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The goal for the patient in shock is rapidly identifying that the patient is in shock, finding the cause of shock and treating the cause while simultaneously resuscitating the patient.

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Read Also : Approach to Undifferentiated Shock

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Clinical Presentation

• Ill appearing/AMS
• Tachycardia
• Hypotension
• Met acidosis (lactate>4 mg/dl or Base def <-5)
• Tachypnea (RR>22 or PCO2<32)
• Oliguria: UOP<0.5 ml/kg/h
• Base deficit, lactate and sublingual capnometry (SLCO2) can help identify patients in early shock and are a predictor of mortality

Resuscitation

• ABCs
• IV/O2/Cardiac monitor
• Foley
• Crystalloids
  • 20ml/kg boluses
  • Caution in CLOCK (CNS, Liver, Older, Children, Kidney disease)
• Antibiotics empirically
• Blood (before Pressors)
• Vasopressors (from α→β: PNEDDI)
  • Phenylephrine
  • Norepinephrine
  • Epinephrine
  • Dopamine
  • Dobutamine
  • Isoproterenol

Causes and Classification of Shock

• Hypovolemic ( Low CVP (Central Venous Pressure), Low CI (Cardiac index), High SVR (systemic vascular resistance) )
  • Volume depletion type
    • Vomiting/Diarrhea, Heat stroke, Burns, decreased intake
    • 3rd Spacing – Pancreatitis, Burns
  • Hemorrhagic type
    • GI bleed/Vaginal bleed
    • AAA rupture/Dissection
    • Trauma

• Cardiogenic (High CVP, Low CI-cardiac index, High SVR)
  • Cardiomyopathy
    • MI/Ischemia
  • Arrhythmias
    • Tachy (AF/VT), Slow (Brady, blocks)
  • Mechanical
    • Valve defect, atrial myxoma, ruptured ventricular aneurysm
  • Obstructive
    • Massive PE, tension PTX, constrictive pericarditis, cardiac tamponade,
  • pulmonary HTN

• Distributive (Low CVP, High CI, Low SVR)
  • Sepsis/SIRS
  • Anaphylaxis, Toxic shock
  • Drugs
  • Addisonian crisis
  • Myxedema coma
  • Neurogenic shock

Assesment of Shock

• Correct emergent and reversible causes
  • Tension PTX → needle thoracostomy
  • Cardiac tamponade → pericardiocentesis/thoracotomy
  • Arrhythmia → shock

• Vital signs
  • Shock index: HR (Heart Rate)/SBP (Systolic Blood Pressure) > 0.9 abnormal
  • SIRS: HR>90; RR>20; Temp<36 or >38; WBC<4 or >12 (>10% bands); PaCO2 <32

• Pediatrics assessment
  • Pediatric assessment triangle
    • Work of breathing
    • General appearance
    • Circulation to skin

• RUSH protocol for sonography (Read more about RUSH Exam)
  • The Pump: Pericardial effusion, LV contractility, RV strain
  • The Tank: IVC/Jugular vein fullness, FAST, Lung (PTX, Pleural fluid, B lines)
  • The Pipes: AAA, Ao Dissection, DVT