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Shock
Dr Mike NichollsEmergency Medicine ConsultantAuckland City Hospital2011
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Shock
Definition: Inadequate oxygen delivery and utilisation by vital organs due to a problem with the circulation.
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Types of shock
Hypovolaemic Distributive Cardiogenic Obstructive
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Shock…look at the observations
Usually can be recognized by the observationsobservations and peripheral circulation
Classic obs are Tachycardic (>90bpm), Hypotensive (<90-100mmHg),
Shock index (pulse/systolic BP) >1 Others
Tachypnoeic Confused
Classic peripheral circulation would be delayed capillary refill and cool peripheries
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What can be done?
Oxygen IV access x2 large bore Fluid bolus…
0.9%saline…at least 1000ml. Usually significantly more than this.
When concerned re CCF, can try 500ml bolus at first (or 250ml if very concerned)
Observe responseObserve response Consider
urinary catheter (further monitoring and obtain sample) Placement : monitoring, resus
Specific treatment (depends on the cause)
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Hypovolaemic
Hypovolaemic (blood loss) Get help : surgical emergency call A B C Blood loss :
iv fluids +/- blood+/-Direct pressuresurgery (arrest bleeding)
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Distributive
SepsisSepsis AnaphylaxisAnaphylaxis Neurogenic
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Sepsis
Sepsis = 2 or more SIRS criteria + suspected or proven infection (1992)
SIRSTemperature >38°C or <36°C Heart rate > 90 beats/min Respiratory rate > 20 breaths/min or PaCO2 <32
torr (<4.3kPa) WBC > 12.000 cells/mm3, <4.000 cells/mm3, or
>10% immature (band)forms
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Distributive Management
Distributive Sepsis :
IV antibiotics, iv fluids, IV inotropes (ARISE trial)
Anaphylaxis : IM adrenaline, iv fluids, steroids, antihistamines
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Cardiogenic
ArrhythmiaArrhythmia Primary pump problemPrimary pump problem Valve problem (acute)
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Cardiogenic Management
Cardiogenic (iv fluid) Tachyarrythmia : DC/chemical cardioversion Bradyarrythmia : Atropine, pacing Pump problem : Inotropes PCI
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Obstructive
PEPE Tension pneumothorax Pericardial tamponade Valvular obstruction
Obstructive PE : heparin, fibrinolytic Tension pneumothorax : Needle decompression Pericardial effusion : Pericardiocentesis
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Shock : What can be done? Summary
Oxygen IV access x2 large bore Fluid bolus…
0.9%saline…at least 1000ml. Usually significantly more than this.
When concern re CCF, can try 500ml bolus at first (or 250ml if very concerned)
Observe responseObserve response Consider
urinary catheter (further monitoring and obtain sample) Placement : monitoring, resus
Specific treatment (depends on the cause)
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But…
Beware…young people Elderly Pregnant Those on beta blockers
Remember the observations!