Hospital Standards for Accreditation for Afghanistan:
Assessment of Progress in Achieving the Standards
Hospital Department or Area:
Emergency Department: Shock Management
Hospital Facility: ___________________________________
Assessor: __________________________
Standard
Number
Standard
1
Rapid initial
assessment of ABCs
is conducted
Date of Assessment: ________________
Emergency Department: Shock Management
Criteria for Verification of Meeting Standard
Compliance in
Meeting Standard
Full Partial None
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Initial assessment by a physician includes:
- Trauma: if trauma occurred, place
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cervical collar unless absolutely sure it
is not required
- Airway: eliciting verbal response
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- Airway: provides oxygen to all patients
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and provides an adjunct airway as
needed; Intubates as required
- Breathing: notes respiratory rate,
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abnormal breath sounds, use of
accessory muscles of respiration,
oxygen saturation
- Circulation: Notes extremity pulses;
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rate, strength, rhythm
- Circulation: Places 2 large bore
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peripheral IVs
Basis for Evaluation Score/
Comments/Action Plan
-
2
Uses a systematic
approach to
determining the
etiology of the
patient’s condition
Circulation: Notes blood pressure (in all
4 extremities if indicated)
- Circulation: Provides isotonic
crystalloid IVFs initially. For unstable
patients, 20-40 ml/kg should be given
rapidly (over 10-20 minutes).
- Neurologic: notes mental status and
GCS or AVPU
- Motor: notes any specific motor deficits
- Disability/Exposure: Performs
complete secondary examination when
appropriate
Shock is tissue hypoperfusion and is
associated with decreased venous oxygen
content and metabolic (lactic) acidosis.
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1
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2
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2
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2
2
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1
0
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-
2
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2
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2
2
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1
0
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2
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2
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-
-
Obtains targeted history of presenting
symptoms and past medical history,
including medications and drug use.
Obtains blood pressure and notes pulse
pressure (SBP – DBP = PP)
Obtains other vital signs, including
temperature, respiratory rate, heart rate.
Observes mental status.
Observes skin for changes including
pallor, sweating, bruising, petechiae,
cyanosis, decreased capillary refill, etc.
Exposes the patient completely to check
for occult wounds/skin changes.
Orders the following laboratory studies
as appropriate or available: Cbc,
-
-
Electrolytes, BUN, creatinine, PTT,
PT/inr, lactate, fibrinogen, d-dimer,
cortisol, urinalysis, abg, liver function
tests, blood/urine/csf cultures
Orders the following as appropriate or
available: Chest xray, EKG, ultrasound
and/or CT scans
Notes that respiratory alkalosis is
common early in shock states.
Notes that lactic/metabolic acidosis
occurs later in shock states.
Notes that hyper/hypoglycemia and
hyperkalemia also occur with shock.
TRAUMA/HYPOVOLEMIC: Following
isotonic crystalloid resuscitation if patient is
still unstable:
- provides direct compression to active
external bleeding
- places surgical consultation for internal
bleeding control
- provides packed red blood cells; fully
cross- matched if available or type O
(negative to women of child-bearing
age) as needed
- Considers use of vasopressors following
IVF resuscitation
- Treats acidosis with IVF and ventilation
- Considers placement of central line
SEPTIC: Checks all vital signs:
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-
Considers septic shock in all patients
with T <36 or >38, SBP < 90 mm Hg,
and inadequate tissue perfusion
Notes tachycardia, wide pulse pressure,
tachypnea, hypotension as signs of
shock
Notes mental status changes may occur
Orders labs and additional studies as
noted above as appropriate
Performs aggressive ABC resuscitation
with IVFs and oxygen.
Provides pressors for patient not
responsive to crystalloid infusion
(dopamine for sbp 70-100 mm Hg,
norepinephrine for sbp <70 mm Hg.
Begins empiric antibiotics after
obtaining cultures and removing
potential infectious sources (e.g.
catheters).
Treats acidosis with IVF and oxygen.
Administers sodium bicarbonate only if
very severe.
Treats DIC with FFP if available.
Treats suspected adrenal insufficiency
with glucocorticoids.
CARDIOGENIC: Checks all vital signs.
- Notes decrease in MAP by 30 mm Hg or
narrow pulse pressure (< 20 mm Hg)
- Checks for tachypnea, rales, wheezing,
confusion, anxiety, cool clammy skin,
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decreased urine output, heart rate
changes.
Obtains EKG immediately to evaluate
for ischemia, infarction, arrhythmias,
electrolyte abnormalities, etc.
Obtains chest xray immediately to
evaluate for widened mediastinum,
pulmonary edema, cardiac silhouette
abnormalities.
Considers checking CK, CK-mb,
troponin levels if available.
Obtains transthoracic echocardiogram if
available.
Aggressively treats ABCs as
appropriate.
Treats arrhythmias, electrolyte
abnormalities, hypoxemia and
hypovolemia appropriately.
Gives aspirin 325 mg to the patient to
chew (unless contraindicated).
Provides other analgesics as appropriate
(nitroglycerin 0.4 ml sl and/or morphine
iv).
Considers use of pressors.
Consults Cardiology if available.
ANAPHYLAXIS: Typically occurs within
minutes to one hour following exposure to
drugs, foods, stings, etc. Anaphylaxis
includes respiratory failure or cardiovascular
collapse.
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-
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-
Obtains a thorough history if possible
Obtains complete set of vital signs.
Administers oxygen
Considers endotracheal intubation and
realizes that this may be difficult due to
angioedema. Is prepared for
cricothyrotomy.
Removes potential contributing
exposures such as IV drugs.
Airway: gives epinephrine 0.3-0.5 mg
IM of 1:1000 (peds 0.01 ml/kg max 0.5
mg)
If hypotensive, give 1-2L IV isotonic
crystalloid fluids.
Consider antihistamines:
Diphenhydramine 25-50 mg IV/IM/PO
and H2 blocker such as ranitidine IV.
Treat bronchospasm with
inhaled/nebulized B2 agonist.
Control persistent or delayed allergic
reactions with corticosteroids
(methylprednisolone IV or prednisone
PO)
Consider glucagons for patients on B
Blockers.
NEUROGENIC: caused by acute injury to
the spinal cord leading to bradycardia and
hypotension.
- Realize that the higher the spinal cord
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injury, the more severe symptoms that
occur.
Perform ABC assessment and trauma
evaluation as outlined above.
Give IVFs as indicated for hypotension.
If refractory, give dopamine or
dobutamine as indicated.
Treat bradycardia with atropine.
Consider high dose methylprednisolone
therapy: 30 mg/kg bolus (in 15 minutes,
then nothing for 45 minutes) followed
by 5.4 mg/kg/h for 23 hours
Consult orthopedics, neurosurgery
and/or trauma surgery as indicated.
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