Approach to Shock

The following approach to shock was designed as a helpful tool for trainees to refer to while on call, when encountering a patient with unexplained hypotension or shock. It is important to note this is not an exhaustive list!

Approach to Shock Definition: life threatening circulatory failure resulting in severe tissue hypoxia and hypoperfusion. Diagnosis: persistent hypotension despite adequate volume resuscitation, with evidence of end organ damage. Types of Shock: - Hypovolemic - blood loss or dehydration. - Cardiogenic - inability of heart to effectively maintain forward flow. - Distributive - widespread blood vessel dilation. - Obstructive - something preventing or blocking adequate circulatory blood flow. - Neurogenic - inappropriate neuronal impulses to maintain adequate blood vessel tone. What to remember: ‘SHOCK-NO’! When a patient has hypotension and end organ damage, despite adequate IV fluids (approximately 30 ml/kg) if appropriate: - S: sepsis - does the patient have a fever, warm extremities, signs or symptoms of infection, and/or immuncompromised state? Send cultures, give antibiotics, provide fluids, trend lactate within 1 hour! Source control within 6 hours! - H: hypovolemia or hemorrhage - is the patient bleeding, was there a hemoglobin drop, or do they appear dry on exam or biochemically? Give fluids or blood! - O: obstructive - is the patient hypoxic or have a unilateral swollen leg, raised JVP, muffled heart sounds, unilateral breath sounds, or a deviated trachea? Think pulmonary embolism, pneumothorax or tamponade! - C: cardiogenic - is there an arrhythmia, signs of congestive heart failure, history of valvular disease, cool extremities, or central/mixed venous saturation of less than 65%? May need inotropy and diuresis when appropriate! - K: anaphyla’k’sis - recent antibiotics or blood product administration with an urticarial rash, wheeze, stridor, or nausea/vomiting/diarrhea? Given IV fluids, epinephrine, steroids, anti-histamines! - N: neurogenic - history of spinal cord injury, traumatic brain injury, or recent spinal anesthesia or procedure? Think neurogenic! - O: others - don’t forget about endocrine related causes, such as adrenal insufficiency and thyroid related causes!

Content by: Dr. Candice Griffin. All rights reserved.

Useful links:
Surviving Sepsis Guidelines
Life in the Fast Lane: Shock

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