Shock
Dr Mike Nicholls
Emergency Medicine Consultant
Auckland City Hospital
2011
Shock

Definition: Inadequate oxygen delivery and utilisation
by vital organs due to a problem with the circulation.
Types of shock

Hypovolaemic
 Distributive
 Cardiogenic
 Obstructive
Shock…look at the observations


Usually can be recognized by the observations and
peripheral circulation
Classic obs are
 Tachycardic (>90bpm),
 Hypotensive (<90-100mmHg),
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Others
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Shock index (pulse/systolic BP) >1
Tachypnoeic
Confused
Classic peripheral circulation would be delayed
capillary refill and cool peripheries
What can be done?

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Oxygen
IV access x2 large bore
Fluid bolus…


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0.9%saline…at least 1000ml. Usually significantly more than
this.
When concerned re CCF, can try 500ml bolus at first (or
250ml if very concerned)
Observe response
Consider



urinary catheter (further monitoring and obtain sample)
Placement : monitoring, resus
Specific treatment (depends on the cause)
Hypovolaemic

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Hypovolaemic (blood loss)
Get help : surgical emergency call
ABC
Blood loss :
 iv fluids +/ blood+/ Direct pressure
 surgery (arrest bleeding)
Distributive



Sepsis
Anaphylaxis
Neurogenic
Sepsis

Sepsis = 2 or more SIRS criteria + suspected or
proven infection (1992)

SIRS
Temperature >38°C or <36°C
 Heart rate > 90 beats/min
 Respiratory rate > 20 breaths/min or PaCO2 <32
torr (<4.3kPa)
 WBC > 12.000 cells/mm3, <4.000 cells/mm3, or
>10% immature (band)forms

Distributive Management

Distributive
 Sepsis :
 IV antibiotics, iv fluids, IV inotropes
 (ARISE trial)
 Anaphylaxis :
 IM adrenaline, iv fluids, steroids, antihistamines
Cardiogenic



Arrhythmia
Primary pump problem
Valve problem (acute)
Cardiogenic Management

Cardiogenic
 (iv fluid)
 Tachyarrythmia : DC/chemical cardioversion
 Bradyarrythmia : Atropine, pacing
 Pump problem : Inotropes
 PCI
Obstructive

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PE
Tension pneumothorax
Pericardial tamponade
Valvular obstruction
Obstructive
 PE : heparin, fibrinolytic
 Tension pneumothorax : Needle decompression
 Pericardial effusion : Pericardiocentesis
Shock : What can be done?
Summary



Oxygen
IV access x2 large bore
Fluid bolus…




0.9%saline…at least 1000ml. Usually significantly more than
this.
When concern re CCF, can try 500ml bolus at first (or 250ml if
very concerned)
Observe response
Consider



urinary catheter (further monitoring and obtain sample)
Placement : monitoring, resus
Specific treatment (depends on the cause)
But…

Beware…young people
Elderly
Pregnant
Those on beta blockers

Remember the observations!
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