Shock

Question 1

A 94 year old female is brought in confused from her home by a neighbour. There is no immediate medical history. Her BP is 80/50. How would you assess and manage her?

Answer 1

Impression
This patient is profoundly shocked and likely peri-arrest and as such would be calling for senior help and beginning emergent resus alongside A to E assessment. Would be considering various causes of shock including;
- Cardiogenic: ACS, valvular, dissection
- Distributive: Septic, neurogenic, anaphylaxis
- Obstructive: tamponade, PE
- Hypovolaemic: blood loss, 3rd spacing, oedema
WIDE differentials for the potential cause of this shock

Want to consider the 4H’s and 4T’s as reversible causes of arrest

Given state of confusion, also consider delirium and its various causes; CUPID SEND HUGS

Goals

• Immediately begin resuscitation
• conduct thorough A to E and further Hx/Ex/Ix once stabilised to determine aetiology of shock
• definitive Mx depending on the cause

Question 2

Shock - Assessment

Answer 2

Assessment
A -Aangioedema in anaphylaxis, ?patent/maintaining. Tube pending GCS
B - RR/SP02 monitoring; stridor, creps, hypoxia. administer supplemental 02 as required, escalate administration technique pending response. Bedside CXR
C - HR/BP monitoring. ECG trace for ?ACS. IVC access x2 for fluid resus with 0.9% NS. ICU input for ?vasopressor support. Get initial bloods: VBG, UEC, FBC, LFT, CRP?ESR, TFT, Trops. Consider ECHO
D - GCS –> intubate if < 8
E - Exposure for other injuries (particularly head if fall), temperature

Question 3

Shock - history

Answer 3

History

• MIST AMPLE
• Collateral from neighbour: where found, how long for, LOC?
• PMHx or what else is known
• review notes for details of any previous admissions, also for NFR/ACD in place to assess if ceiling of care.
• psychosocial for details of home life, any services/level of care, etc

Question 4

Shock - Examination

Answer 4

Examination

- as per A to E

Question 5

Shock - Investigations

Answer 5

Investigations
- as per A to E

• brain imaging if ?fall/ SOL/intracranial HB

Question 6

Shock - Management

Answer 6

Management
Acute
A to E assessment and concurrent resuscitation

Disposition
- Depends on underlying cause: palliation vs cardio vs gen med vs ID

Ongoing

• analgesia
• other supportives
• Call family and inform of situation, ask to attend and advise
• Clear documentation