Shock resident survival guide: Difference between revisions

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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;| | 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; 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: 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: 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;| | C07 |-| C08 | |C07=<div style="background: #FA8072; color: #F8F8FF; padding: 15px; text-align: center;">'''Presence of fever <br> or hypothermia?'''</div>
{{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>}}
|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: 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: 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;| | 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; 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: 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: center; padding: 0;| | C03 | | |C03=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">'''NO''', then proceed to the next question</div>}}
Line 234: Line 234:
{{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;| | C16 |-| C17 | |C16=<div style="background: #FA8072; color: #F8F8FF; padding: 15px; text-align: center;">'''Presence of <br> unexplained <br> hypoxemia?'''</div>
{{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>}}
|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: 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: 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;| | |!| | | |}}
{{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;">'''Abdominal pain or <br> low back pain?'''</div>
{{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;">''' 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>}}
|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: 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: 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;">'''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;">''' 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;| | |!| | | |}}

Revision as of 00:53, 17 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?

❑  Arterial hypotension

❑  SBP <90 mm Hg or
❑  MAP <70 mm Hg

❑  Signs of hypoperfusion

❑  Altered mental status
❑  Cold, clammy skin
❑  Oliguria
❑  Metabolic acidosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
 
 
 
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider other causes (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
 
 
 
 
 
 
 
 
 
 
Abdominal pain or
low back pain?
 
YES, then consider intra-abdominal etiologies
and surgical consultation
 
 
 
 
 
 
 
 
 
 
NO, then proceed to the next question
 
 
 
 
 
 
 
 
 
 
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

Classification of shock based on hemodynamic profiles and echocardiographic findings.[3][4][1]
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.[5]
  • Ventilate
  • Infuse
  • Pump

Don'ts

References

  1. 1.0 1.1 1.2 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. Parrillo, Joseph E.; Ayres, Stephen M. (1984). Major issues in critical care medicine. Baltimore: William Wilkins. ISBN 0-683-06754-0.
  4. Weil, Max Harry; Shubin, Herbert (1967). Diagnosis and Treatment of Shock. Williams & Wilkins. ISBN 1125885874.
  5. 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)
  6. 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)