Undifferentiated shock: Difference between revisions

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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
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