Difference between revisions of "Undifferentiated shock"

Line 2: Line 2:
 
Check/manage the following in order:
 
Check/manage the following in order:
  
#Pulse (assess based on pt's age)
+
*Pulse (assess based on pt's age)
##Too slow or too fast (to the point where CO is affected)?
+
**Too slow or too fast (to the point where CO is affected)?
###If so, HR is likely primary etiology of hypotension
+
***If so, HR is likely primary etiology of hypotension
###Pace or cardiovert
+
***Pace or cardiovert
#Volume Status
+
*Volume Status
##What is the LV end-diastolic volume?
+
**What is the LV end-diastolic volume?
###Approximated by the [[Ultrasound: IVC|IVC diameter]] or CVP
+
***Approximated by the [[Ultrasound: IVC|IVC diameter]] or CVP
###If low:
+
***If low:
####Assess for blood loss versus fluid loss
+
****Assess for blood loss versus fluid loss
#####[[Ultrasound: FAST|FAST]] for intra-abdominal bleed
+
*****[[Ultrasound: FAST|FAST]] for intra-abdominal bleed
#####US for ruptured [[Ultrasound: AAA|AAA]]
+
*****US for ruptured [[Ultrasound: AAA|AAA]]
#####Guaiac for GI bleed
+
*****Guaiac for GI bleed
#####CXR for hemothorax
+
*****CXR for hemothorax
####Treat with IVF and/or pRBC depending on cause
+
****Treat with IVF and/or pRBC depending on cause
#Contractility
+
*Contractility
##Is the myocardium severely depressed in its contractile function (cardiogenic shock)?
+
**Is the myocardium severely depressed in its contractile function (cardiogenic shock)?
###Assess via [[Ultrasound: In Shock and Hypotension|ultrasound]]
+
***Assess via [[Ultrasound: In Shock and Hypotension|ultrasound]]
###Treat w/ inotrope
+
***Treat w/ inotrope
##Is forward flow occurring?
+
**Is forward flow occurring?
###Assess for valvular dysfunction (MR, AR)
+
***Assess for valvular dysfunction (MR, AR)
###Assess for obstruction (PE, tamponade)  
+
***Assess for obstruction (PE, tamponade)  
#Systemic Vascular Resistance
+
*Systemic Vascular Resistance
##Pathologic vasodilation (decreased SVR) suggested by:
+
**Pathologic vasodilation (decreased SVR) suggested by:
###Warm extremities
+
***Warm extremities
###Bounding pulse
+
***Bounding pulse
##Treated based on likely etiology of distributive shock (see below)
+
**Treated based on likely etiology of distributive shock (see below)
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
#Cardiogenic
+
*Cardiogenic
##Acute valvular Regurgitation/VSD
+
**Acute valvular Regurgitation/VSD
##[[CHF]]
+
**[[CHF]]
##[[Dysrhythmia]]
+
**[[Dysrhythmia]]
##[[ACS]]
+
**[[ACS]]
##[[Myocardial Contusion]]
+
**[[Myocardial Contusion]]
##[[Myocarditis]]
+
**[[Myocarditis]]
#Obstructive
+
*Obstructive
##Air embolism
+
**Air embolism
##[[Aortic Stenosis]]
+
**[[Aortic Stenosis]]
##[[Cardiac Tamponade]]
+
**[[Cardiac Tamponade]]
##[[PE]]
+
**[[PE]]
##Tension [[Pneumothorax]]
+
**Tension [[Pneumothorax]]
#Distributive
+
*Distributive
##Adrenal Crisis
+
**Adrenal Crisis
##[[Anaphylaxis]]
+
**[[Anaphylaxis]]
##[[Neurogenic Shock]]
+
**[[Neurogenic Shock]]
##[[Sepsis]]
+
**[[Sepsis]]
##[[Toxicology (Main)|Toxicologic]]
+
**[[Toxicology (Main)|Toxicologic]]
#Hypovolemic
+
*Hypovolemic
##Severe dehydration
+
**Severe dehydration
##Hemorrhage (traumatic and non-traumatic)
+
**Hemorrhage (traumatic and non-traumatic)
###Classes of Hemorrhagic Shock
+
***Classes of Hemorrhagic Shock
 
{| class="wikitable"
 
{| class="wikitable"
 
! Class
 
! Class

Revision as of 06:39, 18 February 2015

Undifferentiated Hypotension Algorithm

Check/manage the following in order:

  • Pulse (assess based on pt's age)
    • Too slow or too fast (to the point where CO is affected)?
      • If so, HR is likely primary etiology of hypotension
      • Pace or cardiovert
  • Volume Status
    • What is the LV end-diastolic volume?
      • Approximated by the IVC diameter or CVP
      • If low:
        • Assess for blood loss versus fluid loss
          • FAST for intra-abdominal bleed
          • US for ruptured AAA
          • Guaiac for GI bleed
          • CXR for hemothorax
        • Treat with IVF and/or pRBC depending on cause
  • Contractility
    • Is the myocardium severely depressed in its contractile function (cardiogenic shock)?
    • Is forward flow occurring?
      • Assess for valvular dysfunction (MR, AR)
      • Assess for obstruction (PE, tamponade)
  • Systemic Vascular Resistance
    • Pathologic vasodilation (decreased SVR) suggested by:
      • Warm extremities
      • Bounding pulse
    • Treated based on likely etiology of distributive shock (see below)

Differential Diagnosis

Class I II III IV
Blood Loss (mL) < 750 750-1000 1500-2000 >2000
Blood Loss (%) < 15 15-30 30-40 >40
Pulse rate (per min) <100 100-120 120-140 >140
Blood Pressure Normal Normal Decreased Decreased
Pulse Pressure (mmHg) Normal or Increased Decreased Decreased Decreased
Respiratory Rate (per min) 14-20 20-30 30-40 >35
Urine Output (mL/hr) >30 20-30 15-May Negligble
Mental Status Slightly Anxious Mildly Anxious Anxious, Confused Confused, Lethargic

See Also

Source

  • Tintinalli
  • Morchi, Undifferentiated Hypotension and Shock, All LA Conference, 05/06/2010