Undifferentiated shock

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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
  2. 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
  3. 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)
  4. Systemic Vascular Resistance
    1. Pathologic vasodilation (decreased SVR) suggested by:
      1. Warm extremities
      2. Bounding pulse
    2. Treated based on likely etiology of distributive shock (see below)

Differential Diagnosis

  1. Cardiogenic
    1. Acute valvular Regurgitation/VSD
    2. CHF
    3. Dysrhythmia
    4. ACS
    5. Myocardial Contusion
    6. Myocarditis
  2. Obstructive
    1. Air embolism
    2. Aortic Stenosis
    3. Cardiac Tamponade
    4. PE
    5. Tension Pneumothorax
  3. Distributive
    1. Adrenal Crisis
    2. Anaphylaxis
    3. Neurogenic Shock
    4. Sepsis
    5. Toxicologic
  4. Hypovolemic
    1. Severe dehydration
    2. Hemorrhage (traumatic and non-traumatic)
      1. Classes of Hemorrhagic Shock
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