Diagnosis
Shock
A life-threatening condition of circulatory failure causing inadequate delivery of oxygen and leads to tissue hypoxia resulting in cellular death and dysfunction of vital organs.
Etiology
Cause [ri2]
Precardial (decreased intravascular volume):
Hemorrhagic hypovolemic: GI-bleeding, peptic ulcer, diverticulosis, trauma, ruptured aortic aneurysm, anticoagulation
Non-hemorrhagic hypovolemic: dehydration, GI losses, renal losses, skin losses (burns, SJS, TEN), 3rd space loss (pancreatitis, cirrhosis, GI obstruction)
Cardial:
Primary cardiac: Cardiomyopathy, myocardial infarction, arrhythmia, valvular defects, cardiac contusion
Obstructive: Cardiac tamponade, pulmonary embolism, tension pneumothorax, pericardial tamponade, restrictive cardiomyopathy, constrictive pericarditis
Postcardial (periferal vasodilatation):
SIRS, sepsis, anaphylaxis
Endocrine (addison/myxedema)
Neurogenic shock
Pathophysiology [ri2]
Precardial/cardial shock: Decrease in blood flow --> decreased oxygen transport
Postcardial shock: Decreased vascular resistance --> abnormal oxygen extraction
Imbalance between supply and demand of oxygen --> Hypoxia
Hypoxia --> acidosis and a decrease in regional blood flow
Pre-shock compensation:
Tachycardia
Tachypnea
Peripheral vasoconstriction
Shock:
Hypotension
Oliguria
Lactacidosis
Abnormal mental status
Cold, clammy extremities
Pale, mottled skin
End-organ dysfunction:
Irreversible organ dysfunction or injury (necrosis)
Multiorgan failure
Death
Epidemiology
Incidence per 100.000 [qes][voa][yys][zvo]
Symptoms & findings
Symptoms
Anuria, Arrhythmia, Atonia, Burns, Cold skin, Confusion, Cyanosis, Decreased consciousness, Diaphoresis, Dyspnea, Fever, Hematemesis, Hypotension, Ileus, Melena, Oliguria, Pallor, Paralysis, Prolonged capillary refill, Rectal sphincter atonia, Stridor, Tachycardia, Tachypnea
Clinical findings
Acidosis, Anemia, Decreased Ejection Fraction, Elevated CRP, Elevated Ejection Fraction, Elevated Lactate, Hemopericardium, Hemoperitoneum, Hemothorax, Leukocytosis, Myocardial hyperkinesia, Myocardial hypokinesia, Pulsus paradoxus
Anamneses
None listed.
Localized findings
Approach
Blood test: lactate, CRP, sendimentation rate, creatinine, glucose levels, prothrombin time, activated partial thromboplastin time, hCG
Blood gas
Blood culture
ECG
Chest x-ray
Abdominal x-ray
Ultrasound abdomen,
Echocardiography
Digital rectal exploration: rectal tone, hemofec, temparature
CT thorax/abdomen/pelvis
Treatment
Three goals of hypovolemic shock treatment: [tji][ri2]
Maximize oxygen delivery:
Airways: Oxygen supply, mechanical ventilation
Breathing: Oxygen saturation, chest tube
Circulation: IV fluid/blood transfusion, intraosseous infusion, vasopressor
Septic shock:
IV isotonic crystalloids 30 mL/kg within 3 hrs
Empiric antibiotic therapy
Vasopressor: Norepinephrine
Anaphylactic shock:
IV fluid resuscitation with 4 to 6 L of IV crystalloids
Stop the offending agent
Intramuscular epinephrine
Antihistamines
Corticosteroids
Nebulized albuterol
Adrenal crisis: IV fluid resuscitation + IV dexamethasone
Hypovolemic shock:
Two large-bore IVs or central line --> 2 to 4 L of isotonic crystalloids
Trendelenburg position
RBC transfusion if ongoing bleed
Vsopressors if needed
Underlying condition:
Trauma: Surgery, coil embolization
Gynecological: Ectopic pregnancy, placenta previa, abruptio placenta, ruptured cyst, miscarriage
GI bleeding: Vasopressin IV, H2 blockers, somatostatin/octreotide IV, Sengstaken-Blakemore
Obstructive cardial shock:
IV crystalloids
Vasopressor: Norepinephrine (+ vasopressin if refractory)
Underlying condition:
Massive pulmonary embolism --> Thrombolysis/Embolectomy
Chest tube
Pericardioscentesis or pericardiotomy
Cardiogenic shock:
Cardiac arrest/arrhythmia --> Advanced cardiac life support
IV fluids in the absence of pulmonary edema
Inotropes: Dobutamine
Vasopressor: Norepinephrine
Intra-aortic balloon pump
STEMI --> thrombolysis, coronary revascularization procedures, IABP, ECMO
Differential diagnoses
Abruptio placentae, Acute pancreatitis, Anaphylaxis, Aortic dissection, Aortic regurgitation, Aortic stenosis, Arrhythmia, Arteriovenous malformation, Bladder perforation, Cardiac contusion, Cardiac tamponade, Colorectal cancer, Disseminated intravascular coagulation, Esophageal varices, Gastric cancer, Gastrointestinal obstruction, Hemolytic anemia, Hemorrhoids, Hypovolemia, Internal hemorrhage, Mallory-Weiss tear, Menorrhagia, Mitral regurgitation, Mitral stenosis, Myocardial infarction, Myocardial rupture, Neurogenic shock, Perforated ulcer, Pulmonary embolism, Renal artery aneurysm, Ruptured aortic aneurysm, Ruptured ectopic pregnancy, Sepsis, Splenic injury, Tension penumothorax, Toxic shock syndrome, Tricuspid stenosis
References
[1] Haseer Koya H, Paul M. Shock. Updated 2023 Jul 24: https://www.ncbi.nlm.nih.gov/books/NBK531492/
[2] Holler JG, Henriksen DP, Mikkelsen S, Rasmussen LM, Pedersen C, Lassen AT. Shock in the emergency department; a 12 year population based cohort study. Scand J Trauma Resusc Emerg Med. 2016 Jun 30;24:87.
[3] Li L, Sunderland N, Rathnayake K, Westbrook J. Epidemiology of sepsis in Australian public hospitals: a mixed methods, national longitudinal study (2013-2018). Sydney: Australian Commission on Safety and Quality in Health Care, 2020. 69 p.
[4] Tian HC, Zhou JF, Weng L, Hu XY, Peng JM, Wang CY, Jiang W, Du XP, Xi XM, An YZ, Duan ML, Du B; for China Critical Care Clinical Trials Group (CCCCTG). Epidemiology of Sepsis-3 in a sub-district of Beijing: secondary analysis of a population-based database. Chin Med J (Engl). 2019 Sep 5;132(17):2039-2045.
[5] Zhou J, Tian H, Du X, Xi X, An Y, Duan M, Weng L, Du B; for China Critical Care Clinical Trials Group (CCCCTG). Population-Based Epidemiology of Sepsis in a Subdistrict of Beijing. Crit Care Med. 2017 Jul;45(7):1168-1176.
[6] http://emedicine.medscape.com/article/760145 (2014-01-02); [Medscape]
[7] Henriksen DP, Laursen CB, Jensen TG, Hallas J, Pedersen C, Lassen AT. Incidence rate of community-acquired sepsis among hospitalized acute medical patients-a population-based survey. Crit Care Med. 2015 Jan;43(1):13-21.