{"id":335,"date":"2016-07-26T12:53:14","date_gmt":"2016-07-26T12:53:14","guid":{"rendered":"http:\/\/emedsa.org.au\/CoreMed\/?p=335"},"modified":"2016-09-20T12:04:40","modified_gmt":"2016-09-20T12:04:40","slug":"shock-a-practical-approach","status":"publish","type":"post","link":"http:\/\/emedsa.org.au\/CoreMed\/2016\/07\/26\/shock-a-practical-approach\/","title":{"rendered":"Shock &#8211; A Practical Approach"},"content":{"rendered":"<p><a href=\"http:\/\/twitter.com\/share?url=http%3A%2F%2Femedsa.org.au%2FCoreMed%2F2016%2F07%2F26%2Fshock-a-practical-approach%2F&amp;count=none&amp;text=Shock - A Practical Approach - CoreMed\" class=\"twitter-share-button\">Tweet<\/a><\/p><p><strong>Introduction<\/strong><\/p>\n<p>The approach to shock should be <em>systematic, focussed and efficient<\/em><\/p>\n<p><strong>Establish there is sufficient evidence of hypoperfusion<\/strong><\/p>\n<p><strong>2 or more<\/strong> of the following without sufficient alternative cause e.g. pain, anxiety, cold<\/p>\n<ul>\n<li>Tachycardia<\/li>\n<li>Decreased capillary refill &gt; 4 secs<\/li>\n<li>Hypotension (including fall of 20% or 20% lower than pre-morbid BP) &#8211; MAP &lt; 65mmHg<\/li>\n<li>Oliguria &lt; 0.5ml\/hr<\/li>\n<li>Altered mentation<\/li>\n<li>Lactate &gt; 2 mmol\/L<\/li>\n<\/ul>\n<p><strong>Confirm a likely cause<\/strong><\/p>\n<p>Attempt to identify the likely underlying aetiology and <a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/07\/26\/shock\/\">pathophysiology\u00a0<\/a><\/p>\n<ul>\n<li><strong>Hypovolaemic?<\/strong> &#8211; Evident blood loss? Trauma? Excessive fluid loss from GIT or drains? \u00a0Flat jugular veins<\/li>\n<li><strong>Cardiogenic?<\/strong> &#8211; Chest pain? New murmurs? \u00a0Injury pattern on ECG? \u00a0 Elevated jugular veins?<\/li>\n<li><strong>Distributive?<\/strong> &#8211; Bounding pulse? wide pulse pressure?\u00a0<a href=\"http:\/\/: http:\/\/emedsa.org.au\/CoreMed\/2016\/07\/26\/sepsis-a-practical-approach\/\">Sepsis<\/a>? Spinal\/epidural anaesthetic? Spinal cord lesion?<\/li>\n<li><strong>Obstructive?<\/strong> &#8211; Risk factors or clinical evidence for pulmonary embolus?\u00a0Pericardial effusion on echo? Clinical or radiological tension pneumothorax? \u00a0Elevated jugular veins?<\/li>\n<\/ul>\n<p>It is possible to augment the assessment with <a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/09\/04\/shock-bedside-ultrasound-guided-management\/\">Bedside Cardiac Ultrasound<\/a><\/p>\n<p><strong>Management<\/strong><\/p>\n<ul>\n<li>If <strong>obstructive, treat immediate cause<\/strong> e.g. drain pneumothorax or tamponade<\/li>\n<li>If a shocked patient already has signs of <strong>pulmonary oedema<\/strong> then fluid should be withheld and\u00a0<strong>pressors<\/strong> considered<\/li>\n<li>If the patient has clear evidence of <strong>hypovolaemia<\/strong> then <strong>fluid resuscitation<\/strong> is justified to restore haemodynamic parameters. \u00a0However, there is a role for\u00a0<a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/08\/16\/permissive-hypotension\/\">limited fluid resuscitation and permissive hypotension<\/a> if the cause is suspected to be active bleeding that requires early intervention to control it<\/li>\n<li>If there is uncertainty, a judicious administration of 10m\/kg fluid (to a maximum of 30ml\/kg) should be trialled. \u00a0If no improvement occurs ,then pressors are recommended until more <a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/07\/26\/fluid-responsiveness\/\">sophisticated means of monitoring<\/a> are available<\/li>\n<li><strong>Treat the underlying cause<\/strong> e.g. antibiotics for sepsis, reperfusion therapy for myocardial infarction<\/li>\n<\/ul>\n<p><strong>Haemodynamic targets<\/strong><\/p>\n<p>Roughly are the ones that triggered a response (see above). \u00a0Major deviations should be corrected within minutes but as parameters normalise the corrections should be slowed over a period of hours to prevent complications of over-treatment.<\/p>\n<p>*fluid resuscitation should replace like for like i.e. crystalloid for water\/electrolyte loss, blood products for bleeding, albumin if protein rich fluid<\/p>\n<p><strong>Situations that may require modified targets<\/strong><\/p>\n<p>Examples<\/p>\n<ul>\n<li>Heart failure<\/li>\n<li>Renal failure<\/li>\n<li>Diuretic use<\/li>\n<li>Sepsis<\/li>\n<li>Cor pulmonale<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>TweetIntroduction The approach to shock should be systematic, focussed and efficient Establish there is sufficient evidence of hypoperfusion 2 or more of the following without sufficient alternative cause e.g. pain,&#8230; <a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/07\/26\/shock-a-practical-approach\/\">Read more &raquo;<\/a><\/p>\n","protected":false},"author":1,"featured_media":984,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"episode_type":"","audio_file":"","cover_image":"","cover_image_id":"","duration":"","filesize":"","date_recorded":"","explicit":"","block":"","filesize_raw":"","footnotes":""},"categories":[1],"tags":[],"class_list":["post-335","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"_links":{"self":[{"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/posts\/335","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/comments?post=335"}],"version-history":[{"count":10,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/posts\/335\/revisions"}],"predecessor-version":[{"id":931,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/posts\/335\/revisions\/931"}],"wp:featuredmedia":[{"embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/media\/984"}],"wp:attachment":[{"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/media?parent=335"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/categories?post=335"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/tags?post=335"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}