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Shock (Clinical presentation (Hypotension (SBP <90), Tachypnoea,…
Shock
Clinical presentation
Hypotension
(SBP <90)
Tachypnoea
Pale/flushed
Cool/warm peripheries
Reduced UO
Altered conciousness
Tachycardia
Aetiology
1. Hypovolemia
Blood loss
Trauma
GI bleed
Ruptured AAA
Ruptured ectopic
Third space loss/redistribution
Pancreatitis
Sepsis
Burns
GI losses (vomit, diarrhoea)
2. Cardiogenic
Primary
MI
Arrhythmia
Valve disease
Myocarditis
Secondary
Tamponade
PE
Tension pneumothorax
3. Septic
Infection
Bacteria, fungi
4. Anaphylactic
5. Neurogenic
6. Other
Posioning
Addison's
Pathophysiology
Compensatory failure
ATP depletion in cells, lactoc acidosis
Cardiovascular insufficiency
Cardiac failure, resp failure, renal failure
DOC and widespread organ failure
Autonomic responses
SNS and RAAS activation
Vasoconstriction increases preload and SV
Heart rate increases to increase SV
Na and water retention to increase BP
Types
Hypovolemic: loss of intravascular fluid
Cardiogenic: pump failure
Peripheral circulation failure (sepsis, anaphylaxis, neurogenic)
Diagnosis
Examination
Resp exam
Pallor, cool/warm peripheries,
any crackles on the chest,
stridor, wheezing (anaphylaxis)
Abdo exam
Pallor, cool/warm peripheries,
tenderness/guarding etc,
Cardio exam
Pallor, cool/warm peripheries, tachycardia, tachypnoea,
any new heart sounds, bounding pulse (septic),
raised JVP, oedema (cardiogenic)
Neuro exam
GCS, confusion etc.,
sezirures, focal signs
Investigations
Bedside
Obs (tachycardia, tachypnoea, may have fever if warm septic, hypotension [low DBP=vasodilatation i.e. sepsis/anaphylaxis; narrow pulse pressure = vasoconstriction i.e. hypovol/cardio],
ECG (cardiac cause)
Bloods
ABG (lactate, metabolic acidosis), FBC (infection, anaemia),
CRP (infection), U+E (renal failure), LFT (liver disease),
clotting, glucose, group and save/crossmatch (if hypovolemic)
Blood cultures (if septic)
Urine
Dipstick, MCS (?sepsis)
Catheterise (low UO)
Imaging
FAST scan (blood loss)
CXR (tamponade, pneumonia etc.)
MRI head (encephalitis, meningitis)
History
DH
Current meds, allergies
FH
Cardiac disease, other conditions
PMH
Heart disease, known medical conditions,
previous surgeries
SH
Living arrangements, occupation,
smoking, alcohol, drugs
PC/HPC
Trauma, infection, collapse etc.
pain anywhere (chest, abdo), SOB, toxins
Management
Initial ABCDE
Definitive
Surgical
Laparotomy
Indication: AAA, spleen/liver trauma,
ruptured ectopic, abdo sepsis etc.
Cardiac surgery
(valve dysfunction)
Conservative
Information, advice, support
Senior/ITU help (monitoring, inotropes, ventilation)
Identify cause
Medical
Antidotes
Indication: posioning
Thrombolysis/angio
Indication: MI, PE
Antibiotics
Indication: septic shock
E.g. empirical if source unclear,
Pericardiocentresis
Indication: tamponade
Definition
Clinical syndrome characterised by
global failure to adequately perfuse and
oxygenate the vital organs of the body,
resulting in metabolic acidosis