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Assessing a Patient who is Shocked

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Assessing a patient in shock requires immediate and precise action. A palpable radial pulse suggests a systolic blood pressure (SBP) of at least 80 mmHg, while a palpable femoral pulse indicates an SBP of at least 70 mmHg.

Initial Shock Management: Oxygen 15 L/min unless COPD. NS = Normal Saline
Insert two large bore IV lines and start crystalloid fluids unless pulmonary oedema is present. Send for FBC, U&E, LFTs, Group and Hold +/- Lactate levels. Further tests: Troponin, D-dimer, ABG, ECG, CXR, AXR, Amylase (if abdominal pain present). Consider inserting a urinary catheter to monitor urine output. Abdominal pain in patients over 50 years: urgent assessment for AAA (abdominal aortic aneurysm). Chest pain: ECG/CXR/CT for STEMI, PE, or aortic dissection. Arrhythmias: Tachycardia: Use Amiodarone or DC Shock. Bradycardia: Use Atropine or pacing. Breathlessness: If tension PTX suspected, check for surgical emphysema; perform needle thoracostomy and chest drain if required. Breathlessness + Risks + High JVP and low BP. Bedside Echo may confirm: PE and low BP consider thrombolysis Breathlessness: ECG/CXR for LVF and listen for severe MR or VSD and ECG for STEMI Tamponade: Consider urgent echo and pericardiocentesis (MI, chest trauma). Fever and sepsis: IV NS, lactate levels, cultures, IV antibiotics, and inotropes. Pale or pigmented skin: Suspect Addison's disease and treat with IV NS and Hydrocortisone (100-200 mg IV). Anaphylaxis: Administer IM Adrenaline and IV NS for urticaria, wheezing, and hypotension. Haematemesis or melaena: Resuscitate for upper GI bleed and consider OGD for possible variceal bleeding. Haemorrhage: IV NS, blood transfusion, pressure application, surgery, or tranexamic acid (TXA). Fertile female + abdominal pain: Suspect ectopic pregnancy, administer IV NS, blood transfusion, and urgent surgery. Fertile female + rash + retained tampon: Suspect toxic shock syndrome, give IV fluids (NS). Non-blanching rash: Suspect meningococcal septicaemia, treat with IV NS and Cefotaxime.

Initial Shock Management: Oxygen 15 L/min unless COPD. NS = Normal Saline

Insert two large bore IV lines and start crystalloid fluids unless pulmonary oedema is present.
Send for FBC, U&E, LFTs, Group and Hold +/- Lactate levels.
Further tests: Troponin, D-dimer, ABG, ECG, CXR, AXR, Amylase (if abdominal pain present).
Consider inserting a urinary catheter to monitor urine output.
Abdominal pain in patients over 50 years: urgent assessment for AAA (abdominal aortic aneurysm).
Chest pain: ECG/CXR/CT for STEMI, PE, or aortic dissection.
Arrhythmias:
- Tachycardia: Use Amiodarone or DC Shock.
- Bradycardia: Use Atropine or pacing.
Breathlessness: If tension PTX suspected, check for surgical emphysema; perform needle thoracostomy and chest drain if required.
Breathlessness + Risks + High JVP and low BP. Bedside Echo may confirm: PE and low BP consider thrombolysis
Breathlessness: ECG/CXR for LVF and listen for severe MR or VSD and ECG for STEMI
Tamponade: Consider urgent echo and pericardiocentesis (MI, chest trauma).
Fever and sepsis: IV NS, lactate levels, cultures, IV antibiotics, and inotropes.
Pale or pigmented skin: Suspect Addison's disease and treat with IV NS and Hydrocortisone (100-200 mg IV).
Anaphylaxis: Administer IM Adrenaline and IV NS for urticaria, wheezing, and hypotension.
Haematemesis or melaena: Resuscitate for upper GI bleed and consider OGD for possible variceal bleeding.
Haemorrhage: IV NS, blood transfusion, pressure application, surgery, or tranexamic acid (TXA).
Fertile female + abdominal pain: Suspect ectopic pregnancy, administer IV NS, blood transfusion, and urgent surgery.
Fertile female + rash + retained tampon: Suspect toxic shock syndrome, give IV fluids (NS).
Non-blanching rash: Suspect meningococcal septicaemia, treat with IV NS and Cefotaxime.

Shock occurs when oxygen delivery is inadequate to meet the metabolic demands of tissues. Hypotension may be a late manifestation, but shock can exist without it. Early recognition and management of circulatory failure are critical to preventing irreversible damage.

Introduction

Shock is defined as acute circulatory collapse with insufficient perfusion to vital organs.
It can be caused by reduced cardiac output, a loss of systemic vascular resistance, or a combination of both.
Early recognition and rapid intervention are vital for improving patient outcomes.

Clinical Features of Shock

Tachypnoea (rapid, shallow breathing).
Tachycardia (>100 bpm).
Hypotension (SBP <100 mmHg).
Altered mental status: confusion, drowsiness, or irritability.
Oliguria: reduced urine output (<0.5 mL/hr/kg).
Multi-organ failure in severe cases.
Vasodilatory shock: Warm peripheries, low diastolic BP.
Hypovolaemic shock: Cold, clammy skin, poor capillary refill.

Classification of Shock

Cardiogenic Shock: Caused by myocardial infarction (MI), myocarditis, or endocarditis.
Obstructive Shock: Due to pulmonary embolism (PE), cardiac tamponade, or tension pneumothorax (PTX).
Septic Shock: Resulting from infections, commonly originating from urinary, chest, or abdominal sources.
Anaphylactic Shock: Triggered by severe allergic reactions (e.g., bee stings, nuts).
Hypovolaemic Shock: Resulting from significant blood loss, gastrointestinal bleed, or trauma.
Neurogenic Shock: Caused by spinal cord injuries, leading to autonomic dysfunction.

Clinical Indicators of Possible Aetiology

Chest Pain: Suggests MI (cardiogenic shock), aortic dissection, or PE.
Breathlessness, Cyanosis: Could indicate LVF, pneumothorax, tamponade, or severe asthma.
Haemoptysis or Melaena: Suggests a GI bleed that requires endoscopic evaluation.
Pelvic or Femur Fracture: Risk of local bleeding, fat embolism, or PE.
Fever, Malaise, Cough, Sputum: Indicative of sepsis, especially in immunocompromised patients.
Abdominal Pain: Consider perforation, sepsis, or a leaking AAA.
Severe Breathlessness with Ketones on Breath: Indicates diabetic ketoacidosis (DKA), treat with fluids, potassium, and insulin.
Pregnancy and Abdominal Pain: Suspect ectopic pregnancy, check beta-HCG, and arrange an ultrasound.
Retained Tampon: Toxic shock syndrome, requires urgent intervention with IV fluids.
Recent Immobility: Increased risk of PE, treat with anticoagulation.
Pigmented Skin: Suspect Addison's disease, treat with steroids (hydrocortisone).
Non-Blanching Rash: Meningococcal septicaemia, treat with IV antibiotics immediately.

Investigations

FBC: Elevated or low WCC may indicate sepsis. Low haemoglobin (Hb) suggests blood loss.
U&E: Monitor for signs of acute kidney injury (AKI).
Glucose: Elevated glucose may indicate diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state (HHS).
Lactate: Elevated levels indicate tissue hypoxia and poor perfusion.
Troponin: Elevated in cases of myocardial infarction.
D-dimer: Elevated in pulmonary embolism or disseminated intravascular coagulation.
CXR: May reveal consolidation (sepsis), widened mediastinum (aortic dissection), or signs of LVF.
Cortisol: Check for suspected Addison's disease (treat empirically if indicated).

Management

ABC Approach: Ensure adequate venous access, provide airway and breathing support, and stabilize circulation.
Treat the underlying cause: Early identification and targeted treatment (e.g., antibiotics for sepsis, fluids for hypovolaemia) are critical to reversing shock.
Seek expert advice early: In complex or deteriorating cases, engage specialists for further management.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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