Shock resident survival guide: Difference between revisions

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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Complete Diagnostic Approach|Diagnosis]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Complete Diagnostic Approach|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Treatment|Treatment]]
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__NOTOC__
__NOEDITSECTION____NOTOC__
{{CMG}}; {{AE}} [[User:Ahmed Zaghw|Ahmed Zaghw, MBChB.]] [mailto:ahmedzaghw@wikidoc.org]
{{CMG}}; {{AE}} [[User:Ahmed Zaghw|Ahmed Zaghw, MBChB.]] [mailto:ahmedzaghw@wikidoc.org]


==Overview==
==Overview==


[[Shock]] is the syndrome of circulatory failure that results in inadequate cellular [[oxygen]] utilization. The diagnosis of [[shock]] is based on clinical signs (eg, [[altered mental status]], [[oliguria]], [[cool extremities|cold]] and [[clammy skin]]) and biochemical abnormalities (eg, [[hyperlactatemia]]) indicative of [[hypoperfusion|tissue hypoperfusion]].<ref name="Vincent-2013">{{Cite journal | last1 = Vincent | first1 = JL. | last2 = De Backer | first2 = D. | title = Circulatory shock. | journal = N Engl J Med | volume = 369 | issue = 18 | pages = 1726-34 | month = Oct | year = 2013 | doi = 10.1056/NEJMra1208943 | PMID = 24171518 }}</ref> Management of [[shock]] consists of stabilization of the [[hemodynamic|hemodynamic status]] and correction of the underlying cause.
[[Shock]] is the syndrome of circulatory failure that results in inadequate cellular [[oxygen]] utilization. The diagnosis of [[shock]] is based on clinical signs (eg, [[altered mental status]], [[oliguria]], [[cool extremities|cold]] and [[clammy skin]]) and biochemical abnormalities (eg, [[hyperlactatemia]], [[Metabolic acidosis|base deficit]]) indicative of [[hypoperfusion|tissue hypoperfusion]].<ref name="Vincent-2013">{{Cite journal | last1 = Vincent | first1 = JL. | last2 = De Backer | first2 = D. | title = Circulatory shock. | journal = N Engl J Med | volume = 369 | issue = 18 | pages = 1726-34 | month = Oct | year = 2013 | doi = 10.1056/NEJMra1208943 | PMID = 24171518 }}</ref> Management of [[shock]] consists of stabilization of the [[hemodynamic|hemodynamic status]] and correction of the underlying cause.


==Causes==
==Causes==
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:* ''Arrhythmic''
:* ''Arrhythmic''
::* [[Atrioventricular block]]
::* [[Sinoatrial block]]
::* [[Sinoatrial block]]
::* [[Atrioventricular block]]
::* [[Supraventricular tachycardia]]
::* [[Ventricular tachycardia]]
::* [[Ventricular tachycardia]]
::* [[Supraventricular tachycardia]]
:* ''Mechanical''
:* ''Mechanical''
::* [[Mitral regurgitation|Acute mitral regurgitation]] ([[papillary muscle rupture]], [[chordae tendinae]] [[rupture]])
::* [[Myocardial rupture|Free wall rupture]]
::* [[Hypertrophic cardiomyopathy]]
::* [[Hypertrophic cardiomyopathy]]
::* [[mitral regurgitation|Acute mitral regurgitation]]
::* [[Left ventricle|Obstruction to left ventricular filling]] ([[mitral stenosis]], [[left atrial myxoma]])
::* [[Left ventricular outflow tract obstruction|Obstruction to left ventricular outflow tract]] ([[aortic stenosis]], [[hypertrophic obstructive cardiomyopathy]])
::* [[Ventricular septal defect]]
::* [[Ventricular septal defect]]
:* ''Myopathic''
:* ''Myopathic''
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::* [[Myocardial infarction]]
::* [[Myocardial infarction]]
::* [[Myocarditis]]
::* [[Myocarditis]]
::* [[Myxedema coma]]
::* [[ischemia|Postischemic]] [[myocardial stunning]]
::* [[ischemia|Postischemic]] [[myocardial stunning]]
::* [[Sepsis|Septic myocardial depression]]
::* [[Sepsis|Septic myocardial depression]]
::* [[Hypothyroidism|Hypothyroidism]]
:* ''Pharmacologic''
:* ''Pharmacologic''
::* [[Anthracycline]]
::* [[Anthracycline]]s
::* [[Calcium channel blockers]]
::* [[Calcium channel blockers]]


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''Click '''[[Shock causes|here]]''' for the complete list of causes.''
''Click '''[[Shock causes|here]]''' for the complete list of causes.''


==FIRE: Focused Initial Rapid Evaluation==
==FIRE: Focused Initial Rapid Evaluation==  


A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref>{{Cite book  | last1 = Rosen | first1 = Peter | last2 = Marx | first2 = John A. | title = Rosen's emergency medicine : concepts and clinical practic | date = 2013 | publisher = Elsevier/Saunders | location = Philadelphia, PA | isbn = 978-1-4557-0605-1 | pages =  }}</ref>


<span style="font-size:85%">Boxes in the salmon color signify that an urgent management is needed.</span>
<span style="font-size:85%">Boxes in the salmon color signify that an urgent management is needed.</span>
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{{Family tree/start}}
{{Family tree/start}}
{{Family tree/start}}
{{Family tree/start}}
{{Family tree|boxstyle=line-height: 15px; width: 350px; text-align: left; font-size: 90%;| | | | | | | | | | | | | | | A01 | | |A01=<div style="padding: 15px;">'''Does the patient have cardinal findings that increase the pretest probability of shock?'''
{{Family tree|boxstyle=width: 350px; text-align: left; font-size: 90%;| | | | | | | | | A01 | | |A01=<div style="padding: 15px;"><BIG>'''Does the patient have cardinal findings that increase the pretest probability of shock?'''</BIG>
❑&nbsp;&nbsp;'''Arterial hypotension'''
: ❑&nbsp;&nbsp;[[SBP|<span style="color: #000000;">SBP</span>]] &lt;90 mm Hg ''or''
: ❑&nbsp;&nbsp;[[MAP|<span style="color: #000000;">MAP</span>]] &lt;70 mm Hg


❑&nbsp;&nbsp;'''+ Signs of hypoperfusion'''
❑&nbsp;&nbsp;Evidence of hypoperfusion
: ❑&nbsp;&nbsp;[[Altered mental status|<span style="color: #000000;">Altered mental status</span>]]
: ❑&nbsp;&nbsp;[[Altered mental status|<span style="color: #000000;">Altered mental status</span>]]
: ❑&nbsp;&nbsp;[[Cool extremities|<span style="color: #000000;">Cold</span>]], [[clammy|<span style="color: #000000;">clammy skin</span>]]
: ❑&nbsp;&nbsp;[[Cool extremities|<span style="color: #000000;">Cool extremities</span>]]
: ❑&nbsp;&nbsp;[[Cyanosis|<span style="color: #000000;">Cyanosis</span>]]
: ❑&nbsp;&nbsp;[[Oliguria|<span style="color: #000000;">Oliguria</span>]]
: ❑&nbsp;&nbsp;[[Oliguria|<span style="color: #000000;">Oliguria</span>]]
</div>}}
: ❑&nbsp;&nbsp;Sustained hypotension
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | | | | | | | | | | | | | | |!| | }}
:: ❑&nbsp;&nbsp;[[SBP|<span style="color: #000000;">SBP</span>]] &lt;90 mm Hg ''or''
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.|}}
:: ❑&nbsp;&nbsp;[[MAP|<span style="color: #000000;">MAP</span>]] ↓ &gt;30 mm Hg below baseline for ≥30 min</div>}}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | | | | | | | | A02 | | | | | | | | | | | A03 |A02=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 5px; font-weight: bold;">YES</div>|A03=<div style="text-align: center; font-weight: bold;">NO</div>}}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | | | | | | | | |!| | }}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | | | | | | | | |!| | | | | | | | | | | |!|}}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | |,|-|-|-|-|-|-|^|-|-|-|-|-|.|}}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 450px;| | | | | | | | | A04 | | | | | | | | | | | A05 |A04=<div style="text-align: left; height: 90px; background: #FA8072; color: #F8F8FF; padding: 15px;">
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | A02 | | | | | | | | | | | | A03 |A02=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 5px; font-weight: bold;">YES</div>|A03=<div style="text-align: center; font-weight: bold;">NO</div>}}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | |!| | | | | | | | | | | | |!|}}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | A04 | | | | | | | | | | | | A05 |A04=<div style="text-align: left; background: #FA8072; color: #F8F8FF; padding: 15px;">
'''Ventilate—Infuse—Pump (VIP)'''
'''Ventilate—Infuse—Pump (VIP)'''


❑&nbsp;&nbsp;[[Oxygen therapy|<span style="color: #FFFFFF;">Oxygen</span>]] ± [[mechanical ventilation|<span style="color: #FFFFFF;">mechanical ventilation</span>]]
❑&nbsp;&nbsp;[[Oxygen therapy|<span style="color: #FFFFFF;">Oxygen</span>]] ± intubation with [[mechanical ventilation|<span style="color: #FFFFFF;">mechanical ventilation</span>]]


❑&nbsp;&nbsp;[[Normal saline|<span style="color: #FFFFFF;">Normal saline 300–500 mL over 20–30 min</span>]]
❑&nbsp;&nbsp;[[Normal saline|<span style="color: #FFFFFF;">Normal saline 300–500 mL over 20–30 min</span>]]


❑&nbsp;&nbsp;± [[Norepinephine|<span style="color: #FFFFFF;">Norepinephrine 0.1–2.0 μg/kg/min</span>]]</div>
❑&nbsp;&nbsp;± [[Norepinephine|<span style="color: #FFFFFF;">Norepinephrine 0.1–2.0 μg/kg/min</span>]]</div>
|A05=<div style="text-align: center; padding: 15px;">Consider other causes (eg, [[chronic hypotension|<span style="color: #000000;">chronic hypotension</span>]], [[syncope|<span style="color: #000000;">syncope</span>]])</div>}}
|A05=<div style="text-align: center; padding: 15px;">Consider alternative conditions <br> (eg, [[chronic hypotension|<span style="color: #000000;">chronic hypotension</span>]], [[syncope|<span style="color: #000000;">syncope</span>]])</div>}}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 250px;| | | | | | | | | |!| }}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 250px;| | |!| }}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 350px;| | | | | | | | | A06 |A06=<div style="text-align: left; background: #FA8072; color: #F8F8FF; padding: 15px;">
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 450px;| | A06 |A06=<div style="text-align: left; background: #FA8072; color: #F8F8FF; padding: 15px;">
'''Workups'''
'''Workup'''


❑&nbsp;&nbsp;[[ECG|<span style="color: #FFFFFF;">ECG monitor</span>]]
❑&nbsp;&nbsp;[[ECG|<span style="color: #FFFFFF;">ECG monitor</span>]]
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❑&nbsp;&nbsp;± [[Pulmonary artery catheter|<span style="color: #FFFFFF;">Pulmonary artery catheter</span>]] '''''([[Right heart catheterization#Indications|<span style="color: #FFFFFF;">Indications</span>]])'''''
❑&nbsp;&nbsp;± [[Pulmonary artery catheter|<span style="color: #FFFFFF;">Pulmonary artery catheter</span>]] '''''([[Right heart catheterization#Indications|<span style="color: #FFFFFF;">Indications</span>]])'''''
</div>}}
</div>}}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 250px;| | | | | | | | | |!| }}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 250px;| | |!| }}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 250px;| | | | | | | | | A07 |A07=<div style="text-align: left; background: #FA8072; color: #F8F8FF; padding: 15px;">
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 250px;| | A07 |A07=<div style="text-align: left; background: #FA8072; color: #F8F8FF; padding: 15px;">
'''Immediate Goals'''
'''Immediate Goals'''


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❑&nbsp;&nbsp;[[urine output|<span style="color: #FFFFFF;">Urine output >0.5 mL/kg/h</span>]]
❑&nbsp;&nbsp;[[urine output|<span style="color: #FFFFFF;">Urine output >0.5 mL/kg/h</span>]]
</div>}}
</div>}}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 250px;| | | | | | | | | |!| }}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 250px;| | |!| }}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 350px;| | | | | | | | | A08 |A08=<div style="text-align: left; background: #FA8072; color: #F8F8FF; padding: 5px;">
{{Family tree|boxstyle=font-size: 90%; text-align: left; padding: 0; background: #FA8072;| | C00 | | |C00=<div style="background: #FA8072; color: #F8F8FF; padding: 15px; text-align: center">'''Identify the cause'''</div>}}
<center>Proceed to '''[[{{PAGENAME}}#Complete Diagnostic Approach|<span style="color: #FFFFFF;">complete diagnostic approach</span>]]''' below</center></div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: left; padding: 0; background: #FA8072;| | C01 |-| C02 | |C01=<div style="background: #FA8072; color: #F8F8FF; padding: 15px; text-align: center;">'''History of significant bleeding <br> or direct trauma to the <br> thoracic cavity?'''</div>
|C02=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''YES''', then consider [[Trauma|<span style="color: #FFFFFF;">cardiac injury</span>]], <br> [[Cardiac tamponade|<span style="color: #FFFFFF;">cardiac tamponade</span>]], [[Tension pneumothorax|<span style="color: #FFFFFF;">tension pneumothorax</span>]], <br> or [[Hemorrhagic shock|<span style="color: #FFFFFF;">hemorrhagic shock</span>]]</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: center; padding: 0; background: #FA8072;| | C03 | | |C03=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''NO''', then proceed to the next question</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: left; padding: 0; background: #FA8072;| | C04 |-| C05 | |C04=<div style="background: #FA8072; color: #F8F8FF; padding: 15px; text-align: center;">'''Evidence of gastrointestinal hemorrhage, <br> vomiting, diarrhea?'''</div>|C05=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''YES''', then consider and manage as <br> [[hypovolemic shock|<span style="color: #FFFFFF;">hypovolemic shock</span>]]</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: center; padding: 0; background: #FA8072;| | C03 | | |C03=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''NO''', then proceed to the next question</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: left; padding: 0; background: #FA8072;| | C07 |-| C08 | |C07=<div style="background: #FA8072; color: #F8F8FF; padding: 15px; text-align: center;">'''Presence of fever <br> or hypothermia?'''</div>
|C08=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''YES''', then consider and manage as <br> [[septic shock|<span style="color: #FFFFFF;">septic shock</span>]]</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: center; padding: 0; background: #FA8072;| | C03 | | |C03=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''NO''', then proceed to the next question</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: left; padding: 0; background: #FA8072;| | C10 |-| C11 | |C10=<div style="background: #FA8072; color: #F8F8FF; padding: 15px; text-align: center;">'''Presence of chest pain and/or <br> ischemic findings on ECG <br> with coronary risk factors?'''</div>|C11=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''YES''', then consider and manage as <br> [[cardiogenic shock|<span style="color: #FFFFFF;">cardiogenic shock</span>]]</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: center; padding: 0;| | C03 | | |C03=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''NO''', then proceed to the next question</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: left; padding: 0; background: #FA8072;| | C13 |-| C14 | |C13=<div style="background: #FA8072; color: #F8F8FF; padding: 15px; text-align: center;">'''Presence of <br> unexplained <br> bradycardia?'''</div>
|C14=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''YES''', then consider [[Inotrope#Negative inotropic agents|<span style="color: #FFFFFF;">negative inotropic agents</span>]], <br> [[Adrenal insufficiency|<span style="color: #FFFFFF;">adrenal insufficiency</span>]], or [[Hypothyroidism|<span style="color: #FFFFFF;">hypothyroidism</span>]]</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: center; padding: 0; background: #FA8072;| | C03 | | |C03=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''NO''', then proceed to the next question</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: left; padding: 0; background: #FA8072;| | C16 |-| C17 | |C16=<div style="background: #FA8072; color: #F8F8FF; padding: 15px; text-align: center;">'''Presence of <br>  unexplained <br> hypoxemia?'''</div>
|C17=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''YES''', then consider and manage as <br> [[pulmonary embolism|<span style="color: #FFFFFF;">acute pulmonary embolism</span>]]</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: center; padding: 0;| | C03 | | |C03=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''NO''', then proceed to the next question</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: left; padding: 0; background: #FA8072;| | C19 |-| C20 | |C19=<div style="background: #FA8072; color: #F8F8FF; padding: 15px; text-align: center;">'''Presence of abdominal pain or <br> low back pain?'''</div>
|C20=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''YES''', then consider intra-abdominal etiologies <br> and surgical consultation</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: center; padding: 0; background: #FA8072;| | C03 | | |C03=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''NO''', then proceed to the next question</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=font-size: 90%; text-align: left; padding: 0; background: #FA8072;| | C22 |-| C23 | |C22=<div style="background: #FA8072; color: #F8F8FF; padding: 15px; text-align: center;">'''Presence of wheezing with hives <br> or skin flushing?'''</div>
|C23=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''YES''', then consider and manage as <br> [[Anaphylactic shock|<span style="color: #FFFFFF;">anaphylactic shock</span>]]</div>}}
{{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
{{Family tree|boxstyle=padding: 0; font-size: 90%; width: 500px;| | A08 |A08=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 5px;">'''NO''', then proceed to <br>[[{{PAGENAME}}#Complete Diagnostic Approach|<span style="color: #FFFFFF;">complete diagnostic approach</span>]] below</div>}}
{{Family tree/end}}
{{Family tree/end}}


==Complete Diagnostic Approach==
==Complete Diagnostic Approach==


{{Family tree/start}}
<div style="width: 80%;">
{{Family tree|boxstyle=line-height: 15px; text-align: left;| | B01 |B01=<div style="padding: 5px;">
{| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
'''History'''
|'''History'''
|-
|
* ''Review all medications''
:* [[Antihypertensives]] can cause significant [[hypotension]], especially in the setting of [[volume depletion]] or [[Diuresis|over-diuresis]].
:* [[Anaphylaxis]] should be considered if the patient recently started on a new drug and presented with [[respiratory distress]].


❑&nbsp;&nbsp;''Review all medications''
* ''Findings suggestive of hypovolemic shock''
:❑&nbsp;&nbsp;[[Antihypertensives]] can cause significant [[hypotension]], especially in the setting of [[volume depletion]] or [[Diuresis|over-diuresis]].
:* [[Abdominal pain]]
:❑&nbsp;&nbsp;[[Anaphylaxis]] should be considered if the patient recently started on a new drug and presented with [[respiratory distress]].
:* [[Diarrhea]]
❑&nbsp;&nbsp;''Accompanying symptoms'' that could pinpoint the underlying disease include:
:* [[Dry skin|Dry skin, mucosa, axillae]]
:❑&nbsp;&nbsp;[[Abdominal pain]]
:* [[Hematemesis]]
:❑&nbsp;&nbsp;[[Chest discomfort]]
:* [[Hematochezia]]
:❑&nbsp;&nbsp;[[Diarrhea]]
:* [[Melena]]
:❑&nbsp;&nbsp;[[Dyspnea]]
:* [[Surgery|Postoperative]]
:❑&nbsp;&nbsp;[[Hematemesis]]
:* [[Trauma]]
:❑&nbsp;&nbsp;[[Hematochezia]]
:* [[Vomiting]]
:❑&nbsp;&nbsp;[[Polydipsia]]
:❑&nbsp;&nbsp;[[Polyuria]]
:❑&nbsp;&nbsp;[[Vomiting]]
</div>}}
{{Family tree|boxstyle=line-height: 15px; text-align: left;| | |!| |}}
{{Family tree|boxstyle=line-height: 15px; text-align: left;| | B02 |B02=<div style="padding: 5px;">
'''Physical Examination'''


❑&nbsp;&nbsp;''Vital signs''
* ''Findings suggestive of cardiogenic shock''
:❑&nbsp;&nbsp;''Temperature''
:* [[Chest pain]]
::❑&nbsp;&nbsp;[[Fever]] may suggest [[sepsis]] or [[anaphylactic reaction]] related to [[transfusion|transfusion]].
:* [[Dyspnea]]
::❑&nbsp;&nbsp;[[Hypothermia]] may be associated with [[sepsis]], [[adrenal crisis]], or [[myxedema]].
:* [[Palpitations]]
:❑&nbsp;&nbsp;''Pulse''
::❑&nbsp;&nbsp;[[Bradycardia]] or [[tachycardia]] can either be a primary or secondary process.
::❑&nbsp;&nbsp;[[Pulsus paradoxus]] may be seen in [[cardiac tamponade]], [[pulmonary embolism]], [[hemorrhagic shock]], or [[tension pneumothorax]].
::❑&nbsp;&nbsp;[[Pulsus alternans]] may be seen in [[heart failure]], severe [[aortic insufficiency]], or [[hypovolemic shock]].
:❑&nbsp;&nbsp;''Respiration''
::❑&nbsp;&nbsp;[[Tachypnea]] commonly occurs in [[pneumothorax]], [[sepsis]], and [[cardiogenic shock]].
::❑&nbsp;&nbsp;[[Hypopnea]] may be seen in [[narcotic]] or [[sedative]] [[overdose]].
:❑&nbsp;&nbsp;''Blood pressure''
::❑&nbsp;&nbsp;Confirm [[hypotension|arterial hypotension]] by checking [[blood pressure]] in both arms manually. [[Arterial line]] may be considered.
::❑&nbsp;&nbsp;[[Postural hypotension]] suggests [[volume depletion]] or [[autonomic dysfunction]]. {{fontcolor|#FF0000|Do not test [[orthostatic hypotension]] in [[hypotension|hypotensive]] patients.}}


❑&nbsp;&nbsp;''Mental status''
* ''Findings suggestive of distributive shock''
:❑&nbsp;&nbsp;[[Altered mental status]] may indicate inadequate [[perfusion]] to vital organs or use of [[sedative]]s or [[narcotic]]s.
:* [[Altered mental status]]
:* [[Chills]]
:* [[Dyspnea]]
:* [[Dysuria]]
:* [[Fatigue]]
:* [[Fever]]
:* [[Flushing]]
:* [[Headache]]
:* [[Hematuria]]
:* [[Malaise]]
:* [[Myalgias]]
:* [[Photophobia]]
:* [[Productive cough]]
:* [[Rash]]
:* [[Tachycardia]]
:* [[Tachypnea]]
|}


❑&nbsp;&nbsp;''Cutaneous''
{| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
:❑&nbsp;&nbsp;[[Volume status#Volume depletion|Decreased skin turgor]] and dry [[mucous membrane]] signify [[dehydration]].
| '''Physical Examination'''
:❑&nbsp;&nbsp;[[Cool extremities]], [[clammy]] and [[mottled skin]], [[peripheral cyanosis]], and [[capillary refill|delayed capillary refill]] are commonly noted in [[cardiogenic shock]] and [[hypovolemic shock]], whereas warm and moist skin may represent hyperdynamic phase of [[septic shock]].
|-
:❑&nbsp;&nbsp;[[Burn|Extensive burns]] and [[Trauma|severe trauma]] may be evident on inspection and are associated with significant fluid loss.
|
:❑&nbsp;&nbsp;[[Hyperpigmentation]] may be an indicator of [[adrenal crisis]].
* ''Vital signs''
:* ''Temperature''
::* [[Fever]] may suggest [[sepsis]] or [[anaphylactic reaction]] related to [[transfusion|transfusion]].
::* [[Hypothermia]] may be associated with [[sepsis]], [[adrenal crisis]], or [[myxedema]].
:* ''Pulse''
::* [[Bradycardia]] or [[tachycardia]] can either be a primary or secondary process.
::* [[Pulsus paradoxus]] may be seen in [[cardiac tamponade]], [[pulmonary embolism]], [[hemorrhagic shock]], or [[tension pneumothorax]].
::* [[Pulsus alternans]] may be seen in [[heart failure]], severe [[aortic insufficiency]], or [[hypovolemic shock]].
:* ''Respiration''
::* [[Tachypnea]] commonly occurs in [[pneumothorax]], [[sepsis]], and [[cardiogenic shock]].
::* [[Hypopnea]] may be seen in [[narcotic]] or [[sedative]] [[overdose]].
:* ''Blood pressure''
::* Confirm [[hypotension|arterial hypotension]] by checking [[blood pressure]] in both arms manually. [[Arterial line]] may be considered.
::* [[Postural hypotension]] suggests [[volume depletion]] or [[autonomic dysfunction]]. Do not test [[orthostatic hypotension]] in [[hypotension|hypotensive]] patients.


❑&nbsp;&nbsp;''Neck''
* ''Mental status''
:❑&nbsp;&nbsp;[[Jugular venous pressure|elevated JVP]]
:* [[Altered mental status]] may indicate inadequate [[perfusion]] to vital organs or use of [[sedative]]s or [[narcotic]]s.
::❑&nbsp;&nbsp;[[Heart failure]]
::❑&nbsp;&nbsp;[[Tricuspid stenosis]]
::❑&nbsp;&nbsp;[[Pulmonary hypertension]]
::❑&nbsp;&nbsp;[[Superior vena cava]] [[obstruction]]
::❑&nbsp;&nbsp;[[Constrictive pericarditis]]
::❑&nbsp;&nbsp;[[Cardiac tamponade]]
:❑&nbsp;&nbsp;[[Kussmaul's sign]]
::❑&nbsp;&nbsp;[[Constrictive pericarditis]]
::❑&nbsp;&nbsp;[[Restrictive cardiomyopathy]]
::❑&nbsp;&nbsp;[[Tricuspid stenosis]]
::❑&nbsp;&nbsp;[[Superior vena cava]] [[obstruction]]
::❑&nbsp;&nbsp;[[Right ventricular infarction]]
:❑&nbsp;&nbsp;[[Abdominojugular reflux]]
::❑&nbsp;&nbsp;A positive [[abdominojugular reflux]] correlates with a [[PCWP]] of 15 mmHg or greater and may be seen in:
::❑&nbsp;&nbsp;[[Cardiac tamponade]]
::❑&nbsp;&nbsp;[[Constrictive pericarditis]]
::❑&nbsp;&nbsp;[[Tricuspid insufficiency]]
::❑&nbsp;&nbsp;[[Inferior vena cava]] [[obstruction]]
::❑&nbsp;&nbsp;[[Heart failure]] (except for pure backward [[heart failure|left-sided heart failure]])


:❑&nbsp;&nbsp;[[Jugular venous pressure#JVP waveform|Jugular venous pressure waveform]]
* ''Cutaneous''
::❑&nbsp;&nbsp;[[Jugular venous pressure#Abnormalities in the JVP Waveforms|Blunted y descent]] suggests [[cardiac tamponade]] or [[tricuspid stenosis]].
:* [[Volume status#Volume depletion|Decreased skin turgor]] and dry [[mucous membrane]] signify [[dehydration]].
::❑&nbsp;&nbsp;[[Jugular venous pressure#Abnormalities in the JVP Waveforms|Steep y descent]] suggests [[constrictive pericarditis]] or severe [[tricuspid insufficiency]].
:* [[Cool extremities]], [[clammy]] and [[mottled skin]], [[peripheral cyanosis]], and [[capillary refill|delayed capillary refill]] are commonly noted in [[cardiogenic shock]] and [[hypovolemic shock]], whereas warm and moist skin may represent hyperdynamic phase of [[septic shock]].
:* [[Burn|Extensive burns]] and [[Trauma|severe trauma]] may be evident on inspection and are associated with significant fluid loss.
:* [[Hyperpigmentation]] may be an indicator of [[adrenal crisis]].


❑&nbsp;&nbsp;''Cardiovascular''
* ''Neck''
:❑&nbsp;&nbsp;[[Systolic murmur|Decrescendo early systolic murmur]]
:* [[Jugular venous pressure|Elevated jugular venous pressure (JVP)]] correlates with increased [[Preload|left ventricular end diastolic pressure (LVEDP)]] and decreased [[LVEF|left ventricular ejection fraction (LVEF)]]. [[Jugular venous distention]] or [[Jugular venous pressure|elevated JVP]] typically occurs in:
::❑&nbsp;&nbsp;[[mitral regurgitation|Acute severe mitral regurgitation]]
::* [[Heart failure]]
:❑&nbsp;&nbsp;[[Third heart sound|Third heart sound (S<sub>3</sub>)]]
::* [[Tricuspid stenosis]]
::❑&nbsp;&nbsp;[[Heart failure]]
::* [[Pulmonary hypertension]]
:❑&nbsp;&nbsp;[[Systolic murmur|Pansystolic murmur along lower left sternal border]] with [[thrill|palpable thrill]]
::* [[Superior vena cava]] [[obstruction]]
::❑&nbsp;&nbsp;[[Ventricular septal defect]]
::* [[Constrictive pericarditis]]
:❑&nbsp;&nbsp;[[Pericardial friction rub]]s
::* [[Cardiac tamponade]]
::❑&nbsp;&nbsp;[[Pericarditis]]
:* [[Kussmaul's sign]]
:❑&nbsp;&nbsp;[[muffled heart sounds|Distant, muffled heart sounds]]
::* [[Constrictive pericarditis]]
::❑&nbsp;&nbsp;[[Cardiac tamponade]]
::* [[Restrictive cardiomyopathy]]
::* [[Tricuspid stenosis]]
::* [[Superior vena cava]] [[obstruction]]
::* [[Right ventricular infarction]]
:* [[Abdominojugular reflux]] (a positive [[abdominojugular reflux]] correlates with a [[PCWP]] of 15 mmHg or greater)
::* [[Cardiac tamponade]]
::* [[Constrictive pericarditis]]
::* [[Tricuspid insufficiency]]
::* [[Inferior vena cava]] [[obstruction]]
::* [[Heart failure]] (except for pure backward [[heart failure|left-sided heart failure]])


❑&nbsp;&nbsp;''Pulmonary''
:* [[Jugular venous pressure#JVP waveform|Jugular venous pressure waveform]]
:❑&nbsp;&nbsp;[[Tracheal deviation]]
::* [[Jugular venous pressure#Abnormalities in the JVP Waveforms|Blunted y descent]] suggests [[cardiac tamponade]] or [[tricuspid stenosis]].
::❑&nbsp;&nbsp;[[Tension pneumothorax]]
::* [[Jugular venous pressure#Abnormalities in the JVP Waveforms|Steep y descent]] suggests [[constrictive pericarditis]] or severe [[tricuspid insufficiency]].
:❑&nbsp;&nbsp;[[Stridor]] and [[wheezing]]
::❑&nbsp;&nbsp;[[Anaphylaxis]]
::❑&nbsp;&nbsp;[[COPD|Acute exacerbation of chronic obstructive pulmonary disease]]
:❑&nbsp;&nbsp;[[Rales]]
::❑&nbsp;&nbsp;[[Anaphylaxis]]
::❑&nbsp;&nbsp;[[Pneumonia]]
::❑&nbsp;&nbsp;[[Heart failure]]
:❑&nbsp;&nbsp;[[percussion|Chest percussion]] may aid in the diagnosis of [[tension pneumothorax]], [[pleural effusions]], and [[pneumonia]]


❑&nbsp;&nbsp;''Abdominal''
* ''Cardiovascular''
:❑&nbsp;&nbsp;[[Grey Turner's sign]]
:* [[Systolic murmur|Decrescendo early systolic murmur]]
::❑&nbsp;&nbsp;[[Acute pancreatitis]]
::* [[mitral regurgitation|Acute severe mitral regurgitation]]
::❑&nbsp;&nbsp;[[Blunt force trauma|Blunt abdominal trauma]]
:* [[Third heart sound|Third heart sound (S<sub>3</sub>)]]
::❑&nbsp;&nbsp;[[Retroperitoneal hemorrhage]]
::* [[Heart failure]]
::❑&nbsp;&nbsp;[[Abdominal aortic aneurysm|Ruptured abdominal aortic aneurysm]]
:* [[Systolic murmur|Pansystolic murmur along lower left sternal border]] with [[thrill|palpable thrill]]
::❑&nbsp;&nbsp;[[Ectopic pregnancy|Ruptured ectopic pregnancy]]
::* [[Ventricular septal defect]]
:* [[Pericardial friction rub]]s
::* [[Pericarditis]]
:* [[muffled heart sounds|Distant, muffled heart sounds]]
::* [[Cardiac tamponade]]


:❑&nbsp;&nbsp;[[Cullen's sign]]
* ''Pulmonary''
::❑&nbsp;&nbsp;[[Acute pancreatitis|Acute pancreatitis]]
:* [[Tracheal deviation]]
::❑&nbsp;&nbsp;[[Blunt force trauma|Blunt abdominal trauma]]
::* [[Tension pneumothorax]]
::❑&nbsp;&nbsp;[[Abdominal aortic aneurysm|Ruptured abdominal aortic aneurysm]]
:* [[Stridor]] and [[wheezing]]
::❑&nbsp;&nbsp;[[ectopic pregnancy|Ruptured ectopic pregnancy]]
::* [[Anaphylaxis]]
:❑&nbsp;&nbsp;[[Hepatomegaly]]
::* [[COPD|Acute exacerbation of chronic obstructive pulmonary disease]]
::❑&nbsp;&nbsp;[[Inferior vena cava]] [[obstruction]]
:* [[Rales]]
::❑&nbsp;&nbsp;[[Heart failure]]
::* [[Anaphylaxis]]
:❑&nbsp;&nbsp;[[Rebound tenderness]] with [[absent bowel sounds]]
::* [[Pneumonia]]
::❑&nbsp;&nbsp;[[Sepsis]] due to [[abdomen|Intraabdominal]] [[infection]]
::* [[Heart failure]]
::❑&nbsp;&nbsp;[[Ischemic colitis]]
:* [[percussion|Chest percussion]] may aid in the diagnosis of [[tension pneumothorax]], [[pleural effusions]], and [[pneumonia]]
::❑&nbsp;&nbsp;[[Gastrointestinal hemorrhage]]
:❑&nbsp;&nbsp;[[Mass|Pulsatile mass]]
::❑&nbsp;&nbsp;[[Abdominal aortic aneurysm]]


❑&nbsp;&nbsp;''Rectal''
* ''Abdominal''
:❑&nbsp;&nbsp;[[Hematochezia|Bright red blood]] or [[melena]]
:* [[Grey Turner's sign]]
::❑&nbsp;&nbsp;[[Gastrointestinal hemorrhage]]
::* [[Acute pancreatitis]]
:❑&nbsp;&nbsp;Diminished [[sphincter|sphincter tone]]
::* [[Blunt force trauma|Blunt abdominal trauma]]
::❑&nbsp;&nbsp;[[Spinal cord injury]]
::* [[Retroperitoneal hemorrhage]]
::* [[Abdominal aortic aneurysm|Ruptured abdominal aortic aneurysm]]
::* [[Ectopic pregnancy|Ruptured ectopic pregnancy]]


❑&nbsp;&nbsp;''Extremities''
:* [[Cullen's sign]]
:❑&nbsp;&nbsp;[[Digital clubbing]]
::* [[Acute pancreatitis|Acute pancreatitis]]
::❑&nbsp;&nbsp;[[Heart failure]]
::* [[Blunt force trauma|Blunt abdominal trauma]]
:❑&nbsp;&nbsp;[[Edema]]
::* [[Abdominal aortic aneurysm|Ruptured abdominal aortic aneurysm]]
::❑&nbsp;&nbsp;[[Heart failure]]
::* [[ectopic pregnancy|Ruptured ectopic pregnancy]]
:❑&nbsp;&nbsp;[[Erythema]] at the site of [[intravenous therapy|venous access]]
:* [[Hepatomegaly]]
::❑&nbsp;&nbsp;[[Catheter|Catheter-associated]] [[infection]]
::* [[Inferior vena cava]] [[obstruction]]
:❑&nbsp;&nbsp;[[Pelvic girdle pain|Pelvic girdle pain or instability]]
::* [[Heart failure]]
::❑&nbsp;&nbsp;[[Pelvic fracture]]
:* [[Rebound tenderness]] with [[absent bowel sounds]]
::* [[Sepsis]] due to [[abdomen|Intraabdominal]] [[infection]]
::* [[Ischemic colitis]]
::* [[Gastrointestinal hemorrhage]]
:* [[Mass|Pulsatile mass]]
::* [[Abdominal aortic aneurysm]]


❑&nbsp;&nbsp;''Genitals''
* ''Rectal''
:❑&nbsp;&nbsp;Perform a [[pelvic examination]] in women of childbearing age to rule out [[ectopic pregnancy]] or [[pelvic inflammatory disease]].
:* [[Hematochezia|Bright red blood]] or [[melena]]
::* [[Gastrointestinal hemorrhage]]
:* Diminished [[sphincter|sphincter tone]]
::* [[Spinal cord injury]]


❑&nbsp;&nbsp;''Neurologic''
* ''Extremities''
:❑&nbsp;&nbsp;[[Agitation]] or [[delirium]]
:* [[Digital clubbing]]
::❑&nbsp;&nbsp;Poor [[Cerebral perfusion pressure|cerebral perfusion]]
::* [[Heart failure]]
:❑&nbsp;&nbsp;[[Meningeal signs]]
:* [[Edema]]
::❑&nbsp;&nbsp;[[Meningitis]]
::* [[Heart failure]]
</div>}}
:* [[Erythema]] at the site of [[intravenous therapy|venous access]]
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::* [[Catheter|Catheter-associated]] [[infection]]
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:* [[Pelvic girdle pain|Pelvic girdle pain or instability]]
'''Laboratory Findings'''
::* [[Pelvic fracture]]
 
* ''Genitals''
:* Perform a [[pelvic examination]] in women of childbearing age to rule out [[ectopic pregnancy]] or [[pelvic inflammatory disease]].
 
* ''Neurologic''
:* [[Agitation]] or [[delirium]]
::* Poor [[Cerebral perfusion pressure|cerebral perfusion]]
:* [[Meningeal signs|Meningeal signs (nuchal rigidity, Brudzinski's sign, and Kernig's sign]]
::* [[Meningitis]]
|}


❑&nbsp;&nbsp;''Complete blood count''
{| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
:❑&nbsp;&nbsp;In acute [[hemorrhage|blood loss]], [[hemoglobin]] and [[hematocrit]] levels may remain normal until volume repletion.
| '''Laboratory Findings'''
:❑&nbsp;&nbsp;[[Leukocytosis]] with or without a [[Granulocytosis#Left Shift|left shift of neutrophils]] suggests [[sepsis]].
|-
:❑&nbsp;&nbsp;[[Thrombocytopenia]] with alterations in [[coagulation]] panel indicates [[disseminated intravascular coagulation|disseminated intravascular coagulation (DIC)]], which may be a complication of [[sepsis]].
|
❑&nbsp;&nbsp;''Electrolytes''
:❑&nbsp;&nbsp;Decreased [[bicarbonate]] levels may be the primary deficit in [[metabolic acidosis]] or the compensatory change in [[respiratory alkalosis]].
:❑&nbsp;&nbsp;[[Hyperkalemia]] due to transcellular shift is commonly associated with [[metabolic acidosis]].
❑&nbsp;&nbsp;''Coagulation panel (PT, PTT, INR, etc.)''
:❑&nbsp;&nbsp;Abnormalities in [[coagulation]] panel may be caused by [[disseminated intravascular coagulation|disseminated intravascular coagulation (DIC)]], [[anticoagulation|over-anticoagulation]], or [[hepatic failure]].
❑&nbsp;&nbsp;''Cardiac markers''
:❑&nbsp;&nbsp;Check [[troponin]] and [[Creatine kinase|CK-MB]] levels when suspecting [[myocardial infarction]].
:❑&nbsp;&nbsp;Elevation in [[cardiac markers]] may be associated with both cardiac and extracardiac etiologies.
❑&nbsp;&nbsp;''Liver function''
:❑&nbsp;&nbsp;Increased levels of [[conjugated bilirubin]], [[alkaline phosphatase]], and [[aminotransferase|hepatic aminotransferases]] are typically seen in [[ischemic hepatitis|ischemic hepatitis ("shock liver")]] due to [[cardiogenic shock]].
❑&nbsp;&nbsp;''Renal function''
:❑&nbsp;&nbsp;[[Acute kidney injury|Prerenal azotemia]] and/or [[acute tubular necrosis]] may be associated with conditions of [[hypovolemia]] or reduced [[cardiac output]].
:❑&nbsp;&nbsp;[[Oliguria|Oliguria (urine output <0.5 mL/kg/h)]] is usually evident.
❑&nbsp;&nbsp;''Lactate''
:❑&nbsp;&nbsp;[[Lactate|Hyperlactatemia]] generally reflects the development of anaerobic metabolism in hypoperfused tissue and/or imparied hepatic clearance.
:❑&nbsp;&nbsp;[[Lactate]] level could decrease within hours with effective therapy.<ref name="Vincent-2013">{{Cite journal | last1 = Vincent | first1 = JL. | last2 = De Backer | first2 = D. | title = Circulatory shock. | journal = N Engl J Med | volume = 369 | issue = 18 | pages = 1726-34 | month = Oct | year = 2013 | doi = 10.1056/NEJMra1208943 | PMID = 24171518 }}</ref>


❑&nbsp;&nbsp;''Arterial blood gas''
* ''Complete blood count''
:❑&nbsp;&nbsp;[[Lactic acidosis]] may be an indicator of [[hypoperfusion|tissue hypoperfusion]] typically seen in [[septic shock]].
:* In acute [[hemorrhage|blood loss]], [[hemoglobin]] and [[hematocrit]] levels may remain normal until volume repletion.
:❑&nbsp;&nbsp;Combined [[acid-base disorders]] are fequently encountered in different stages of shock.
:* [[Leukocytosis]] with or without a [[Granulocytosis#Left Shift|left shift of neutrophils]] suggests [[sepsis]].
:❑&nbsp;&nbsp;Severe [[acidosis]] could blunt the effectiveness of [[vasopressor]]s and potentiate the development of [[arrhythmia]]s.
:* [[Thrombocytopenia]] with alterations in [[coagulation]] panel indicates [[disseminated intravascular coagulation|disseminated intravascular coagulation (DIC)]], which may be a complication of [[sepsis]].
❑&nbsp;&nbsp;''Cultures''
* ''Electrolytes''
:❑&nbsp;&nbsp;Samples of [[blood culture|blood]], [[urine culture|urine]], and/or [[sputum culture|sputum]] should be sent for culture before administering [[antibiotics]] if [[sepsis]] is concerned.
:* Decreased [[bicarbonate]] levels may be the primary deficit in [[metabolic acidosis]] or the compensatory change in [[respiratory alkalosis]].
❑&nbsp;&nbsp;''Nasogastric aspirate''
:* [[Hyperkalemia]] due to transcellular shift is commonly associated with [[metabolic acidosis]].
:❑&nbsp;&nbsp;A negative [[nasogastric intubation|nasogastric aspirate]] does not rule out [[gastrointestinal hemorrhage|upper gastrointestinal bleeding]].
* ''Coagulation panel (PT, PTT, INR, etc.)''
❑&nbsp;&nbsp;''Pregnancy test''
:* Abnormalities in [[coagulation]] panel may be caused by [[disseminated intravascular coagulation|disseminated intravascular coagulation (DIC)]], [[anticoagulation|over-anticoagulation]], or [[hepatic failure]].
:❑&nbsp;&nbsp;A [[pregnancy test]] should be performed on [[hypotension|hypotensive]] women of childbearing age presenting with lower [[abdominal pain]].
* ''Cardiac markers''
</div>}}
:* Check [[troponin]] and [[Creatine kinase|CK-MB]] levels when suspecting [[myocardial infarction]].
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:* Elevation in [[cardiac markers]] may be associated with both cardiac and extracardiac etiologies.
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* ''Liver function''
'''ECG Findings'''
:* Increased levels of [[conjugated bilirubin]], [[alkaline phosphatase]], and [[aminotransferase|hepatic aminotransferases]] are typically seen in [[ischemic hepatitis|ischemic hepatitis ("shock liver")]] due to [[cardiogenic shock]].
* ''Renal function''
:* [[Acute kidney injury|Prerenal azotemia]] and/or [[acute tubular necrosis]] may be associated with conditions of [[hypovolemia]] or reduced [[cardiac output]].
:* [[Oliguria|Oliguria (urine output <0.5 mL/kg/h)]] is usually evident.
* ''Lactate''
:* [[Lactate|Hyperlactatemia]] generally reflects the development of anaerobic metabolism in hypoperfused tissue and/or imparied hepatic clearance.
:* [[Lactate]] level could decrease within hours with effective therapy.<ref name="Vincent-2013">{{Cite journal | last1 = Vincent | first1 = JL. | last2 = De Backer | first2 = D. | title = Circulatory shock. | journal = N Engl J Med | volume = 369 | issue = 18 | pages = 1726-34 | month = Oct | year = 2013 | doi = 10.1056/NEJMra1208943 | PMID = 24171518 }}</ref>


❑&nbsp;&nbsp;[[ST segment elevation]] or [[ST segment depression|depression]], [[Pathologic Q Waves|pathologic Q waves]], [[tented T waves|hyperacute]] or [[T wave inversion|negative T waves]]
* ''Arterial blood gas''
:❑&nbsp;&nbsp;[[Myocardial infarction|Myocardial infarction or ischemia]]
:* [[Lactic acidosis]] may be an indicator of [[hypoperfusion|tissue hypoperfusion]] typically seen in [[septic shock]].
❑&nbsp;&nbsp;[[Sinus tachycardia]] with [[S1Q3T3|S1Q3T3 pattern]]
:* Combined [[acid-base disorders]] are fequently encountered in different stages of shock.
:❑&nbsp;&nbsp;[[pulmonary embolism|Acute pulmonary embolism]]
:* Severe [[acidosis]] could blunt the effectiveness of [[vasopressor]]s and potentiate the development of [[arrhythmia]]s.
❑&nbsp;&nbsp;[[Low QRS voltage]] with [[electrical alternans]]
* ''Cultures''
:❑&nbsp;&nbsp;[[Cardiac tamponade]]
:* Samples of [[blood culture|blood]], [[urine culture|urine]], and/or [[sputum culture|sputum]] should be sent for culture before administering [[antibiotics]] if [[sepsis]] is concerned.
❑&nbsp;&nbsp;[[QRS complex|QS deflections]] in [[precordial lead]]s with [[right axis deviation]] and [[low QRS voltage]]  
* ''Nasogastric aspirate''
:❑&nbsp;&nbsp;[[Pneumothorax|Pneumothorax]]
:* A negative [[nasogastric intubation|nasogastric aspirate]] does not rule out [[gastrointestinal hemorrhage|upper gastrointestinal bleeding]].
❑&nbsp;&nbsp;[[Bradyarrhythmias]] or [[tachyarrhythmias]]
* ''Pregnancy test''
:* A [[pregnancy test]] should be performed on [[hypotension|hypotensive]] women of childbearing age presenting with lower [[abdominal pain]].
|}


'''Radiographic Findings'''
{| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
|'''ECG Findings'''
|-
|
* [[ST segment elevation]] or [[ST segment depression|depression]], [[Pathologic Q Waves|pathologic Q waves]], [[tented T waves|hyperacute]] or [[T wave inversion|negative T waves]]
:* [[Myocardial infarction|Myocardial infarction or ischemia]]
* [[Sinus tachycardia]] with [[S1Q3T3|S1Q3T3 pattern]]
:* [[pulmonary embolism|Acute pulmonary embolism]]
* [[Low QRS voltage]] with [[electrical alternans]]
:* [[Cardiac tamponade]]
* [[QRS complex|QS deflections]] in [[precordial lead]]s with [[right axis deviation]] and [[low QRS voltage]]
:* [[Pneumothorax|Pneumothorax]]
* [[Bradyarrhythmias]] or [[tachyarrhythmias]]
|}


❑&nbsp;&nbsp;''[[Chest radiograph]]'' may aid in establishing diagnosis in the following conditions:
{| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
:❑&nbsp;&nbsp;[[Aortic dissection]]
|'''Radiographic Findings'''
:❑&nbsp;&nbsp;[[Cardiac tamponade]]
|-
:❑&nbsp;&nbsp;[[Pneumonia]] complicating [[septic shock]]
|
:❑&nbsp;&nbsp;[[Pulmonary edema]] complicating [[cardiogenic shock]]
* ''[[Chest radiograph]]'' may aid in establishing diagnosis in the following conditions:
:❑&nbsp;&nbsp;[[Tension pneumothorax]]
:* [[Aortic dissection]]
:* [[Cardiac tamponade]]
:* [[Pneumonia]] complicating [[septic shock]]
:* [[Pulmonary edema]] complicating [[cardiogenic shock]]
:* [[Tension pneumothorax]]


❑&nbsp;&nbsp;''[[Computed tomography|CT scan]]'' may aid in directing management in the following conditions:
* ''[[Computed tomography|CT scan]]'' may aid in directing management in the following conditions:
:❑&nbsp;&nbsp;[[Hemorrhage|Occult internal hemorrhage]]
:* [[Hemorrhage|Occult internal hemorrhage]]
:❑&nbsp;&nbsp;[[Pulmonary embolism]]
:* [[Pulmonary embolism]]
</div>}}
|}
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{| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
'''Hemodynamic Profiles and Echocardiography Findings'''
|'''Hemodynamic Profiles and Echocardiography Findings'''
<table style="border: 2px solid #A8A8A8; width: 100%;" align="center">
|-
|
<table style="border: 2px solid #A8A8A8; width: 100%; font-size: 80%;" align="center">
<tr>
<tr>
<td align="center" style="background: #A8A8A8;" colspan="2"> <b>Type of Shock</b>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>Type of Shock</b>
</td>
</td>
<td align="center" style="background: #A8A8A8; width: 55px;"> <b>CO</b>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>Etiology</b>
</td>
</td>
<td align="center" style="background: #A8A8A8; width: 55px;"> <b>SVR</b>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>CO</b>
</td>
</td>
<td align="center" style="background: #A8A8A8; width: 55px;"> <b>PCWP</b>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>SVR</b>
</td>
</td>
<td align="center" style="background: #A8A8A8; width: 55px;"> <b>CVP</b>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>PCWP</b>
</td>
</td>
<td align="center" style="background: #A8A8A8; width: 55px;"> <b>SVO2</b>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>CVP</b>
</td>
</td>
<td align="center" style="background: #A8A8A8;"> <b>Echocardiographic Findings</b>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>SVO2</b>
</td>
<td align="center" style="background: #B0B0B0;"> <b>Echocardiographic Findings</b>
</td></tr>
</td></tr>
<tr>
<tr>
Line 576: Line 652:
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"> Small cardiac chambers with normal or high contractility
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"> Small cardiac chambers with normal or high contractility
</td></tr></table>
</td></tr></table>
</div>}}
|}
{{Family tree/end}}
 
</div>


==Treatment==
==Treatment==
Line 583: Line 660:
Management of shock consists of stabilization of the hemodynamic status and correction of the underlying cause once it is identified.
Management of shock consists of stabilization of the hemodynamic status and correction of the underlying cause once it is identified.


====[[Cardiogenic shock resident survival guide|Cardiogenic shock]]====
'''[[Cardiogenic shock resident survival guide|Cardiogenic shock]]'''


====[[Obstructive shock resident survival guide|Obstructive shock]]====
'''[[Obstructive shock resident survival guide|Obstructive shock]]'''


====[[Distributive shock resident survival guide|Distributive shock]]====
'''[[Distributive shock resident survival guide|Distributive shock]]'''


====[[Hypovolemic shock resident survival guide|Hypovolemic shock]]====
'''[[Hypovolemic shock resident survival guide|Hypovolemic shock]]'''


==Do's==
==Do's==

Latest revision as of 17:40, 18 April 2014

Shock
Resident Survival Guide
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Zaghw, MBChB. [2]

Overview

Shock is the syndrome of circulatory failure that results in inadequate cellular oxygen utilization. The diagnosis of shock is based on clinical signs (eg, altered mental status, oliguria, cold and clammy skin) and biochemical abnormalities (eg, hyperlactatemia, base deficit) indicative of tissue hypoperfusion.[1] Management of shock consists of stabilization of the hemodynamic status and correction of the underlying cause.

Causes

Life Threatening Causes

Shock is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Cardiogenic Shock
  • Arrhythmic
  • Mechanical
  • Myopathic
  • Pharmacologic
Obstructive Shock
  • Decreased cardiac compliance
  • Decreased ventricular preload
  • Increased ventricular afterload
Hypovolemic Shock
  • Fluid depletion
  • Hemorrhage
Distributive Shock

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[2]

Boxes in the salmon color signify that an urgent management is needed.

Abbreviations: CBC, complete blood count; CI, cardiac index; CK-MB, creatine kinase MB isoform; CVP, central venous pressure; DC, differential count; ICU, intensive care unit; INR, international normalized ratio; LFT, liver function test; MAP, mean arterial pressure; MVO2, mixed venous oxygen saturation; PCWP, pulmonary capillary wedge pressure; PT, prothrombin time; PTT, partial prothrombin time; SaO2, arterial oxygen saturation; SBP, systolic blood pressure; SCVO2, central venous oxygen saturation; SMA-7, sequential multiple analysis-7.

 
 
 
 
 
 
 
 
Does the patient have cardinal findings that increase the pretest probability of shock?

❑  Evidence of hypoperfusion

❑  Altered mental status
❑  Cool extremities
❑  Cyanosis
❑  Oliguria
❑  Sustained hypotension
❑  SBP <90 mm Hg or
❑  MAP ↓ >30 mm Hg below baseline for ≥30 min
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
 
 
 
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Ventilate—Infuse—Pump (VIP)

❑  Oxygen ± intubation with mechanical ventilation

❑  Normal saline 300–500 mL over 20–30 min

❑  ± Norepinephrine 0.1–2.0 μg/kg/min
 
 
 
 
 
 
 
 
 
 
 
Consider alternative conditions
(eg, chronic hypotension, syncope)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify the cause
 
 
 
 
 
 
 
 
 
 
History of significant bleeding
or direct trauma to the
thoracic cavity?
 
 
 
 
 
 
 
 
 
 
 
NO, then proceed to the next question
 
 
 
 
 
 
 
 
 
 
Evidence of gastrointestinal hemorrhage,
vomiting, diarrhea?
 
YES, then consider and manage as
hypovolemic shock
 
 
 
 
 
 
 
 
 
 
NO, then proceed to the next question
 
 
 
 
 
 
 
 
 
 
Presence of fever
or hypothermia?
 
YES, then consider and manage as
septic shock
 
 
 
 
 
 
 
 
 
 
NO, then proceed to the next question
 
 
 
 
 
 
 
 
 
 
Presence of chest pain and/or
ischemic findings on ECG
with coronary risk factors?
 
YES, then consider and manage as
cardiogenic shock
 
 
 
 
 
 
 
 
 
 
NO, then proceed to the next question
 
 
 
 
 
 
 
 
 
 
Presence of
unexplained
bradycardia?
 
 
 
 
 
 
 
 
 
 
 
NO, then proceed to the next question
 
 
 
 
 
 
 
 
 
 
Presence of
unexplained
hypoxemia?
 
YES, then consider and manage as
acute pulmonary embolism
 
 
 
 
 
 
 
 
 
 
NO, then proceed to the next question
 
 
 
 
 
 
 
 
 
 
Presence of abdominal pain or
low back pain?
 
YES, then consider intra-abdominal etiologies
and surgical consultation
 
 
 
 
 
 
 
 
 
 
NO, then proceed to the next question
 
 
 
 
 
 
 
 
 
 
Presence of wheezing with hives
or skin flushing?
 
YES, then consider and manage as
anaphylactic shock
 
 
 
 
 
 
 
 
 
 
NO, then proceed to
complete diagnostic approach below

Complete Diagnostic Approach

History
  • Review all medications
  • Findings suggestive of hypovolemic shock
  • Findings suggestive of cardiogenic shock
  • Findings suggestive of distributive shock
Physical Examination
  • Vital signs
  • Temperature
  • Pulse
  • Respiration
  • Blood pressure
  • Mental status
  • Cutaneous
  • Neck
  • Cardiovascular
  • Pulmonary
  • Abdominal
  • Rectal
  • Extremities
  • Genitals
  • Neurologic
Laboratory Findings
  • Complete blood count
  • Electrolytes
  • Coagulation panel (PT, PTT, INR, etc.)
  • Cardiac markers
  • Liver function
  • Renal function
  • Lactate
  • Hyperlactatemia generally reflects the development of anaerobic metabolism in hypoperfused tissue and/or imparied hepatic clearance.
  • Lactate level could decrease within hours with effective therapy.[1]
  • Arterial blood gas
  • Cultures
  • Nasogastric aspirate
  • Pregnancy test
ECG Findings
Radiographic Findings
  • CT scan may aid in directing management in the following conditions:
Hemodynamic Profiles and Echocardiography Findings
Type of Shock Etiology CO SVR PCWP CVP SVO2 Echocardiographic Findings
Cardiogenic Acute Ventricular Septal Defect ↓↓ N — ↑ ↑↑ ↑ — ↑↑ Large ventricles with poor contractility
Acute Mitral Regurgitation ↓↓ ↑↑ ↑ — ↑↑
Myocardial Dysfunction ↓↓ ↑↑ ↑↑
RV Infarction ↓↓ N — ↓ ↑↑ Dilated RV, small LV, abnormal wall motions
Obstructive Pulmonary Embolism ↓↓ N — ↓ ↑↑ Dilated RV, small LV
Cardiac Tamponade ↓ — ↓↓ ↑↑ ↑↑ Pericardial effusion, small ventricles, dilated inferior vena cava
Distributive Septic Shock N — ↑↑ ↓ — ↓↓ N — ↓ N — ↓ ↑ — ↑↑ Normal cardiac chambers with preserved contractility
Anaphylactic Shock N — ↑↑ ↓ — ↓↓ N — ↓ N — ↓ ↑ — ↑↑
Hypovolemic Volume Depletion ↓↓ ↓↓ ↓↓ Small cardiac chambers with normal or high contractility

Treatment

Management of shock consists of stabilization of the hemodynamic status and correction of the underlying cause once it is identified.

Cardiogenic shock

Obstructive shock

Distributive shock

Hypovolemic shock

Do's

  • Initial Management
  • Resuscitation should be initiated while investigation is ongoing. Correct the cause of shock immediately once it is identified.
  • The VIP (Ventilate-Infuse-Pump) approach is useful for ensuring an orderly sequence of therapeutic-diagnostic maneuvers.[3]
  • Ventilate
  • Infuse
  • Pump

Don'ts

References

  1. 1.0 1.1 Vincent, JL.; De Backer, D. (2013). "Circulatory shock". N Engl J Med. 369 (18): 1726–34. doi:10.1056/NEJMra1208943. PMID 24171518. Unknown parameter |month= ignored (help)
  2. Rosen, Peter; Marx, John A. (2013). Rosen's emergency medicine : concepts and clinical practic. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1-4557-0605-1.
  3. Weil, MH.; Shubin, H. (1969). "The VIP approach to the bedside management of shock". JAMA. 207 (2): 337–40. PMID 5818156. Unknown parameter |month= ignored (help)
  4. Dellinger, RP.; Levy, MM.; Rhodes, A.; Annane, D.; Gerlach, H.; Opal, SM.; Sevransky, JE.; Sprung, CL.; Douglas, IS. (2013). "Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012". Crit Care Med. 41 (2): 580–637. doi:10.1097/CCM.0b013e31827e83af. PMID 23353941. Unknown parameter |month= ignored (help)