Day 4 - Shock

Types of Shock

Distributive

  • Includes: Endocrine causes, sepsis, anaphylaxis

Septic

  • Look for SIRS/qSOFA criteria, infectious symptoms, mottled extremities/knees

  • Initial Treatment:

    • Early antibiotics

    • Fluid resuscitation

    • Vasopressors to keep MAP>65 if required

      • Norepinephrine is the first line vasopressor

Anaphylactic

  • Look for mucocutaneous edema, urticaria, respiratory distress, abdominal pain or nausea

  • Treatment:

    • Epinephrine IM (preferred over IV) dilution to 1:1000, administer 0.3-0.5mg, can repeat in 5-15min intervals

    • Adjunctive administration of H2 antihistamines (Ranitidine), and glucocorticoids

Endocrine

Adrenal Crisis

  • Look for hyponatremia, hyperkalemia, hypotension refractory to fluids, nausea, vomitting

  • Treatment: Hydrocortisone 100mg IV x 1 loading dose, then 50mg IV q6h

    Myxedema Coma

  • Look for in patients with hypothyroidism, bradycardia, hypothermia, altered LOC

  • Treatment: IV levothyroxine + IV hydrocortisone


Hypovolemic

  • Look for signs of dehydration or hemorrhage

  • Treatment:

    • Fluid resuscitation

    • If bleeding - GIVE BLOOD

    • Treat underlying cause

Obstructive

  • Includes: Massive pulmonary embolism, tension pneumothorax, cardiac tamponade

  • Treat underlying cause

Cardiogenic

  • Look for evidence of coronary artery disease, acute myocardial infarction, cold extremities, pulmonary edema, arrhythmias (Bradycardia, unstable tachycardia)

  • Treatment:

    • Initial vasopressor is norepinephrine to target MAP 60-65

    • Initial inotrope is milrinone or dobutamine

 
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