Approach to Shock
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Shock is a state of acute circulatory failure leading to decreased organ perfusion, with inadequate delivery of oxygenated blood to tissues and resultant end-organ dysfunction and it is an emergency condition. Adherence to evidence-based care of the specific causes of shock can enhance a patient’s chances of surviving.
Clinical presentation
- Low blood pressure (systolic BP below 80 mmHg) is the key sign of shock
- Weak and rapid pulse
- Rapid and shallow breathing
- Restlessness and altered mental state
- Weakness
- Low urine output
Table 1.1: Types of shock & Additional Symptoms
Type of shock |
Description |
Additional Symptoms |
Initial Management |
Hypovolemic |
Most common type of shock; Primary cause is loss of fluid from circulation due to haemorrhage, burns, diarrhoea, etc. |
Weak thread pulse, cold and clammy skin |
|
Cardiogenic shock |
Caused by the failure of heart to pump effectively e.g. in myocardial infarction, cardiac failure etc. systolic blood pressure less than 80 or 90mmhg |
Distended neck veins, weak or absent pulses |
|
Septic shock |
Caused by an overwhelming infection, leading to vasodilatation. |
Elevated body temperature |
|
Neurogenic shock |
Caused by trauma to the spinal cord, resulting in sudden decrease in peripheral vascular resistance and hypotension. |
Warm and dry skin -hypotension -bradycardia -hypothermia |
|
Anaphylactic shock |
Caused by severe allergic reaction to an allergen, or drug. |
Bronchospasm, angioedema and/or Urticaria |
Investigations
The following investigations can be performed depending on the type of shock
- Basic serum chemistry (including renal function)
- Liver function tests
- Blood culture
- POC Ultrasound- lungs, IVC, Cardiac
- Echocardiography
- CSF analysis if a patient is suspected with meningitis
- Troponins
- Blood gases
- Serum Electrolytes
- Lactate
- Hb Level
Non-pharmacological Treatment
Prompt diagnosis of underlying cause is essential to ensure optimal treatment.
- Perform ABCD approach. Intervene when needed
- Maintain open airway
- Administer oxygen with face mask and if needed after intubation with assisted ventilation
- Check for and manage hypoglycemia
Pharmacological Treatment
Treatment depends on the type of shock. Intravenous fluid therapy is important in the treatment of all types of shock except for cardiogenic shock.
A: 0.9% sodium chloride (IV): Adultgive 2 litres bolus infusion. Repeat bolus until blood pressure is improved. Transfuse blood and plasma expanders in hemorrhagic shock. Paediatrics give 20ml/kg as a slow infusion.
All children with shock which is not obviously due to trauma or simple watery diarrhea should receive antibiotic cover for probable septicemia.
If the pressure doesn’t improve after two bolus of IV Fluids (4lts in adults and 40mls/kg in pediatrics), administer Ionotropes/vasopressors (Refer Sepsis and septic shock topic section)
CAUTION!
- Do not administer calcium containing fluids, e.g. Ringer Lactate, within 48 hours of administering ceftriaxone
- Do not administer IV fluids in case of cardiogenic shock but maintain IV line
- If patient develops respiratory distress, discontinue fluids but maintain IV line
- Ceftriaxone is contra-indicated in neonatal jaundice
Referral: Refer the patient urgently with the escort of a nurse to high level facility to establish the cause and address all medication given in the referral letter.