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
- blood loss (malena, haemorrhage into drains…)
- inotropes and vasopressors
- blood and blood products
- type of ventilation (NIV, invasive, spontaneous breaths, controlled, oscillation, ECMO)
- assess ventilation strategy (ARDS, bronchospasm)
- level of support
- 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
- Level 1 rapid infuser
- 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
-> quick examination
- fluid balance
- intra-abdominal pressure
- trend in lactate
- cardiac output data (trend in SvO2)
- renal function
- trend in Hb and transfusion requirements
- microbiology: sepsis
- 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.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of LITFL.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of two amazing children.
On Twitter, he is @precordialthump.