UNDIFFERENTIATED SHOCK Flashcards
MANAGEMENT
- AIRWAY: RAPID SEQUENCE INTUBATION
Critical Sign: STRIDOR
Failure to Oxygenate
Failure to Ventilate
Failure to protect the airway
AVOID IN: OBSTRUCTIVE SHOCK
Pulmonary Embolism
Tension Pneumothorax
Cardiac Tamponade
POST-INTUBATION HYPOTENSION
A shock index of >0.8 portends a higher likelihood of post-intubation hypotension.
Have vasopressors available and ready to administer.
PHENYLEPHRINE
10 mg in 100 ml of saline = 100 mcg / ml
Bolus Dose:
100 mcg IV (1 ml bolus) PRN
Infusion Dose:
0.1 - 1.0 mcg / kg / min
- BREATHING
CRITICAL SIGN: RESPIRATORY RATE. >/ 30, 02 sats 90% on Fi02 30%.
NASAL PRONG:
Flow rates up to 1-5 L
Fi02 up to 25-40% depending on Vt
SIMPLE MASK:
VENTURI MASK:
Fi02 24-50%
NON-REBREATHER MASK:
Flow Rate: 6 - 10 lpm
Fi02: 80 - 90% Fi02 depending on breathing
make sure reservoir does not collapse
TARGET Sp02 > 94%
REDUCE Fi02 < 0.6
NON-INVASIVE VENTILATION
CPAP:
Start with PEEP 5-20 mmHg
BiPAP:
Start at 15/8-10
THEN
Titrate to 20/8-10
- CIRCULATION: FLUID RESUSITATION
CRITICAL SIGN: MOTTLED APPEARANCE
HYPOVOLEMIC / DISTRIBUTIVE:
30 ml / kg Lactated RIngers bolus (less in cardiogenic shock), reassess often
> / 30 cc/kg IVF within the first 60 min
CARDIOGENIC SHOCK
5 ml / kg over 15 min
FOLLOWING INITIAL BOLUS:
a. Assess fluid responsiveness via passive leg raise
b. Reassess for pulmonary edema
c. If hypoperfusion AND no pulmonary edema repeat bolus:
5 ml / kg for cardiogenic shock
10 ml / kg for hypovolemic
- DISABILITY
CRITICAL SIGN: GCS 8
- EXPOSURE
TAKE DOWN DRESSINGS
- POCUS: HI-MAP
POCUS: RUSH EXAM
+/-PELVIC SCAN
H - Heart Subxyphoid +/- four-chamber view and parasternal
I - Inferior vena cava (check for volume status)
M - Morrison’s pouch/focused assessment with sonography in trauma exam (looking for free fluid)
A - Aorta (to identify AAA)
P - Pneumothorax (looking for tension pneumothorax)
P - PELVIS
- CALCULATE SHOCK INDEX
SI = HR / SBP
Normal: 0.5-0.7
>1.0 a/w impaired LVF & higher mortality
- VASSOPRESSORS AND INOTROPES
NOREPINEPHRINE
First line for undifferentiated shock: septic, cardiogenic, neurogenic
Weight Based (Preferred):
0.01 - 3 ug / kg / min
Initial dose 0.01 - 0.1 ug / kg / min
BP in boots (SBP 70) start at 0.3
Fixed Dose:
1-300 ug / min
Initial Dose 1-10 ug / min
EPINEPHRINE
Alternate to Norepinephrine in Undifferentiated Shock
Anaphylactic, Septic, Cardiogenic, Post Arrest
Weight Based:
0.01-0.5 ug/kg/min
Fixed Dose:
2-10 ug/min (titrated to effect).
VASOPRESSIN
Resue Pressor for Septic Shock
Weight Based Dose (preferred):
0.02-0.1 U/min
Fixed Dose:
6 cc / hr
DOBUTAMINE
Decompensated heart failure, cardiogenic shock
2-20 μg/kg/min
Monitor for hypotension
- INVESTIGATIONS
Fingerstick Glucose
CBC with diff
Electrolytes / Extended lytes
Glucose
Creatinine
Liver Function Test
Lipase
VBG
Serum Lactate
Base Deficit
Cardiac Markers
Group / Screen
Blood Cultures
Urinalysis
Urine Culture
Quantitative sputum culture
Pregnancy test
REASSESSMENT
Goal Directed Therapy:
MAP > 65 mm Hg
SBP > 90
UO > 0.5 ml / kg / hr
Dynamic measurement to guide fluid resuscitation: passive leg raise with CO OR fluid bolus challenge against SV, SVV, PPV, echocardiogram
Guide resuscitation to decrease lactate
Capillary refil as an adjunct to other measures of perfusion
- DISPOSITION:
ADMIT TO ICU WITHIN 6 HRS
TARGETED THERAPY FOR SPECIFIC SHOCK ETIOLOGIES
TENSION PNEUMOTHORAX:
NEEDLE DECOMPRESSION
Peds – 2nd intercostal space midclavicular line
Adults – 5th intercostal space anterior to midaxillary line
5 cm or 8 cm over-the-needle catheter with Luer-Lok 10 cc syringe
Aspirate the syringe while advancing
Puncture Pleura
Remove Syringe
Listen to air escape
Advance catheter into the pleural space
Stabilize and prepare for chest tube insertion
TAMPONADE:
PERICARDIOCENTESIS
Blind Approach
18-gauge spinal needle
* 20-mL syringe
* Position the patient supine.
* Use the subxiphoid approach.
* Clean the area and inject 2.5-5 mL of lidocaine 1% with epinephrine to create a wheal over the needle insertion area, if patient is not in cardiac arrest.
* Place an 18-gauge spinal needle on the 20-mL syringe.
* Insert the needle 1 cm inferior to the junction between the left costal arch and xiphoid process.
* Angle the needle between 15° and 30°, aiming toward the left shoulder.
o A medial or steep entry carries a risk of right atrial or intra-abdominal puncture.
* Slowly advance the needle with continual aspiration until fluid is obtained.
o Redirection, using an anterior-to-posterior motion, may be required if no fluid is aspirated.
PULMONARY EMBOLISM:
THROMBOLYTICS
ABSOLUTE C/I:
Prior intracranial hemorrhage
Known intracranial neoplasm, arteriovenous malformation, or aneurysm
Within previous 3 months:
Ischemic stroke
Gastrointestinal bleed
Active bleeding at a non-compressible site
Known bleeding diathesis
Liver failure with international normalized ratio >1.7
Within previous 21 days:
Surgery or invasive procedure requiring opening of the chest, peritoneum, skull, or spinal canal
Significant trauma
TENECTEPLASE (TNK-tPA):
<60 kg: 30 mg as an intravenous bolus over 5-10 seconds
60 to 69 kg: 35 mg as an intravenous bolus over 5-10 seconds
70 to 79 kg: 40 mg as an intravenous bolus over 5-10 seconds
80 to 89 kg: 45 mg as an intravenous bolus over 5-10 seconds
≥90 kg: 50 mg as an intravenous bolus over 5-10 seconds
Note: This is the same dose for submassive pulmonary embolism.
STEMI:
THOMBOLYTICS
ABSOLUTE C/I::
Any prior ICH
Known structural cerebral vascular lesion (eg, arteriovenous malformation)
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke within 3 mo
EXCEPT acute ischemic stroke within 4.5 h
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head or facial trauma within 3 mo
Intracranial or intraspinal surgery within 2 mo
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 mo
Tenecteplase (TNK-tPA):
Reconstitute a 50-mg vial in 10 mL sterile water (5 mg/mL)
Single weight-based bolus, IV push over 5 sec
<60 kg: 30 mg
60-69 kg: 35 mg
70-79 kg: 40 mg
80-89 kg: 45 mg
>90 kg: 50 mg
DOCUMENTATION
- HISTORY
Ask about:
1-2 most concerning symptoms of the patient or historian.
THEN
Move to closed ended questions.
SEPSIS:
Fevers, chills, shortness of breath, cough, vomiting, abdominal pain, dysuria, areas of erythema of skin / soft tissue, joint swelling, headaches / neck stiffness
HYPOVOLEMIC:
Abdominal Pain
Persistent Vomiting
Diarrhea
Inability to tolerate PO / decreased PO intake
HEMORRHAGIC:
Traum
Recurrent epistaxis
Hematemesis
Melena
BRBPR
Use of Anticoagulants
H/o GI bleed, Liver disease
OBSTRUCTIVE:
Pleuritic Chest Pain
Dyspnea
Hematemesis
Pre Syncope
Leg Swelling
H/o DVT / PE, Cancer in last 6 months, Surgery in last 4 weeks, Estrogen, recent travel
CARDIOGENIC SHOCK:
Chest Pain
Radiation to jaw / arm / back
Shortness of breath
Diaphoresis
Vomiting
Headache / Abdo pain / Back Pain
H/o: CAD, CHF, HTN
ANAPHYLAXIS:
Pruritis
Hives
Diffuse erythroderma
Dyspnea
Wheezing
Abdominal Pain
Vomiting
Chest Pain
Recent new medication, new food, insect sting, known allergen exposure
- PHYSICAL EXAM
Document:
VITAL SIGNS
SHOCK INDEX
SI = HR / SBP
Normal: 0.5-0.7
>/8 in medical patients
OR
>1.0 in trauma patients a/w at risk / higher mortality
PRIMARY SURVEY
GCS
Mental Status
Cap Refill > 3 secs
Mottled Skin
Distal Pulses
Cool / Warm Extremities
Heart Sounds
Abdominal Tenderness
Airway
Tachypnea
Work of breathing
Tracheal Position
Lungs Sounds
Chest Wall Crepitus
PERRLA
Lateralizing signs
Glucose
Take down dressing
Remove clothing
Log roll
Urine Output <0.5 cc / kg / hr
SECONDARY SURVEY
CLINICAL FEATURES ASSOCIATED WITH DECREASED END-ORGAN PERFUSION:
AMS
Poor Skin Perfusion
Oliguria
- POCUS: HI-MAP
HEART PSL / PSS / 4CA:
Cardiac activity: positive / negative / indeterminate
Gross LV systolic function: normal / moderately depressed / severely depressed / indeterminate
Hyperdynamic LV: positive / negative / indeterminate
RV strain: present / absent / indeterminate
RV hypertrophy [6]: positive (RV free wall>5 mm) / negative (RV free wall≤5 mm) / indeterminate
Pericardial effusion: positive / negative / indeterminate
Left pleural effusion: positive / negative / indeterminate
Aortic outflow tract: >4 cm / ≤4 cm / indeterminate. Note presence of intimal flap, if seen
Descending aorta: >3 cm / ≤3 cm / indeterminate. Note presence of intimal flap, if seen
IVC: flat / full / grey zone / indeterminate
MORRISON’S POUCH:
FF(UQ) positive
FF(UQ) negative
FF(UQ) indeterminate
AORTA:
Aorta ___ cm (if positive)
Aorta < 3 cm (if negative)
Aorta indeterminate
PULMONARY: RESPIRATORY DISTRESS PROTOCOL:
Pneumothorax (left/right/bilateral): positive (small, medium, large[1]) / negative / indeterminate.
Pleural effusion (left/right/bilateral): positive (trace, moderate, large) / negative / indeterminate.
B-lines: positive (3 or more in one intercostal space) / negative / indeterminate.
Interstitial syndrome: positive (2 or more positive zones for B-lines in EACH lung) / negative / indeterminate.
ADHF: positive (interstitial syndrome, in the acutely dyspneic patient) / negative / indeterminate. Severity can be estimated by overall number of B-lines seen and whether they are found in both upper and lower lung zones.
- SIRS:
Fever > 38 or < 36
HR > 90
RR > 20 or pC02 < 32
WBC > 12000 or < 4000
DDX
- GENERAL CATEGORY:
SHOCKEY
Sepsis
Hypovolemia / Hemorrhage
Obstructive
Cardiogenic
AnaphylaKtic
Endocrine
- SPECIFIC ETIOLOGY:
OBSTRUCTIVE
Massive Pulmonary Embolism
Pericardial Tamponade
Tension Pneumothorax
Severe Pulmonary Hypertension
CARDIOGENIC
Massive Myocardial Infarction
Acute Heart Failure
Dysrhythmias
Myocarditis
Papillary Muscle Rupture / Valvular dysfunction
Free Wall Rupture
End Stage Cardiomyopathy
HYPOVOLEMIC
Traumatic Hemorrhage
Non-traumatic Hemorrhage
Non-hemorrhaging volume loss (eg. GI losses, Burns)
DISTRIBUTIVE
Sepsis
SIRS (eg. pancreatitis)
Neurogenic
Anaphylaxis
Endocrine (eg. Acute Adrenal Insufficiency)
Drug / Toxin (eg. snake bite)
