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	Ensure patency of the airway Assess breathing and administer oxygen if indicated Place two large bore cannula and initiate 2lts of saline/crystalloids (20mls/kg in pediatrics). Reassess after giving fluids Assess for mental status blood products (RBC,plasma,platelets) 1:1:1 if no improvent then refer
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	Ensure patency of the airway Assess breathing and administer oxygen if indicated Place two large bore cannula and AVOID giving IV fluids, if needed give small volume (adult: 250mls-500mls and pediatrics: 5mls/kg) Assess for mental status Inotropes (Dobutamine 2-20mcg/kg/min or vasopressor (Dopamine 1-50mcg/kg/min) Give blood if needed
Septic shock	Caused by an  overwhelming infection, leading to vasodilatation.	Elevated body temperature	Ensure patency of the airway Assess breathing and administer oxygen if indicated Place two large bore cannula and initiate 2lts of saline/crystalloids (20mls/kg in pediatrics) Assess for mental status Empirical antibiotic therapy within 1 hr
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	Ensure patency of the airway Assess breathing and administer oxygen if indicated Place two large bore cannula and initiate 2lts of saline/crystalloids (20mls/kg in pediatrics) - Assess for mental status Inotropes (Dobutamine 2-20mcg/kg/min or vasopressor (Dopamine 1-50mcg/kg/min) Give blood if needed
Anaphylactic shock	Caused by severe allergic reaction to an allergen, or drug.	Bronchospasm, angioedema and/or Urticaria	Refer to anaphylaxis section

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.