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 5-10g/kg/min
o
IV dobutamine 5-10g/kg/min (esp for cardiogenic shock)
o
IV norepinephrine 5-20g/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
Swimmers 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

0.5ml if 50-65kg; 0.6ml if >65kg)

o
Convert to Oral warfarin later
Thrombolysis
o
Intra pul. 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. Line
Cardiac

IV fluid bolus 500ml N/S

DGIM Last updated March 2005
Septic Shock
tamponade

IV dopamine infusion 5g/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, <4000/mm3,or >10% immature forms

U/E/Cr
Hx / PE

Identify site of infxn UTI (indwelling cathether), gallbladder dz, peritonitis,

DIVC screen (D-dimer)

pneumonia, appendicitis, immunocompromised state

ABG
Invx

FBC - TW
o
PaO2 & N/ PaCO2

U/E/Cr
o
widened alveolo-arterial P02 gradient (AaPO2 >20mmHg)

DIVC screen PT/PTT, pltlet, fibrinogen, 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, 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, pericarditis

if no response to fluid Rx

CXR (may be normal)

Inotropic
o
Westermark sign oligaemic lung fields
support

Noradrenaline (drug of choice) - 1g/kg/min OR

o
Pul infarcts wedge shape opacities w apex pointing

Dopamin 5-20g/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. arteries

Quinolone
o
Exclude DDxes pneumothorax, pneumonia, L heart

PLUS aminoglycoside (Gentamicin

failure, tumour, rib #, massive pleural effusion, lobar
80mg)
collapse
Gram-positive (burns, FB / lines

IV cefazolin 2g

Spiral CT, Echo, MRI, lung scintigraphy, pulmonary angiogram (gold std)
present)

IV vancomycin 1g if hx of IVDA,
indwelling cath. Or penicillin allergy
Rx
Anaerobic source (intra-abdo,

IV metronidazole 500mg + ceftriazone

Pain relieve use Opioids with caution

biliary, female genital tract,
1g + IV gentamicin 80mg

Fluid Rx & inotropic support if haemodynamically unstable

aspiration pneumonia)

Anticoagulation Rx:
o
IV heparin 5000U bolus or SC fraxiparine (0.4ml if <50kg;

DGIM Last updated March 2005

Anaphylactic Shock
Definitions

Urticaria oedematous & pruritic plaques w pale centre & raised edges

Angioedema oedema of deeper layers of the skin. Non-pruritic. May be a/w numbness & pain

Anaphylaxis severe systemic allergic rxn to an Ag. Ppt by abrupt release of chemical
mediators in a previously sensitized patient

Anaphylactoid rxn resembles anaphylactic rxn, but due to direct histamine release from mast
cells w/o need for prior sensitization
Common causes

Drugs penicililns & NSAIDS commonest, aspirin, TCM, sulpha drugs

Food shellfish, egg white, peanuts

Venoms bees, wasps, hornets

Environment dust, pollen

Infections EBV, HBV, coxsackie virus, 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 Hartmans or N/S bolus

Drug Rx
Adrenaline

Normotensive 0.01ml/kg (max 0.5ml) 1:1000 dilution

SC/IM

Hypotensive 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, pregnancy, -blocker
use

0.5-1.0mg IV/IM. 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, q 6hr

DGIM Last updated March 2005