Shock

Dr Mike NichollsEmergency Medicine ConsultantAuckland City Hospital2011

Shock

Definition: Inadequate oxygen delivery and utilisation by vital organs due to a problem with the circulation.

Types of shock

Hypovolaemic Distributive Cardiogenic Obstructive

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

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)

Hypovolaemic

Hypovolaemic (blood loss) Get help : surgical emergency call A B C Blood loss :

iv fluids +/- blood+/-Direct pressuresurgery (arrest bleeding)

Distributive

SepsisSepsis AnaphylaxisAnaphylaxis Neurogenic

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

Distributive Management

Distributive Sepsis :

IV antibiotics, iv fluids, IV inotropes (ARISE trial)

Anaphylaxis : IM adrenaline, iv fluids, steroids, antihistamines

Cardiogenic

ArrhythmiaArrhythmia Primary pump problemPrimary pump problem Valve problem (acute)

Cardiogenic Management

Cardiogenic (iv fluid) Tachyarrythmia : DC/chemical cardioversion Bradyarrythmia : Atropine, pacing Pump problem : Inotropes PCI

Obstructive

PEPE Tension pneumothorax Pericardial tamponade Valvular obstruction

Obstructive PE : heparin, fibrinolytic Tension pneumothorax : Needle decompression Pericardial effusion : Pericardiocentesis

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)

But…

Beware…young people Elderly Pregnant Those on beta blockers

Remember the observations!