Shock Hot Case

GENERAL APPROACH

Find the shock (is it PROVED?)

• Pump, rate/ rhythm = Cardiogenic – myocardial, valves, rhythm, pericardium, left and right sided (signs: cool peripherally, shut down, bounding pulse, narrow pulse pressure, inotropes, high CVP, low SvO2, low Q, crackles in chest, oedema)
• Obstructive – TP, tamponade, abdominal compartment syndrome (signs: cool peripherally, narrow pulse pressure, inotropes, vasopressors, high CVP, muffled heart sounds, low Q)
• Volume =Hypovolaemic – bleeding, dehydration, 3rd spacing (signs: cool peripherally, CR, pale, low CVP, low BP, narrow pulse pressure, high HR)
• Endocrine — adrenal insufficiency, thyroid disorders
• Distributive – SIRS, septic, anaphylaxis (signs: WWP, dilated, bounding pulse, low diastolic pressure, wide pulse pressure, pressors, low CVP, high Q, low SVRI, active praecordium)
• ? = Technical – transducer height, quality of trace

INTRODUCTION

CUBICLE

• blood loss (malena, haemorrhage into drains…)

INFUSIONS

• inotropes and vasopressors
• vasopressin
• blood and blood products
• APC

VENTILATOR

• type of ventilation (NIV, invasive, spontaneous breaths, controlled, oscillation, ECMO)
• assess ventilation strategy (ARDS, bronchospasm)
• level of support

MONITOR

• check transducer heights and calibration
• MAP (pressure, swing, pulsus paradoxus)
• pulse pressure
• heart rate and rhythm
• CVP (number and waveform)
• PICCO and PAC recent data
• SpO2
• temperature

EQUIPMENT

• Level 1 rapid infuser
• IABP
• pacing (mode, working properly)
• intercostals drains (number, swinging, bubbling, blood loss)
• surgical drains (type and amount of fluid being lost)
• recent urinary output
• Edgerton bed (spinal injury)
• Halo brace (spinal injury)

QUESTION SPECIFIC EXAMINATION

• identification of the predominant cause of shock
• hands -> head -> chest -> abdo -> feet -> back

-> cardiovascular
-> respiratory
-> abdominal

• neurological

-> paralysed
-> quick examination
-> unconscious
-> conscious

• fluid balance
• intra-abdominal pressure

RELEVANT INVESTIGATIONS

Bedside

• ABG
• ECG
• trend in lactate
• cardiac output data (trend in SvO2)

Laboratory

• CXR
• TNI
• renal function
• trend in Hb and transfusion requirements
• microbiology: sepsis

Imaging

• ECHO
• CTPA

OPENING STATEMENT

• My approach to shock is to rule out technical problems and then look for hypovolaemic, distributive, obstructive and cardiogenic causes.
• = I believe that this patient has primarily has… shock as evidenced by… (present positives and relevant negatives)
• I would like to rule out other causes by ordering… investigations.