Shock management

Description

Critical illness Mind Map on Shock management, created by greenfylde on 01/12/2013.
greenfylde
Mind Map by greenfylde, updated more than 1 year ago
greenfylde
Created by greenfylde about 11 years ago
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Resource summary

Shock management
  1. essence
    1. circ fialure -> inadquate organ perfusion
      1. generally systolic BP <90mm Hg
      2. signs
        1. pallor, pulse up, cap return down (press nailbed), air hunger, oliguria (put catheter in)
        2. cause
          1. pump fail
            1. cardiogenic shock
            2. periph circ fail
              1. hypovolemia
                1. hemorrhage
                  1. trauma, rupture AAA, ruptured ectopic pregnancy
                  2. most common cuase + reversible
                    1. fluid loss
                      1. vomiting (eg GI obstruction), diarrhea (eg cholera), burns, pools of sequestered fluids ('third spacing' eg in pancreatitis)
                      2. heat exhaustion
                        1. 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
                        2. TREATMENT
                          1. fluid replacement
                            1. 0.9% saline or colloid initially. If bleeding, use blood (also if exsanguinating, severe hemm or >1L of fluid req to maintain BP)
                            2. treat underlying cause
                              1. correct electrolyte abnorms (acidosis often responds to fluid replace)
                            3. anaphylaxis
                              1. type-1 IgE mediated hypersensitivity reaction
                                1. release of histamine + other agents -> capillary leak; wheeze; cyanosis; edema; (larynx, lids, tongue, lips); urticaria
                                  1. more common in atopic ppl
                                  2. precipitants
                                    1. drugs, (eg penicillin, contrast media), latex, stings, eggs, fish, peanuts, strawberries, semen (rare)
                                  3. signs/symps
                                    1. itching, sweating, diarreha + vomiting, erythema, urticaria, edema; wheeze, laryngeal obstruction, cyanosis, tachycardia, hypotension
                                  4. sepsis

                                    Annotations:

                                    • 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
                                    1. manage
                                      1. give abx w/in 1hr (preferably after blood culture)
                                        1. 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
                                        2. give colloid or crystalloid by IVI. refer to ITu if poss for monitoring +/- inotropes
                                          1. Aim for CVP 8-12 mmHg, mean pressure >65 mmHg, urine >35ml?h
                                            1. low dose steroids may help if hypotensive despite fluids + vasopressors as may recombinant human-activated prot C
                                        3. SIRS def (click on me)

                                          Annotations:

                                          • SIRS- involving cytokine cascades. free radical production + the release of vasoactive mediators. defined as  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
                                        4. neurogenic
                                          1. endocrine failure
                                            1. iatrogenic
                                          2. assessment
                                            1. ABC
                                              1. ECG rate rhythm ischemia
                                                1. General
                                                  1. cold, coamm? -> cardiogenic or fluid loss
                                                    1. signs of anemai or dehyd? (eg skin turgor, postural hypotens)
                                                      1. warm + well perfused w/bounding pulse? -> septic shock (or other vasodilat)
                                                      2. 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
                                                        1. JVP or central venous pressure- if up, cardiogenic shock likely
                                                        2. check abdo: any signs trauma or AAA? ev of GI bleed? check for melena
                                                        3. manage (general)
                                                          1. flowchart
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