duaa )

oild 0 needle thoracentesis uauiodiaucnucBu ICD iaua 5:haiouoMuiIdRauR 5U

2) Pulmonary embolism ( PE) > iilubnnoiIijRR tial IOIB oa: Dxldriaulo > cnao
otu setting n BP drop , 02 sat drop ( cnaoiOu 02 sat drop fiau BP drop R 0 UU:R 5U ) , lung
clear

oincifio 0131 EKG ui run louwau Ml evidence U 30 acute RV pressure overload riOHaiu
idu RBBB, S1Q3T3 pattern > 5:H 310 UO load uildfiau lia:0 WU1U1U confirm Dx jlillu

PE M5alu 033015111 CT chest

Id 05rufi53iiLlu PE uaa d 0 Rfuwi500 thrombohtics H50 surgery

5:H 3ioutii IV fluid
(05runlM thrombolytic Idle )

3) Cardiac tamponade > setting lu ward med 3:ood 5:uim CA nu metastasis M 50

oau hematologic malignancy > Q 5335ioniuIuR 0 uIo 0 uiauoM 3b (distant heart
sound) olio setting uuuu OMI EKG uirnlouwau > lao electrical alternates ( iQu
QRS aocnauo iciuoauo aauould doiOuwaaio swinging heart)
> ua :nq CXR oau aia
lo globular heart shape
5:M 310 UIM IV fluid Id d 0 RfUWi500 echo ou pericardiocentesis

3.5 nauniOu cardiogenic shock nUTd left side

1) Inferior wall Ml fhiaa ST elevation fu lead II, III, aVF Iii aolariauyiu RV infarction 5
^
lUai IhldhOu EKG mrn lead V3 R , V4R Itriuwau > mu ST elevation niOu RV
infarction luuuina: > rh BP drop nIhLnlUriouiwol!fiiao (nuuItJmuaiuI(7i

2) nauniQu arrhythmia > faunari cardiac arrhythmia mrasuiu shock IQ FiD5U

HR > 150/min hSa HR < 50/ min OyludDO 50-150/min liutru
> nmin HR
arrhythmia omiwolnuhi arrhythmia uuiOuanHcnuao shock im5u Imjooamhcnauriau
I 1

laua

3) nauniQu severe metabolic acidosis mn7 na cna H+ uua:uqnnQm5mo3uaaohak>

(myocardial supressant) amiOu cardiogenic shock naiU7 uoifiimu uua:mMifi(ri
systemic vasodilatationI(7iuin cfau > mssnun n nmaimci aiaM 7.5% NaHC03
7 ^
danmalQ amauRRnofSao dialysis QDU
-> riauM 7.5% NaHC03 Qhauu:n5uai calcium
u
(
^
fnSitJai iwrum H 7.5% NaHC03 a:
induce Tnificn alkalosis 3oa:nw!h bound form iua:du aauuao free form a:a (nao >
ina severe hypocalcemia IQ

4) Hypocalcemia nauua:naiu7 severe metabolic acidosis n5u Fia u myocardial

supression saunu systemic vasodilataion > wanuarintalu shock nlQiaatniua
(massive blood transfusion), acute pancreatitis, high dose vasopressor, shock lu cell
^
lysis (tutor lysis syndrome, rhabdomyolysis)

-> aaorn EKG Rfiau maid QT prolongation aauuao ST segment naald (cvsonu phase
2 uao action potential waa) uaanm: calcium Id
-> aa Tucnaomu-saaorn Chvostek' s sign (aiu^ Q tube wiRLncnao facial nerve waQ) aau
Trosseaus sign nldcnaoumau RuIuFioIduuaomifiR carpopedal spasm
-> rmcnaild nuan 10% calcium gluconate Id

4. anmldncnao monitor Idumau

UIU7 riauncnaoaFi BP Fiau uolu shock imaci BP nn 10 mnltriuhan (mucnaumaiaQrin 1

du. u:R 5u nuIucnuwaQ)
Q HR R 5u > rhmtoaiaih iiaanuIumauauaoQ HR ataao
 > mlhuilUbat acao uUaai fluid leak ithlUluUaR
Q 02 sat R 5U
V/ Q mismatch > acunau crystalloids
^ uao aiaanUauuTUfd
02 sat

colloids hSa vasopressor

inc

nta

aniumaaiiai
-
Wo lung QTIU crepitation nSalu laaiWoiiRdiuiJaR aiaarhjwaurR su cnaoaatn steth Id
QiuMaouaonuIu iwairuiardauauirSiaoiu u

(CXR , ABG Riunao)

Lab ncilU nan7 U5:umj CBC, BUN/ Cr, E'lvte > naruaoau Die naowan PT, PTT cau
131 PBS uiecnaunenau (m MAHA blood picture) > refractory shock 111117 DUiauci
Ca taau

Urine output Rcfauailcn 0.5 mL/ kg/hr mbniOuQuRhuiunc

Lactate lairlcnniai: target lainuaunai 2 mmol/ L (hSaiai lactate clearance > 10%) >
rnluuthiai: ne wide AG metabolic acidiosis, pH > fhluunR urine output aulU

===> ni BPluuu noaQuouua:i5uooai iiaaui3:lUmolHU DnioiaonoanuiUa:maiun5u

1

1) ncrmayiomulHij muouuIaluni R aamomuaaocnaiaoay nlhuicnuwacnaaaaiomu

^ ^
uu

2) niluuulalumaciaaaaiomauoocnaioo acium monitoring dau iiaaiiciaia:naio:bI(ririou

- IVC ultrasound Uaauuuuuldnuiuormn Iduaniaao fluid responsive test utimnloTu
auauQuinun > mmuauauRaiuiaiiaoriau

- Central line insertion lOuasROiRU utrinlRRi CVP n accurate Ua:uiaiuo iitriai !!!!!!! riau
laaiu central line nihaaucnoiwan platelet, coag URUOU:R 5U mlubaancnaoiaiuiliiriau
laaiu central line (inRURUaauuIdiLlu ultrasound guide)
====>
^
ailaiauaai CVP RURUU TuIt duanaiuidiR uaauiinu ucri trend uao CVP a:dau
uanaiiTiRa lUnioIhu ( tn load hSatn restrict)
^
: ta central line iaaa auiauWo lung nriRao (Lidia: pneumothorax haa hemothorax)
uarniRulUiuuuIu portable CXR 3307 amoamrin (cnaocicniiihuoaiu central line ciauu:
aianLSiUai cnaoc complication nuanlUuaacfau)

nirnlRRiuu uarmuiufyaioRoiu7 3 n *
da . :
1.uaMfiuau
2. ucinriaoIaaniiMa: iQu extern iQuaunamfeTuTfluaunairiinu "
i
Idm 3iK5unnnun
3 UD5U:
U