Approach to a patient with Shock

Approach to a patient with Shock

Contact email: [email protected]

Learning Outcomes

• Define shock• Understand the importance of early recognition of shock• List the causes of shock • Understand the body compensation mechanism• Assess the patient using the ABCDE approach• Identify and treat the different types of shock

SHOCK

• Clinical syndrome resulting from inadequate delivery, or use, of oxygen by vital organs. Inadequate delivery of oxygen to vital tissue

• Shock is reviewed as momentary pause to death

• Shock is diagnosed by Pulse Rate, pulse character, Respiratory Rate, skin perfusion and Pulse pressure (difference bet systolic and diastolic Blood pressure)

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SHOCK

Preload Pump Afterload

SHOCK

Preload

Hypovolaemic Obstructed Venous Return

Pump

Cardiogenic

Afterload

Distributive

SHOCK

Preload

Hypovolaemic

Blood lossPlasma loss

Inadequate intakeApparent loss (venodilators,

Hyponatraemia)

Obstructed Venous Return

PregnancyPE

Cardiac temponadeAcute asthma

Tension PneumothoraxHigh mean airway pressure

(High PPV)

Pump

Cardiogenic

MyocardialEndocardialEpicardial

Afterload

Distributive

SepticAnaphylaticNeurogenic

Spinaltoxaemia

Spinal Vs. Neurogenic Shock

Spinal Shock Neurogenic Shock

Definition Immediate temporary loss of total power, sensation and reflexes below the level of injury

Sudden loss of the sympathetic nervous system signals

BP Hypotension Hypotension

Pulse Bradycardia Bradycardia

Bulbocavernosus reflex Absent Variable

Motor Flaccid paralysis Variable

Time 48-72 hrs immediate after SCI

Mechanism Peripheral neurons become temporarilyunresponsive to brain stimuli

Disruption of autonomic pathways -> loss of sympathetic tone and vasodilation

Approach to sick patientA Talk to the patient +/_ airway manoeuvre

+/_ airway adjunctsnebuliser

B RR, SatsInspection, palpation, percussion, auscultation

+/_ 100% O2Needle aspiration for tension Pneumothorax

C BP, PR, JVP, CR, UO, TempListen to the heartAbdo examination

+/_ IV cannulae+/_ Taking bloods+/_ fluids

D AVPU, Pupil, BM, Pain +/_ air way+/_ glucose+/_ analgesia

E Abdo exam, Head to Toe , environment

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Shock

Hypovolaemic

Narrow pulse pressure

Cold, pale, thready pulses

Obstructive



Cardiogenic



Distributive

Wide pulse pressure

Warm, pink, bounding

pulses in sepsis

Distributive Shock

Septic

Gradual onset

Anaphylatic

Acuteonset

Neurogenic

Acute onset

Distributive Shock

Septic

Gradual onset

Low BPHigh PR

Anaphylatic

Acuteonset

Low BPHigh PR

Neurogenic

Acute onset

Low BPLow PR

Management of Neurogenic shock

•ABCDE•Vasopressor•Atrophine• Spinal team input

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Shock

Hypovolaemic



May or may not response to first

bag of fluids

Obstructive




bag of fluids

Cardiogenic



May get worse after first bag

Distributive

Wide pulse pressure

Warm, pink, bounding pulses

in sepsis


bag of fluids

Management of cardiogenic shock

•ABCDE• Stop IV fluids• Inotropes

SHOCK

Preload

Hypovolaemic



Hyponatraemia)


PregnancyPE


Tension PneumothoraxHigh mean airway pressure

(High PPV)

Pump

Cardiogenic


Afterload

Distributive


Spinaltoxaemia

Management of Hypovolaemic shock

•ABCDE •RRR•Resuscitation•Replacement of the loss•Removal of the cause

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Total Body Water ~ 45L

Intracellular Fluid ~ 30L Extracellular Fluid ~ 15L

Interstitial fluid ~ 10L

Plasma ~ 5L

Prevention of Hypovolaemic shock

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SHOCK

Preload

Hypovolaemic



Hyponatraemia)


PregnancyPE


Tension Pneumothorax

Pump

Cardiogenic


Afterload

Distributive


Management of Septic Shock

• ABCDE

•SEPTIC SIX

• 3 in 3 out

Management of Anaphylatic shock

• ABCDE

•1, 10, 100, 1000, AAA• 1:1000 Adrenaline, IM injection, every 3-5 minutes• 10mg antihistamine• 100mg hydrocortisone

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5th Floor, Tavistock House North, Tavistock Square, London WC1H 9HR Telephone (020) 7388-4678 • Fax (020) 7383-0773 • Email [email protected] www.resus.org.uk • Registered Charity No. 286360

Resuscitation Council (UK)

Anaphylaxis algorithm

March2008

When skills and equipment available: • Establish airway • High flow oxygen Monitor: • IV fluid challenge 3 • Pulse oximetry • Chlorphenamine 4 • ECG • Hydrocortisone 5 • Blood pressure

Adrenaline 2

• Call for help • Lie patient flat • Raise patient’s legs

Diagnosis - look for: • Acute onset of illness • Life-threatening Airway and/or Breathing and/or Circulation problems 1 • And usually skin changes

Airway, Breathing, Circulation, Disability, Exposure

Anaphylactic reaction?

1 Life-threatening problems: Airway: swelling, hoarseness, stridor Breathing: rapid breathing, wheeze, fatigue, cyanosis, SpO2 < 92%, confusion Circulation: pale, clammy, low blood pressure, faintness, drowsy/coma

3 IV fluid challenge: Adult - 500 – 1000 mL Child - crystalloid 20 mL/kg Stop IV colloid if this might be the cause of anaphylaxis

4 Chlorphenamine 5 Hydrocortisone (IM or slow IV) (IM or slow IV) Adult or child more than 12 years 10 mg 200 mg Child 6 - 12 years 5 mg 100 mg Child 6 months to 6 years 2.5 mg 50 mg Child less than 6 months 250 micrograms/kg 25 mg

2 Adrenaline (give IM unless experienced with IV adrenaline) IM doses of 1:1000 adrenaline (repeat after 5 min if no better) • Adult 500 micrograms IM (0.5 mL) • Child more than 12 years: 500 micrograms IM (0.5 mL) • Child 6 -12 years: 300 micrograms IM (0.3 mL) • Child less than 6 years: 150 micrograms IM (0.15 mL) Adrenaline IV to be given only by experienced specialists Titrate: Adults 50 micrograms; Children 1 microgram/kg

SHOCK

Preload

Hypovolaemic


Inadequate intake


PregnancyPE


Tension Pneumothorax

Pump

Cardiogenic


Afterload

Distributive


Spinal

Learning Outcomes

• Define shock• Understand the importance of early recognition of shock• List the causes of shock • Understand the body compensation mechanism• Assess the patient using the ABCDE approach• Identify and treat the different types of shock

Refrences

● Advanced Life support group, Acute Medical emergencies, The practical approach, second edition, 2010, Blackwell Publishing

● Uptodate.com. 2021. UpToDate. [online] Available at: <https://www.uptodate.com/contents/definition-classification-etiology-and-pathophysiology-of-shock-in-adults

● www.orthobullets.com/spine/2006spinal-cord injuries● Advanced Trauma Life Support, Student Curse manual, Tenth edition,

2018, American College of surgeons

Any Questions

• Thinking about your thinking: double- check to identify/rule out life-threatening causes.

Approach to a patient with Shock

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