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ck
Signs specific to the mechanism of shock
Hypovolaemic shock
T he co m m o n signs o f sho ck listed abo ve are ty p ical o f hy p o vo laem ic sho ck .
D o no t und erestim ate hy p o vo laem ia. S igns o f sho ck m ay no t beco m e evid ent until a
5 0 % lo ss o f blo o d vo lum e in ad ults.
Anaphylactic shock
– S ignificant and sud d en d ro p in B P
– T achy card ia
– F requent cutaneo us signs: rash, urticaria, angio ed em a
– R esp irato ry signs: d y sp no ea, bro ncho sp asm
Septic shock
– H igh fever o r hy p o therm ia (< 3 6 °C ) , rigo rs, co nfusio n
– B P m ay be initially m aintained , but rap id ly , sam e p attern as fo r hy p o vo laem ic sho ck .
Cardiogenic shock
– R esp irato ry signs o f left ventricular failure (acute p ulm o nary o ed em a) are d o m inant:
tachy p no ea, crep itatio ns o n auscultatio n.
– S igns o f righ t ventricular failure: raised jugular veno us p ressure, h ep ato jugular
reflux, so m etim es alo ne, m o re o ften asso ciated with signs o f left ventricular failure.
T he aetio lo gical d iagno sis is o riented by :
– T he co ntext: traum a, insect bite, o ngo ing m ed ical treatm ent, etc.
– T he clinical exam inatio n:
• fever
• sk in p inch co nsistent with d ehy d ratio n
• tho racic p ain fro m a m y o card ial infarctio n o r p ulm o nary em bo lus
• abd o m inal p ain o r rigid ity o f th e abd o m inal wall fro m p erito nitis, abd o m inal
d istensio n fro m intestinal o bstructio n
• blo o d in sto o ls, vo m iting blo o d in intestinal haem o rrhage
• subcutaneo us crep itatio ns, lik ely anaero bic infectio n
Management
S y m p to m atic and aetio lo gical treatm ent m ust tak e p lace sim ultaneo usly .
In all cases
– E m ergency : im m ed iate attentio n to the p atient.
– W arm th e p atient, lay him flat, elevate legs ( excep t in resp irato ry d istress, acute
p ulm o nary o ed em a).
– I nsert a p erip h eral I V line using a large calibre cath eter ( 1 6 G in ad ults) . I f no I V
access, use intrao sseo us ro ute.
– O xy gen therap y , assisted ventilatio n in the event o f resp irato ry d istress.
– A ssisted ventilatio n and external card iac co m p ressio n in the event o f card iac arrest.
– Intensive m o nito ring: co nscio usness, p ulse, B P , C R T , resp irato ry rate, ho urly urinary
o utp ut (insert a urinary catheter) and sk in m o ttling.
18
Signs specific to the mechanism of shock
Hypovolaemic shock
T he co m m o n signs o f sho ck listed abo ve are ty p ical o f hy p o vo laem ic sho ck .
D o no t und erestim ate hy p o vo laem ia. S igns o f sho ck m ay no t beco m e evid ent until a
5 0 % lo ss o f blo o d vo lum e in ad ults.
Anaphylactic shock
– S ignificant and sud d en d ro p in B P
– T achy card ia
– F requent cutaneo us signs: rash, urticaria, angio ed em a
– R esp irato ry signs: d y sp no ea, bro ncho sp asm
Septic shock
– H igh fever o r hy p o therm ia (< 3 6 °C ) , rigo rs, co nfusio n
– B P m ay be initially m aintained , but rap id ly , sam e p attern as fo r hy p o vo laem ic sho ck .
Cardiogenic shock
– R esp irato ry signs o f left ventricular failure (acute p ulm o nary o ed em a) are d o m inant:
tachy p no ea, crep itatio ns o n auscultatio n.
– S igns o f righ t ventricular failure: raised jugular veno us p ressure, h ep ato jugular
reflux, so m etim es alo ne, m o re o ften asso ciated with signs o f left ventricular failure.
T he aetio lo gical d iagno sis is o riented by :
– T he co ntext: traum a, insect bite, o ngo ing m ed ical treatm ent, etc.
– T he clinical exam inatio n:
• fever
• sk in p inch co nsistent with d ehy d ratio n
• tho racic p ain fro m a m y o card ial infarctio n o r p ulm o nary em bo lus
• abd o m inal p ain o r rigid ity o f th e abd o m inal wall fro m p erito nitis, abd o m inal
d istensio n fro m intestinal o bstructio n
• blo o d in sto o ls, vo m iting blo o d in intestinal haem o rrhage
• subcutaneo us crep itatio ns, lik ely anaero bic infectio n
Management
S y m p to m atic and aetio lo gical treatm ent m ust tak e p lace sim ultaneo usly .
In all cases
– E m ergency : im m ed iate attentio n to the p atient.
– W arm th e p atient, lay him flat, elevate legs ( excep t in resp irato ry d istress, acute
p ulm o nary o ed em a).
– I nsert a p erip h eral I V line using a large calibre cath eter ( 1 6 G in ad ults) . I f no I V
access, use intrao sseo us ro ute.
– O xy gen therap y , assisted ventilatio n in the event o f resp irato ry d istress.
– A ssisted ventilatio n and external card iac co m p ressio n in the event o f card iac arrest.
– Intensive m o nito ring: co nscio usness, p ulse, B P , C R T , resp irato ry rate, ho urly urinary
o utp ut (insert a urinary catheter) and sk in m o ttling.
18
