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?
 +
*Which of the following is contributing?
 +
 +
Check the following in order:
 +
 +
#HR (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 CVP, IVC diameter
 +
##If low must rule-out occult blood loss:
 +
###FAST for intra-abdominal source
 +
###US to rule-out AAA
 +
###Guaiac to rule-out GI bleed
 +
###CXR to rule-out hemothorax
 +
 +
  
Check:
 
  
#HR (age appropriate)
 
##<40 and >150-180 --> likely HR = Primary etiology
 
###Tx with cardioversion/defib or pace
 
##Plasma vs. RBC loss
 
###Evaluate CVP, IVC, UOP
 
###Check for GI, intraperitoneal, lung, retroperitoneal loss/sequestration
 
 
#Contractility
 
#Contractility
##Bounding/thready pulse, hyperdynamic precordium
+
##Is the myocardium severely decreased in its contractile function?
##Dx with ultrasound
+
###Poor contractility on ultrasound, bounding/thready pulse, hyperdynamic precordium  
###Will have high afterload
+
##Is forward flow occurring?
####May be due to STEMI, CHF
+
###Assess for valvular dysfunction (MR, AR)
#Forward flow
+
###Assess for obstruction (PE, HOCM)  
##Valvular dysfunction (MR) or obstruction
+
 
###Evaluate via auscultation, ultrasound
+
#Systemic Vascular Resistance
####Consider PE, HOCM  
+
##Pathologic vasodilation (decreased SVR) suggested by:
#Volume Status - LVEDP (approx by CVP, IVC, etc.)
+
###Warm extremities
##History of volume loss
+
###Bounding pulse
##Lung Exam
+
###The other three components are normal (HR, volume status, contractility)
##Mucous membrane
 
##Ultrasound IVC (RUQ window or AAA)
 
##Hemeacuu, Guaic
 
##Cardiac Ultrasound
 
#SVR
 
##Pathologic vasodilation
 
###Warm extremities, bounding pulse
 
####Consider sympathetic dysregulation/neurogenic shock
 
##Cool extremities and "normal" BP
 
###Consider vasoconstriction and treat as hypotension from the top
 
  
 
== Lack of Response to Normal Tx (DDX)  ==
 
== Lack of Response to Normal Tx (DDX)  ==

Revision as of 02:53, 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

  • Which of the following is the main cause?
  • Which of the following is contributing?

Check the following in order:

  1. HR (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, IVC diameter
    2. If low must rule-out occult blood loss:
      1. FAST for intra-abdominal source
      2. US to rule-out AAA
      3. Guaiac to rule-out GI bleed
      4. CXR to rule-out hemothorax



  1. Contractility
    1. Is the myocardium severely decreased in its contractile function?
      1. Poor contractility on 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
      3. The other three components are normal (HR, volume status, contractility)

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