Difference between revisions of "Undifferentiated shock"

(Undifferentiated Hypotension Algorithm)
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== Undifferentiated Hypotension Algorithm ==
 
== Undifferentiated Hypotension Algorithm ==
*Which of the following is the main cause?
+
Check/manage the following in order:
*Which of the following is contributing?
 
  
Check the following in order:
+
#Pulse (assess based on pt's age)
 
+
##Too slow or too fast (to the point where CO is affected)?
#HR (assess based on pt's age)
+
###If so, HR is likely primary etiology of hypotension
##Too slow or too fast? (to the point where CO is affected)
 
###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 CVP, IVC diameter
+
###Approximated by the CVP or IVC diameter
##If low must rule-out occult blood loss:
+
###If low:
###FAST for intra-abdominal source
+
####Assess for blood loss versus fluid loss
###US to rule-out AAA
+
#####FAST for intra-abdominal bleed
###Guaiac to rule-out GI bleed
+
#####US for ruptured AAA
###CXR to rule-out hemothorax
+
#####Guaiac for GI bleed
 
+
#####CXR for hemothorax
 
+
####Treat with IVF and/or pRBC depending on cause
 
 
  
 
#Contractility
 
#Contractility
##Is the myocardium severely decreased in its contractile function?
+
##Is the myocardium severely depressed in its contractile function?
###Poor contractility on ultrasound, bounding/thready pulse, hyperdynamic precordium  
+
###Assess via ultrasound, bounding/thready pulse, hyperdynamic precordium  
 
##Is forward flow occurring?
 
##Is forward flow occurring?
 
###Assess for valvular dysfunction (MR, AR)
 
###Assess for valvular dysfunction (MR, AR)
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###Warm extremities
 
###Warm extremities
 
###Bounding pulse
 
###Bounding pulse
###The other three components are normal (HR, volume status, contractility)
+
##Treat with transfusion versus inotrope (see [[Sepsis]])
  
 
== Lack of Response to Normal Tx (DDX)  ==
 
== Lack of Response to Normal Tx (DDX)  ==

Revision as of 03:16, 7 May 2012

Definition

  1. SBP <90 in normal pt
  2. SBP <100 with h/o HTN or age >60
  3. Lactate > 4 or base def < -4

Types

Type Skin HR Oth
Hypovolemic cold inc
Obstructive cold inc
Cardiogenic cold inc/dec  ?dysth
Distributive warm inc
Neurogenic warm dec

Undifferentiated Hypotension Algorithm

Check/manage the following in order:

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

Lack of Response to Normal Tx (DDX)

  1. Cardiogenic
    1. Acute Valvular Regurg/VSD
    2. CHF
    3. Dysrhythmia
    4. Ischemia/Infarction
    5. Myocardial Contusion/Myocarditis
  2. Obstructive
    1. Air embolism
    2. Aortic Stenosis
    3. Cardiac Tamponade
    4. Massive PE
    5. Tension Pneumo
  3. Distributive
    1. Adrenal Crisis
    2. Anaphylaxis
    3. Neurogenic
    4. Sepsis
    5. Toxicologic
  4. Hypovolemic
    1. Hemorrhage Traumatic and Non-traumatic
    2. Severe Dehydration

See Also

Source

2/06 DONALDSON (Adapted from Tintinalli)

Morchi 2010