Shock

Introduction
This section will examine the aspects of shock, both medical and traumatic. The concentration
will be on the physiology and hemodynamics rather than the processes that surround each
clinical scenario. For more specifics on select causes of shock, refer to chapters on individual
illnesses and trauma.

What is the definition of shock?

What are the different categories of shock? What are different etiologies of each of these
categories?

Fill in the following table with the correct hemodynamic profile.

Pulmonary Artery Pressure

Systemic Resistance

Cardiac Output

Cardiogenic
Obstructive
Distributive
Hypovolemic

Pulmonary artery pressure can be represented by capillary wedge pressure.

Systemic resistance can be represented by blood pressure.
Cardiac output use stroke volume multiplied by heart rate.

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Case I
Bill is a 28 year old male who has suffered injuries from a motor vehicle accident. He was an
unrestrained driver who had a head-on collision with the tree while traveling at 35 MPH. His car
was no equipped with airbags. On scene he opened his eyes to verbal command. He is
disoriented and mumbles random phrases. He does not obey other verbal commands for motor
movement, but localizes pain. Paramedics determined that his ABCs were intact and did not
perform any interventions. There were no obvious injuries on their survey, however, his
abdomen was tender to palpation. He was boarded and collared for transport.

What is his mental status score on the Glasgow Coma Scale?

What is your first step and the evaluation of this patient?

You initiate the primary ATLS survey. Bill has patent airway. His is breathing comfortably. He
has thready pulses in his upper and extremities. While you are checking this, the nurse is starting
two large bore IVs and placing him on a monitor. His initial vital signs are:
Respiratory rate - 16
Pulse - 106
Blood pressure 86/52
What class of shock is this patient in? What fluid deficit this represent?

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What is your next step in fluid resuscitation?

You continue your primary survey. He appears to become more confused and somnolent. Prior to
starting the secondary survey you recheck his vital signs. They are as follows:
Respiratory rate - 20
Pulse 118
Blood pressure 76/50
What stage shock is he in at this time?

What would you do now? What would follow if he did not respond?

What is on your differential? What can you do to rule in or rule out these conditions?

Prior to continuing onto the secondary survey you conduct a FAST scan. On ultrasound you find
a large amount of free fluid in Morisons Pouch and the perisplenic space. Your fluid
resuscitation continues to blood products and there is a small response noted. The trauma surgery
team finishes the evaluation and the patient is taken to the OR for an exploratory laparotomy.
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Case II
Hilary is a 65 year old female elementary school teacher. She presents to the emergency
department after three days of a stomach bug. She is unable to tolerate any oral intake, and her
partner was starting to worry about her extreme loss of energy. Her symptoms began several
days ago with nausea and vomiting. Over the last 24 hours in his progressed to watery diarrhea.
She is having intermittent low grade fevers. She feels malaise and weakness.

What do you do for your initial assessment and intervention?

Hilary appears noticeably ill. Her skin is pale, cool, and clammy. Her lips are dry. She has a
respiratory rate of 18, pulse of 120, and blood pressure of 90/46. The nurse is having difficulties
attaining venous access.
You continue on and start your history and physical. Your history includes the seven important
parts: History of Present Illness (HPI), Review of Systems (ROS), Past Medical History (PMHx),
Past Surgical History (PSHx), Allergies, Medications, Social History.

What specific features of the physical exam would provide you information on hydration status
of your patient?

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What additional features of the physical exam would you utilize for in a young child or infant?

What is your first step in fluid resuscitations?

How would you assess for the effectiveness of your resuscitations?

How would your fluid resuscitation differ when treating an infant or child?

Hilary had an ultrasound guided peripheral line placed. She received 2 L of normal saline. Her
mental status improved significantly at this time and vital signs showed a decrease in heart rate
to 88 and an increase in blood pressure to 128/64. She felt better and did well with a trial of an
antiemetic. She was discharged home with a prescription for an antiemetic and to increase oral
intake.

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Case III
Charles is a 69 year old male he was found unresponsive on his apartment floor by his children
who had not heard from him in several days. EMS arrived promptly and transferred him to your
emergency department. He aroused with some verbal stimuli, but was confused. There was no
notable trauma or cause for his current status.

What do you do for your initial assessment and intervention?

The patient still have a decreased mental status. He has rapid and labored respirations. His pulses
are weak and tachycardic. His skin is warm and flushed. Two IVs are started by the resuscitation
team and he is placed on supplemental oxygen.
His vitals are as follows:
Respiratory rate 28
Pulse Ox 94%
Heart Rate 124
Blood pressure 76/48

What are the classic general presentations of the different categories of shock?
Cardiogenic:
Obstructive:
Distributive:

Hypovolemic:

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What type of shock is occurring in this patient? What is it pathophysiology?

Define the following terminology referring to sepsis.

Bacteremia:

Septicemia:

Systemic Inflammatory Response Syndrome (SIRS):

Sepsis:

Septic shock:

What are common etiologies and pathogens of septic shock?

25% 25% 15% 15% 10% 5% 5% 40

What fluid resuscitation would you attempt?

What diagnostic steps should be taken?

Laboratory studies:

Cultures:

Diagnostic imaging:

Cardiac studies:

Diagnostic interventions:

Over the last decade, the principle of early goal-directed therapy (EGDT) has prevailed in the
treatment of septic shock. While at one time this was only applicable to the critical care
departments, studies have shown that starting in the emergency department reduces mortality.
The foundation of this therapy is the early identification of septic patients, the quick initiation of
broad spectrum antibiotics, fluid resuscitation, and diagnostic testing. The critical aspect of
EDGT is using fluids and vasopressors to ensure adequate vascular pressures resulting in good
oxygenation.
Charles was identified as having septic shock within 20 minutes of arrival to the emergency
department. When his lines were started during the initial evaluation, nursing drew cultures and
other lab work. A gram of vancomycin was given and the work up continued.

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