Shock management

Shock management

1. essence

   • circ fialure -> inadquate organ perfusion
   • generally systolic BP <90mm Hg

2. signs

   • pallor, pulse up, cap return down (press nailbed), air hunger, oliguria (put catheter in)

3. cause

   • pump fail
     • cardiogenic shock
   • periph circ fail
     • hypovolemia
       • hemorrhage
         • trauma, rupture AAA, ruptured ectopic pregnancy
       • most common cuase + reversible
       • fluid loss
         • vomiting (eg GI obstruction), diarrhea (eg cholera), burns, pools of sequestered fluids ('third spacing' eg in pancreatitis)
       • heat exhaustion
         • treat w/ tepid sponging + fanning (avoid ice and immersion); reusc w/high sodium lvl (such as 0.9% saline +/- hydrocorisone 100mg IV); stop cooling when T <39
       • TREATMENT
         • fluid replacement
           • 0.9% saline or colloid initially. If bleeding, use blood (also if exsanguinating, severe hemm or >1L of fluid req to maintain BP)
         • treat underlying cause
         • correct electrolyte abnorms (acidosis often responds to fluid replace)
     • anaphylaxis
       • type-1 IgE mediated hypersensitivity reaction
         • release of histamine + other agents -> capillary leak; wheeze; cyanosis; edema; (larynx, lids, tongue, lips); urticaria
           • more common in atopic ppl
         • precipitants
           • drugs, (eg penicillin, contrast media), latex, stings, eggs, fish, peanuts, strawberries, semen (rare)
       • signs/symps
         • itching, sweating, diarreha + vomiting, erythema, urticaria, edema; wheeze, laryngeal obstruction, cyanosis, tachycardia, hypotension
     • sepsis
       • septic shock from endotoxin-induced vasodilat may be SUDDEN and SEVERE with shock + coma but no signs of infection (fever, WCC up)
       • sepsis: SIRS occuring in presence of infection severe sepsis: sepsis w/evidence of organ hypoperfusion eg hypoxemia, oliguria, lactic acidosis, or altered cerebral function septic shock: severe sepsis w/hypotension (systolic &lt;90mmHg) despite adequate fluid resusc or the req for vasopressors/inotropes to maintain BP
       • manage
         • give abx w/in 1hr (preferably after blood culture)
           • if no clue to source, give IV co-amoxiclav 1.2g/18h or merpenem 1g/8h, or gentamicin (do lvls, reduce in renal fail) + antipseudomonal penicillin
         • give colloid or crystalloid by IVI. refer to ITu if poss for monitoring +/- inotropes
           • Aim for CVP 8-12 mmHg, mean pressure >65 mmHg, urine >35ml?h
             • low dose steroids may help if hypotensive despite fluids + vasopressors as may recombinant human-activated prot C
       • SIRS def (click on me)
         • SIRS- involving cytokine cascades. free radical production + the release of vasoactive mediators. defined as&nbsp; T &gt;38 or &lt;36 Tachycardia &gt;90bpm RR &gt;20breaths/min or PaCO2 &lt;4.3 kPa WBC &gt;12x10^9/L or &lt;4x10^9/L or &gt;10% immature forms
     • neurogenic
     • endocrine failure
     • iatrogenic

4. assessment

   • ABC
   • ECG rate rhythm ischemia
   • General
     • cold, coamm? -> cardiogenic or fluid loss
     • signs of anemai or dehyd? (eg skin turgor, postural hypotens)
     • warm + well perfused w/bounding pulse? -> septic shock (or other vasodilat)
   • CVS- usually tachyardic (unless on B-blocker or in spinal shock) and hypotensive (but in young + fit or preg, systolic BP may stay normal, although PULSE PRESSURE will narrow, with up to 30% blood vol depletion. Difference btw arms >20mmHg- aortic dissect
     • JVP or central venous pressure- if up, cardiogenic shock likely
   • check abdo: any signs trauma or AAA? ev of GI bleed? check for melena

5. manage (general)

   • flowchart

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