Acute Medicine: Shock Hypovolaemic Shock

Definition – inadequate tissue and organ perfusion leading to a hypoperfusion state & eventual Invxs  FBC - Hct in acute alcoholic binge due to diuresis. Hct is an Inaccurate
cellular hypoxia and its attendant sequelae. marker of bld loss acutely.
 GXM 6 units
S/S: Hypotension, urine output, tachycardia, diaphoresis, AMS  U/E/Cr
 Troponin T & Cardiac enzymes
 Coagulation profile with DIVC screen (PT/PTT, pltlet, D-dimer)
Types of Shock  ABG – metab acidosis, lactate, base deficits are poor Px factors
‘White’ shock ‘Red’ shock  UPT - ?ectopic pregnancy? Ask for LMP
Types Hypovolaemic Cardiogenic Neurogenic Septic Anaphylactic  Examine abdomen for pulsatile AAA
Causes Haemorrhage AMI Spinal injury Infxns Fluid Rx  1 L crystalloid fast infusion w/in 1 hr
Burns Dysrhythmia  Assess response
Ruptured ectopic  Subsequent colloid or whole blood infusion
pregnancy  CVP line  Used to guide fluid Rx, esp in CCF patients
Severe GE
Acute pancreatitis
S/S Pallor Pallor Warm skin Fever, rigors Fever, rigors Cardiogenic Shock
Cold clammy skin Cold clammy N/ heart Warm skin Warm skin ECG  Manage accordingly – refer acute coronary syndrome &
peri vas  skin rate Trop T & cardiac enzymes ACLS notes
peri vas  Neuro deficit
Invxs  Hct (late) Cardiac FBC
enzymes Bld C/S Neurogenic Shock
ECG Hx/PE  Trauma – site, mechanism, force
 Neuro exam, DRE – document initial neurological deficits
Also, Obstructive Shock due to tension pneumothorax, cardiac tamponade or pulmonary Immobilize  Immobilize spine in neutral position
embolism Invxs  C-spine X-ray (AP & lat) – ensure visualization up to C7/T1 junction
  Swimmer’s view (visualize C7/T1 jn) & open mouth view (visualize C1/2
Management
injury)
 Thoracic & lumbar spine X-ray (AP & lat)
General Mx
  CT scan
Airway  Maintain airway – consider intubation if necessary
  MRI later
Breathing  100% O2 via non-rebreather mask
Fluid Rx  Titrate fluid resus with urine output
Circulation  2 large bore (14-16G) cannulae
  vasopressors if BP does not respond to fluid challenge
  Inotropic support
 IV methyl  30 mg/kg over 15mins, followed by 5.4mg/kg/h for nxt 23 hrs
o IV dopamine 5-10g/kg/min  Indications – non-penetrating spinal cord injury & w/in 8 hrs of injury
prednisolone
o IV dobutamine 5-10g/kg/min (esp for cardiogenic shock)  Contraindications
o IV norepinephrine 5-20g/kg/min (esp for septic shock) o <13YO
Monitoring  Pulse oximetry o pregnancy
 ECG o mild injury of the cauda equina / nerve root
 BP o abdominal trauma present
 Heart rate o major life-threatening morbidity
 Urine output – catheterize patient
Disposition  Refer Ortho / NeuroSx

DGIM – Last updated March 2005

 o Complete IVC ligation or partial caval interruption
Obstructive Shock
Tension  Decompression: insert 14G cannula over 2nd intercostals space in mid-
Pneumothorax clav. Line Septic Shock
Cardiac  IV fluid bolus 500ml N/S Sepsis =  2 of the following present:
tamponade   IV dopamine infusion 5g/kg/min o Temp >38 or <36oC
 Prepare for pericardiocentesis o HR > 90bpm
Pul Embolism Invx o RR > 20 breaths/min OR PaCO2<32mmHg
 FBC o WCC>12000/mm3, <4000/mm3,or >10% immature forms
 GXM 6 units Hx / PE  Identify site of infxn – UTI (indwelling cathether), gallbladder dz, peritonitis,
 U/E/Cr pneumonia, appendicitis, immunocompromised state
 DIVC screen (D-dimer) Invx  FBC -  TW
 ABG  U/E/Cr
o  PaO2 & N/ PaCO2  DIVC screen – PT/PTT, pltlet, fibrinogen, D-dimer
o widened alveolo-arterial P02 gradient (AaPO2 >20mmHg)  Bld C/S (2 different sites)
 ECG (may be normal)  Capillary bld glucose
o non-specific ST depression & T wave inversion  ABG
o Sinus tachycardia  CXR – pneumonia, ARDS
o Right heart strain  ECG
 Urine dipstick – UTI
 Right axis deviation
 Urine C/S
 Transient RBBB
 T wave inversion in V1-3 Fluid Rx  Rapid infusion 1-2L crystalloids
 P pulmonale   CVP line insertion
 S1Q3T3  Inotropic  if no response to fluid Rx
o Exclude DDxes – MI, pericarditis support  Noradrenaline (drug of choice) - 1g/kg/min OR
 CXR (may be normal)  Dopamin 5-20g/kg/min
o Westermark sign – oligaemic lung fields Empirical ABx Immunocompetent w/o obvious  3rd gen cephalosporin (IV ceftriaxone
o Pul infarcts – wedge shape opacities w apex pointing source 1g) OR
towards the hilum  Quinolones (ciprofloxacin 200mg)
o Atelectasis Immunocompromised w/o  Anti-pseudomonal ABx (IV ceftazidime
o Pleural effusions obvious source 1g) OR
o Raised diaphragm  Quinolone
 PLUS aminoglycoside (Gentamicin
o Consolidation
80mg)
o ‘Plump’ pul. arteries
Gram-positive (burns, FB / lines  IV cefazolin 2g
o Exclude DDxes – pneumothorax, pneumonia, L heart present)  IV vancomycin 1g if hx of IVDA,
failure, tumour, rib #, massive pleural effusion, lobar indwelling cath. Or penicillin allergy
collapse Anaerobic source (intra-abdo,  IV metronidazole 500mg + ceftriazone
  Spiral CT, Echo, MRI, lung scintigraphy, pulmonary angiogram (gold std) biliary, female genital tract, 1g + IV gentamicin 80mg
aspiration pneumonia)
Rx
 Pain relieve – use Opioids with caution
 Fluid Rx & inotropic support if haemodynamically unstable
 Anticoagulation Rx:
o IV heparin 5000U bolus or SC fraxiparine (0.4ml if <50kg;
0.5ml if 50-65kg; 0.6ml if >65kg)
o Convert to Oral warfarin later
  Thrombolysis
o Intra pul. arterial urokinase fro 12-24 hrs
 Surgical

DGIM – Last updated March 2005

Anaphylactic Shock
Definitions
 Urticaria – oedematous & pruritic plaques w pale centre & raised edges
 Angioedema – oedema of deeper layers of the skin. Non-pruritic. May be a/w numbness & pain
 Anaphylaxis – severe systemic allergic rxn to an Ag. Ppt by abrupt release of chemical
mediators in a previously sensitized patient
 Anaphylactoid rxn – resembles anaphylactic rxn, but due to direct histamine release from mast
cells w/o need for prior sensitization

Common causes
 Drugs – penicililns & NSAIDS commonest, aspirin, TCM, sulpha drugs
 Food – shellfish, egg white, peanuts
 Venoms – bees, wasps, hornets
 Environment – dust, pollen
 Infections – EBV, HBV, coxsackie virus, parasites
Stop Pptant  Stop administration of suspected agent / flick out insect stinger with tongue
blade
 Gastric lavage & activated charcoal if drug was ingested
Airway  Prepare for intubation or cricothyroidectomy – ENT/Anaesthesia consult
Fluid Rx  2L Hartman’s or N/S bolus
Drug Rx Adrenaline  Normotensive – 0.01ml/kg (max 0.5ml) 1:1000 dilution
SC/IM
 Hypotensive – 0.1ml/kg (max 5ml) 1:10,000 dilution IV
over 5 mins
Glucagon  Indications: failure of adrenaline Rx OR if adrenaline is
contraindicated eg IHD, severe HPT, pregnancy, -blocker
use
 0.5-1.0mg IV/IM. Can be repeated once after 30mins
Antihistamines  Diphenhydramine 25mg IM/IV
 Chlorpheniramine 10mg IM/IV
 Promethazine 25mg IM/IV
Cimetidine  For persistent symptoms unresponsive to above Rx
 200-400mg IV bolus
Nebulised  for persistent bronchospasm
bronchodilator  Salbutamol 2:2 q20-30mins
Corticosteroids  Hydrocortisone 200-300mg IV bolus, q 6hr

DGIM – Last updated March 2005