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]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Treatment|Treatment]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Treatment|Treatment]]
|-
|-
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Don'ts|Don'ts]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Don'ts|Don'ts]]
|}
|}
__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]


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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.<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>
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>
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{{Family tree/start}}
{{Family tree/start}}
{{Family tree/start}}
{{Family tree/start}}
{{Family tree|boxstyle=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>]]
: ❑&nbsp;&nbsp;[[Metabolic acidosis|<span style="color: #000000;">Metabolic acidosis</span>]]</div>}}
: ❑&nbsp;&nbsp;Sustained hypotension
:: ❑&nbsp;&nbsp;[[SBP|<span style="color: #000000;">SBP</span>]] &lt;90 mm Hg ''or''
:: ❑&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;| | | | | | | | | |!| | }}
{{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;| | |,|-|-|-|-|-|-|^|-|-|-|-|-|.|}}
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'''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: 450px;| | 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;">
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{{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: 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;| | |!| | | |}}
{{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 pof wheezing with hives <br> or skin flushing?'''</div>
{{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>}}
|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=font-size: 90%; text-align: left;| | |!| | | |}}
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==Complete Diagnostic Approach==
==Complete Diagnostic Approach==


===History===
<div style="width: 80%;">
 
{| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
|'''History'''
|-
|
* ''Review all medications''
* ''Review all medications''
:* [[Antihypertensives]] can cause significant [[hypotension]], especially in the setting of [[volume depletion]] or [[Diuresis|over-diuresis]].
:* [[Antihypertensives]] can cause significant [[hypotension]], especially in the setting of [[volume depletion]] or [[Diuresis|over-diuresis]].
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:* [[Tachycardia]]
:* [[Tachycardia]]
:* [[Tachypnea]]
:* [[Tachypnea]]
|}


===Physical Examination===
{| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
 
| '''Physical Examination'''
|-
|
* ''Vital signs''
* ''Vital signs''
:* ''Temperature''
:* ''Temperature''
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:* [[Meningeal signs|Meningeal signs (nuchal rigidity, Brudzinski's sign, and Kernig's sign]]
:* [[Meningeal signs|Meningeal signs (nuchal rigidity, Brudzinski's sign, and Kernig's sign]]
::* [[Meningitis]]
::* [[Meningitis]]
|}


===Laboratory Findings===
{| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
| '''Laboratory Findings'''
|-
|


* ''Complete blood count''
* ''Complete blood count''
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* ''Pregnancy test''
* ''Pregnancy test''
:* A [[pregnancy test]] should be performed on [[hypotension|hypotensive]] women of childbearing age presenting with lower [[abdominal pain]].
:* A [[pregnancy test]] should be performed on [[hypotension|hypotensive]] women of childbearing age presenting with lower [[abdominal pain]].
|}


===ECG 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]]
* [[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]]
:* [[Myocardial infarction|Myocardial infarction or ischemia]]
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:* [[Pneumothorax|Pneumothorax]]
:* [[Pneumothorax|Pneumothorax]]
* [[Bradyarrhythmias]] or [[tachyarrhythmias]]
* [[Bradyarrhythmias]] or [[tachyarrhythmias]]
|}


===Radiographic Findings===
{| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
 
|'''Radiographic Findings'''
|-
|
* ''[[Chest radiograph]]'' may aid in establishing diagnosis in the following conditions:
* ''[[Chest radiograph]]'' may aid in establishing diagnosis in the following conditions:
:* [[Aortic dissection]]
:* [[Aortic dissection]]
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:* [[Hemorrhage|Occult internal hemorrhage]]
:* [[Hemorrhage|Occult internal hemorrhage]]
:* [[Pulmonary embolism]]
:* [[Pulmonary embolism]]
|}


===Hemodynamic Profiles and Echocardiography Findings===
{| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
 
|'''Hemodynamic Profiles and Echocardiography Findings'''
{| style="border: 2px solid #A8A8A8; font-size: 90%;" align="center"
|+ <SMALL>''Classification of shock based on hemodynamic profiles and echocardiographic findings.''<ref name="isbn0-683-06754-0">{{Cite book  | last1 = Parrillo | first1 = Joseph E. | last2 = Ayres | first2 = Stephen M. | title = Major issues in critical care medicine | date = 1984 | publisher = William  Wilkins | location = Baltimore | isbn = 0-683-06754-0 | pages =  }}</ref><ref name="isbn1125885874">{{cite book | author = Weil, Max Harry; Shubin, Herbert | authorlink = | editor = |others = | title = Diagnosis and Treatment of Shock | edition = | language = |publisher = Williams & Wilkins | location = | year = 1967 |origyear = | pages = |quote = | isbn = 1125885874 | oclc = |doi = |url = | accessdate = }}</ref><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></SMALL>
| align="center" style="background: #A8A8A8; width: 105px;"| '''Type of Shock'''
| align="center" style="background: #A8A8A8; width: 55px;"| '''Etiology'''
| align="center" style="background: #A8A8A8; width: 55px;"| '''CO'''
| align="center" style="background: #A8A8A8; width: 55px;"| '''SVR'''
| align="center" style="background: #A8A8A8; width: 55px;"| '''PCWP'''
| align="center" style="background: #A8A8A8; width: 55px;"| '''CVP'''
| align="center" style="background: #A8A8A8; width: 55px;"| '''SVO2'''
| align="center" style="background: #A8A8A8;"| '''Echocardiographic Findings'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC; width: 80px;" align=center rowspan=4 | '''Cardiogenic'''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC; width: 20%;" | '''[[Ventricular septal defect|Acute Ventricular Septal Defect]]'''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓↓
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑ — ↑↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" rowspan=3 | Large ventricles with poor contractility
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" | '''[[Mitral regurgitation|Acute Mitral Regurgitation]]'''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓↓
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑ — ↑↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" | '''[[Myocardium|Myocardial Dysfunction]]'''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓↓
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" | '''[[RV infarction|RV Infarction]]'''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓↓
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" | Dilated RV, small LV, abnormal wall motions
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" rowspan=2 align=center | '''Obstructive'''
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" | '''[[Pulmonary embolism|Pulmonary Embolism]]'''
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓↓
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |N  — ↓
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑↑
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" | Dilated RV, small LV
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" |'''[[Cardiac tamponade|Cardiac Tamponade]]'''
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓ — ↓↓
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑↑
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑↑
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" | Pericardial effusion, small ventricles, dilated inferior vena cava
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" rowspan=2 align=center | '''Distributive'''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" | '''[[Septic shock|Septic Shock]]'''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓ — ↓↓
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑ — ↑↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" rowspan=2 | Normal cardiac chambers with preserved contractility
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" | '''[[Anaphylactic shock|Anaphylactic Shock]]'''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑↑
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓ — ↓↓
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑ — ↑↑
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" rowspan=1 align=center | '''Hypovolemic'''
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" | '''[[Volume depletion|Volume Depletion]]'''
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓↓
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓↓
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓↓
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" | Small cardiac chambers with normal or high contractility
|-
|-
|
<table style="border: 2px solid #A8A8A8; width: 100%; font-size: 80%;" align="center">
<tr>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>Type of Shock</b>
</td>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>Etiology</b>
</td>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>CO</b>
</td>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>SVR</b>
</td>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>PCWP</b>
</td>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>CVP</b>
</td>
<td align="center" style="background: #B0B0B0; width: 55px;"> <b>SVO2</b>
</td>
<td align="center" style="background: #B0B0B0;"> <b>Echocardiographic Findings</b>
</td></tr>
<tr>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC; width: 80px;" align="center" rowspan="4"> <b>Cardiogenic</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC; width: 20%;"> <b>Acute Ventricular Septal Defect</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑ — ↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" rowspan="3"> Large ventricles with poor contractility
</td></tr>
<tr>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;"> <b>Acute Mitral Regurgitation</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑ — ↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓
</td></tr>
<tr>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;"> <b>Myocardial Dysfunction</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓
</td></tr>
<tr>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;"> <b>RV Infarction</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;"> Dilated RV, small LV, abnormal wall motions
</td></tr>
<tr>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" rowspan="2" align="center"> <b>Obstructive</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"> <b>Pulmonary Embolism</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">N  — ↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"> Dilated RV, small LV
</td></tr>
<tr>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"><b>Cardiac Tamponade</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓ — ↓↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"> Pericardial effusion, small ventricles, dilated inferior vena cava
</td></tr>
<tr>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" rowspan="2" align="center"> <b>Distributive</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;"> <b>Septic Shock</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓ — ↓↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑ — ↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" rowspan="2"> Normal cardiac chambers with preserved contractility
</td></tr>
<tr>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;"> <b>Anaphylactic Shock</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↑↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓ — ↓↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑ — ↑↑
</td></tr>
<tr>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" rowspan="1" align="center"> <b>Hypovolemic</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"> <b>Volume Depletion</b>
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↑
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓
</td>
<td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"> Small cardiac chambers with normal or high contractility
</td></tr></table>
|}
|}
</div>


==Treatment==
==Treatment==
Line 566: 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)