Shock

Dr Mike Nicholls
Emergency Medicine Consultant
Auckland City Hospital
2011
Shock

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

Hypovolaemic
Distributive
Cardiogenic
Obstructive
Shocklook at the observations
Usually can be recognized by the observations 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%salineat least 1000ml. Usually significantly more than
this.
When concerned re CCF, can try 500ml bolus at first (or
250ml if very concerned)
Observe 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 pressure
surgery (arrest bleeding)



Distributive

Sepsis
Anaphylaxis
Neurogenic

Sepsis
Sepsis = 2 or more SIRS criteria + suspected or
proven infection (1992)

SIRS
Temperature >38C or <36C
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

Arrhythmia
Primary pump problem
Valve problem (acute)

Cardiogenic Management

Cardiogenic
(iv fluid)
Tachyarrythmia : DC/chemical cardioversion
Bradyarrythmia : Atropine, pacing
Pump problem : Inotropes
PCI
Obstructive
PE
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%salineat least 1000ml. Usually significantly more than
this.
When concern re CCF, can try 500ml bolus at first (or 250ml if
very concerned)
Observe response
Consider
urinary catheter (further monitoring and obtain sample)
Placement : monitoring, resus
Specific treatment (depends on the cause)

But
Bewareyoung people
Elderly
Pregnant
Those on beta blockers


Remember the observations!