Shock and its management

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It is a clinical state characterized by hypotension, tachycardia, cold & clammy extremities and excessive sweating due to decreased perfusion at the cellular level.  Find out the type and cause of shock by taking a brief history.

Types of Shock

1.   Hypovolaemic.

2.   Endotoxic (Septic).

3.   Cardiogenic.

4.   Vasovagal.

5.   Anaphylactic.

Classification & Recognition Of Shock

1-Hypovolaemic Shock

Results from:

  • Loss of at least 20% circulatory blood volume due to acute haemorrhage.
  • Fluid depletion e.g. vomiting, diarrhoea, burns.

2-Cardiogenic Shock

Results From Inadequate Cardiac Output

  • Acute MI (commonest cause).
  • Valvular stenosis.
  • Ischaemic heart disease.
  • Arrhythmias.
  • Cardiomyopathy.
  • Massive pulmonary embolism.

3-Endotoxic Shock (Septic Shock)

Results from systemic infections:  (Gram-ve bacteria or their products)

Typically, sepsis is manifested by a hyperdynamic state consisting of tachycardia, vasodilatation with decreased cardiac filling pressure, decreased peripheral resistance and increased cardiac output.

 

4-Neurogenic Shock

Results due to sudden grievous situation, painful stimuli, anxiety, prolonged standing in up right position etc.  It is manifested by fainting and bradycardia.

5-Anaphylactic Shock

Due to drugs, insect bites, foods etc.  It is characterized by pruritis, urticaria, angioedema, respiratory distress (laryngospasm, bronchospasm), hypotension, abdominal cramps & diarrhoea.

Treatment

Depending on the type and cause of shock.

Hypovolaemic

1.   Maintain airway.  An airway may be inserted if patient is obtunded. Occasionally, alternative airway in the form of endotracheal intubation or tracheotomy may be required.

2.   Stop apparent bleeding by pressure.

3.   Resuscitation.

4.   Give Oxygen

5.   Pass two Branulas (Size 16 or 18).

6.   I/V Fluids.

  • If due to blood loss, take a sample of blood for Hb, grouping & cross-matching &
  • Serum electrolytes.
  • Start Hartman’s solution or normal saline until blood is arranged.  Give fluid 3 times the amount of blood loss.
  • If due to vomiting or diarrhea Hartman’s soln. or normal saline.

7.     Maintain B.P., pulse, temperature and intake / output record.  Measure urine output with condom or Foley catheter.

8.   Raise foot end of the bed.

9.   Inform the consultant.

10. Avoid hypothermia by keeping the patient warm and infusing warm fluids.

Cardiogenic Shock

  • Cardiac Resuscitation if needed.
  • Oxygen.
  • ECG.
  • Pass Branula to maintain I/V line.
  • Send a sample of blood for cardiac enzymes.
  • Set up cardiac monitor.
  • Narcotic Analgesia.

Inj. morphine 10 mg for chest pain.

  • Dopamine 3-10 microgram/kg-min.  Dilution can be achieved by one ampoule (40 mg) + 500 ml D/W-at 8-12 drops/min.
  • Dubatrex 10-30 microgram/kg-min.  Dilution can be achieved by one ampoule (250 mg) + 500 ml D / ½ saline at 16-20 drops/min.
  • Defibrillate.
  • Consult cardiologist.

Septic Shock

  • Maintain airway.
  • Oxygen.
  • Pass Branula
  • Catheterize the patient.
  • Send ABGs
  • I/V Fluids.
  • I/V Antibiotics:  3rd generation cephalosporins like Fortum, or
  • Inform Consultant and seek advice.

Neurogenic Shock

Raise the foot end of bed or if the patient is lying on the floor, elevate the legs.

Anaphylactic Shock

  • 100% oxygen; alternate airway if needed.
  • Pass Branula.
  • Epinephrine – should be administered immediately 3-5 mg S/C, 3-5 ml of a 1:1000 solution and repeat after 20-minute interval if necessary.
  • I/V Fluids.
  • Vasodilators, Name of drug.
  • Steroids:  Glucocorticoid injection Solu-Cortef 500 mg I/V (adults).
  • Inj. Solu-cortef 250 mg (children), to prevent relapse.
  • Antihistaminics (Inj. Avil 1 ampoule I/V stat).