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SHOCK
Definition & Classification
• Shock is an acute metabolic emergency where compromised oxygen transport leads to cellular oxygen utilisation which is insufficient to sustain normal aerobic metabolism. • The aim of therapy in shock is to optimise tissue oxygen delivery in relation to oxygen requirements, whilst making a specific diagnosis and treating the underlying problem.• Shock may result from inadequate oxygen delivery to the tissues (hypovolaemia, anaemia, low cardiac output), maldistribution of blood flow (sepsis, anaphylaxis) or the inability of the cells to utilise oxygen (sepsis).
TRADITIONAL CLASSIFICATION (aetiological):
• Hypovolaemic
• Septic
• Cardiogenic
• Anaphylactic
• Obstructive
• Neurogenic
FUNCTIONAL CLASSIFICATION (pathophysiological):
Intact oxygen utilisation | Abnormal |
Cardiogenic Hypovolaemic Obstructive (e.g. PE, tension pneumothorax, tamponade) | Sepsis Anaphylactic Late low flow shock |
Clinical Presentation
Clinical evidence of organ dysfunction:
• Tachypnoea
• Tachycardia
• Hypotension
• Poor peripheral perfusion
• Abnormal mental state
• Oliguria
| Class I | Class II 15-30% 750-1500 | Class III 30-40% 1500-2000 | Class IV >40% >2000 |
| Pulse Rate | <100 | >100 | >120 | >140 |
| Blood Pressure | Normal | Normal | Decreased | Decreased |
| Pulse Pressure (mmHg) | Normal or increased | Normal | Decreased | Decreased |
| RR | 14-20 | 20-30 | 30-40 | >35 |
| UO (ml/hr) | >30 | 20-30 | 5-15 | negligble |
| CNS/mental state | Slightly anxious | Mildly anxious | Anxious and confused | Confused and lethargic |
| Fluid Replacement | Crystalloid or colloid | Crystalloid or colloid | Crystalloid, colloid and blood | Crystalloid, colloid and blood |
* For a 70kg male © ACS
Management
• Assess ABCDE and treat accordingy.
• Get help.
• Correct hypoxaemia with high concentration oxygen by mask.
• Secure adequate IV access: this may be difficult.
• Correct hypovolaemia with colloid, crystalloid and blood as appropriate maintaining haemoglobin around 100g/l.
• Take blood and other samples for culture and give appropriate antibiotics. Early surgical intervention may be crucial e.g. laparotomy for perforated bowel, control of haemorrhage, abscess drainage.