approach to shock

cardiovascular

How do you approach the patient in shock? Traditionally we start with the classifications of shock, and there’s even the mnemonic SHOCK: Septic Hypovolemic Obstructive Cardiogenic, anaphylactiK. But these are both broad and incomplete. More recently the advent of Emergency Department Echo (EDE) has led to the development of more focused protocols like RUSH, which use the HIMAP mnemonic to work through the differential: Heart IVC Morrisons Aorta Pleura. While this highlights the contributions of ultrasound, it still gives an incomplete picture of shock. We can integrate into a systemic approach to the patient in shock, with an emphasis on the CARDIOVASCULAR system:

A: AIRWAY

-consider intubation

 

B: CHEST

-give oxygen

-POCUS: r/o tension pneumo, look for pneumonia

 

C: CARDIOVASCULAR

Rhythm instability (arrhythmogenic): monitor –> unstable rhythm

  • Cardiac arrhythmia: ECG to r/o arryhthmia as the cause of shock, e.g. heart block –> pace, unstable SVT/AF/VT –> cardiovert

Pump failure (obstructive, cardiogenic): ECG changes, EDE chest/cardio –> obstruction/failure + IVC dilation

  • Around heart: EDE pneumothorax (unilateral loss lung sliding) –> needle thoracostomy; pericardial tamponade (pericardial effusion + RV collapse + IVC dilation) –> pericardiocentesis
  • RV strain:  ECG antero-inferior changes; EDE RV strain (RV dilation, IVC dilation) + DVT –> thrombolyze
  • Dysfunctional LV: ECG ischemic changes; EDE CHF (pulmonary edema, reduced LV contractility, IVC dilation) –> thrombolyze STEMI, inotrope/pressor
  • Incompetent valve: new murmur + ECH (pulmonary edema, IVC dilation) –> surgery
  • Outflow dissection: ECG possible inferior ST elevation; EDE possible flap or pericardial effusion –> surgery

Volume loss (hypovolemic, hemorrhagic): EDE –> cardiac hypercontractility + IVC collapse +/- aneurysm/free fluid

  • Volume depletion –> fluid
  • Abdominal bleed: EDE free fluid –> RBC, surgery
  • Soft tissue bleed: EDE AAA –> RBC, surgery
  • Child-bearing: FF + pregnant –> RBC, surgery

Tone loss (distributive): EDE –> cardiac hypercontractility, IVC collapse

  • Urticaria: anaphylaxis –> epi, fluid
  • Lactate: septic –> antibiotics, fluid, source control
  • Addisonsian crisis –> steroids, fluid
  • Rx –> fluids, antidote (eg reverse beta blocker/calcium channel blocker)

 

D: NEUROLOGIC

-consider encephalitis/meningitis source

 

E: ENDO

-consider hormonal (hypo/hyperthyroid, adrenal)

 

Fluid/fertility

-consider pregnant

-consider urosepsis +/- stone

 

G: ABDOMINAL

-consider source: Ascites (SBP), Biliary, Organomeg (spleen bleed), Appy/tic, Loose stool (colitis)

 

H: HEME

-assess CBC, coagulopathy

 

I:INTOX

-consider tox

 

J: Joint, ortho, derm

-consider infected joint/bone/soft tissue

 

shock

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