Management of shock

Management
If BP unrecordable, call the cardiac arrest team.

Specific measures:
Anaphylaxis: refer to later blog entry
Cardiogenic shock: refer to later blog entry

Septic shock: (if no clue to source): IV cefuroxime 1.5g/6-8h (after blood culture) or gentamicin, do levels; reduce in renal failure) + antipseudomonal penicillin, eg ticarcillin (as Timentin, max dose 3.2g/4h IVI). Give colloid, or crystalloid, by IVI. Refer to ITU if possible for monitoring inotropes; aim for CVP 8-12mmHg, MAP >65mmHg. Urine >35ml/h. Low dose steroids may help as may recombinant human activated Protein C.

Hypovolaemic shock: Fluid replacement: saline or colloid initially; if bleeding use blood; Titrate against BP, CVP, urine output. Treat the underlying cause. If severe haemorrhage, exsanguinating, or more than 1L of fluid required to maintain BP, consider using group-specific blood. Correct electrolyte abnormalities. Acidosis often responds to fluid replacement.

Heat exposure (heat exhaustion): tepid sponging + fanning; avoid ice and immersion. Resuscitate with high-sodium IVI, such as 0.9% saline ± hydrocortisone 100mg IV. Dantrolene seems ineffective. Chlorpromazine 25mg IM may be used to stop shivering. Stop cooling when core temperature <39°C.

Coma: Immediate management

Immediate management

Assess airway, breathing, and circulation. Consider intubation if GCS <8. Support the circulation if required (ie IV fluids). Give O2 and treat any seizures. Protect the cervical spine.
Check blood glucose in all patients. Give 50mL 50% dextrose IV immediately if presumed hypoglycaemia.
IV thiamine if any suggestion of Wernicke's encephalopathy.
IV naloxone for opiate intoxication (may also be given IM or via ET tube); IV flumazenil for benzodiazepine intoxication if airway compromised (may precipitate seizures especially if tricyclic intoxication)




Examination
Vital signs are vital - obtain full set, including temperature.
Signs of trauma haematoma, laceration, bruising, CSF/blood in nose or ears, fracture deformity of skull, subcutaneous emphysema, "˜panda eyes"
Stigmata of other illnesses: liver disease, alcoholism, diabetes, myxoedema.
Skin for needle marks, cyanosis, pallor, rashes, poor turgor.
Smell the breath (alcohol, hepatic fetor, ketosis, uraemia).
Meningism but do not move neck unless cervical spine is cleared.
Pupils size, reactivity, gaze.
Heart/lung exam for murmurs, rubs, wheeze, consolidation, collapse.
Abdomen/rectal for organomegaly, ascites, bruising, peritonism, melaena.
Are there any foci of infection (abscesses, bites, middle ear infection?)
Any features of meningitis: neck stiffness, rash, focal neurology?
Note the absence of signs, eg no pin-point pupils in a known heroin addict.