Difference between revisions of "Undifferentiated shock"

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#Volume Status
 
#Volume Status
 
##What is the LV end-diastolic volume?
 
##What is the LV end-diastolic volume?
###Approximated by the CVP or IVC diameter
+
###Approximated by the IVC diameter or CVP
 
###If low:
 
###If low:
 
####Assess for blood loss versus fluid loss
 
####Assess for blood loss versus fluid loss
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#Contractility
 
#Contractility
##Is the myocardium severely depressed in its contractile function?
+
##Is the myocardium severely depressed in its contractile function (cardiogenic shock)?
###Assess via ultrasound, bounding/thready pulse, hyperdynamic precordium
+
###Assess via ultrasound
 +
###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, HOCM)  
+
###Assess for obstruction (PE, tamponade)  
  
 
#Systemic Vascular Resistance
 
#Systemic Vascular Resistance
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###Warm extremities
 
###Warm extremities
 
###Bounding pulse
 
###Bounding pulse
##Treat with transfusion versus inotrope (see [[Sepsis]])
+
##Treated based on likely etiology (see [[Distributive Shock]]
 
 
== Lack of Response to Normal Tx (DDX)  ==
 
  
 +
== Lack of Response to Normal Treatment (DDX)  ==
 
#Cardiogenic
 
#Cardiogenic
##Acute Valvular Regurg/VSD
+
##Acute valvular Regurgitation/VSD
 
##CHF
 
##CHF
 
##Dysrhythmia
 
##Dysrhythmia
 
##Ischemia/Infarction
 
##Ischemia/Infarction
##Myocardial Contusion/Myocarditis
+
##Myocardial contusion
 +
##Myocarditis
 
#Obstructive
 
#Obstructive
 
##Air embolism
 
##Air embolism
 
##Aortic Stenosis
 
##Aortic Stenosis
##Cardiac Tamponade
+
##Tamponade
##Massive PE
+
##PE
##Tension Pneumo
+
##Tension PTX
 
#Distributive
 
#Distributive
 
##Adrenal Crisis
 
##Adrenal Crisis
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##Toxicologic
 
##Toxicologic
 
#Hypovolemic
 
#Hypovolemic
##Hemorrhage Traumatic and Non-traumatic
+
##Hemorrhage (traumatic and non-traumatic)
##Severe Dehydration
+
##Severe dehydration
  
 
==See Also==
 
==See Also==
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== Source ==
 
== Source ==
2/06 DONALDSON (Adapted from Tintinalli)
+
*Tintinalli)
 
+
*Morchi, Undifferentiated Hypotension and Shock, All LA Conference, 05/06/2010
Morchi 2010
 
  
 
[[Category:Airway/Resus]]
 
[[Category:Airway/Resus]]
 
[[Category:Cards]]
 
[[Category:Cards]]

Revision as of 03:37, 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 IVC diameter or CVP
      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 (cardiogenic shock)?
      1. Assess via ultrasound
      2. Treat w/ inotrope
    2. Is forward flow occurring?
      1. Assess for valvular dysfunction (MR, AR)
      2. Assess for obstruction (PE, tamponade)
  1. Systemic Vascular Resistance
    1. Pathologic vasodilation (decreased SVR) suggested by:
      1. Warm extremities
      2. Bounding pulse
    2. Treated based on likely etiology (see Distributive Shock

Lack of Response to Normal Treatment (DDX)

  1. Cardiogenic
    1. Acute valvular Regurgitation/VSD
    2. CHF
    3. Dysrhythmia
    4. Ischemia/Infarction
    5. Myocardial contusion
    6. Myocarditis
  2. Obstructive
    1. Air embolism
    2. Aortic Stenosis
    3. Tamponade
    4. PE
    5. Tension PTX
  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

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