Undifferentiated shock

Pt with h/o respiratory compromise, arterial occlusion presents with acute onset hemodynamic instability. Tachycardia, tachypnea, hypotension, confusion/delirium, increased WOB, dry mucous membranes, JVD, arrhythmia, cyanosis/mottling on exam. Systolic BP <90 with MAP <65; urine output <0.5 mL/kg/hr.

  • Labs

    • Obtain CBC with diff, CMP, ABG, serum lactate

    • Obtain troponin, CKMB, BNP, creatinine kinase

    • Obtain U/A, blood cultures, sputum cultures

    • Obtain type and PT/PTT/INR, D-dimer

    • Consider urine drug screen

  • Triage

    • ABG shows high anion gap metabolic acidosis, serum lactate >2

    • Serum lactic acid >4: Transfer pt to MICU

  • Imaging

    • Obtain EKG, CXR, U/S of IVC

    • Start continuous cardiac telemetry

    • CT if concern for trauma and/or intracranial hemorrhage

  • Stabilize respiratory status

    • Titrate supplemental O2 to maintain SPO2 > 92%: Administer oxygen via NC 6L/min; if insufficient proceed to HFNC 20L/min, then BiPAP 12/5, and finally intubation

    • GCS<8 or marked respiratory distress/hemodynamic instability with no suspected tension pneumothorax: Administer ketamine 1.5 mg/kg IV, rocuronium 1.5 mg/kg IV and intubate

    • Specific interventions

      • Anaphylaxis: IV epinephrine

      • Tension pneumothorax: Chest tube

      • Massive pulmonary embolus: Thrombolytic therapy

  • Circulatory

    • Establish IV access; administer 1L LR bolus followed by maintenance fluid

    • If peripheral access cannot be obtained and/or vasopressors indicated, place central line

    • MAP <65 s/p fluid resuscitation; start noradrenaline (Levophed) at 0.2 mcg/kg/hr and titrate to MAP >65

    • Specific interventions

      • Stroke: Evaluate for tPA; consult neurology

      • Arrhythmia with hemodynamic decompensation: ACLS protocols

      • Myocardial infarction: Coronary revascularization

      • Cardiac tamponade: Pericardiocentesis

  • Sepsis

    • Initiate broad-spectrum antibiotics

    • Calculate Q-SOFA score

Notes

  • MAP > 60 required to maintain cerebral perfusion

  • Serum lactate

    • >2 indicates likely shock

    • >4 is "not for the floor" as it predicts increased mortality independent of organ hypoperfusion

  • Q-SOFA score

    • One point for each of the following

      • GCS <15

      • Respiratory rate >21

      • SBP <101

    • Score of 2 or greater indicates high risk of poor outcome in patients with suspected infection, i.e. 3 to 14 times higher risk of in-hospital mortality

Cardiogenic shock

Pt with h/o severe HTN, DM, CAD, MI, HFrEF, dilated cardiomyopathy, aortic stenosis, stable abdominal aortic aneurysm presents with arrythmia s/p ingestion of beta-blockers during suicide attempt. Reports dyspnea, acute on chronic chest pain, syncope, recent chest trauma, and alcohol/cocaine abuse. Systolic BP < 90 mmHg, bradycardia, tachypnea, JVD, bibasilar pulmonary crackles, mid-systolic ejection murmur at R upper sternal border, cool extremities, confusion on exam.

  • Obtain CBC, CMP, serial troponin, ABG, lactic acid, PT/PTT/INR

  • Obtain EtOH level, urine drug screen

  • Strict I&O’s and monitoring for oliguria

  • EKG shows myocardial ischemia: Evaluate for acute coronary syndrome

  • CXR shows tension pneumothorax and new onset pulmonary congestion

  • CTA shows pulmonary embolism

  • Obtain echocardiography; evaluated for acute myopericarditis, takotsubo cardiomyopathy, HFrEF, pericardial tamponade, ascending aortic dissection

  • Treatment based on underlying condition

Notes

  • May be due to the heart itself (vessel/muscle/valve), arrhythmia (tachy/brady), or obstruction

  • Heart defects

  • Arrhythmia: Treat per ACLS guidelines

  • Obstruction

    • Decreased cardiac return

      • Vena cava syndrome

      • Massive pulmonary embolism

    • Cardiac compression

      • Tension pneumothorax

      • Pericardial tamponade

    • Outflow obstruction: Ascending aortic aneurysm

Distributive shock

Pt with h/o anaphylactic shock, hypothyroidism, hypoadrenalism presents with spinal trauma. Recently diagnosed with group A strep pneumonia and suffered bee sting prior to admission. Fever, hypotension, confusion/delirium, facial edema, dry mucous membranes, inspiratory stridor, hives, skin warmth below level of spinal injury, localized area of skin necrosis with abscess on exam. No LE edema, JVD noted. Systolic BP < 90 with MAP < 65, urine output < 0.5 mL/kg/hr.

  • Diagnostic approach

    • Obtain q 1 hour vital signs until stable

    • Obtain CBC with differential, CMP, ABG, type and cross

    • Obtain serum lactate now, at 2 hours, and then q6h until stable

    • Obtain blood culture, sputum culture, U/A with culture, wound culture

    • Obtain troponin, CKMB, BNP, creatinine kinase

    • U/S shows IVC > 1.5 cm, i.e. adequate blood volume

  • Initial treatment

    • Secure airway, correct hypoxemia (nasal cannula → high flow nasal cannula → BiPap)

    • Transfuse for hemoglobin < 7 g/dL

    • Place central line if peripheral access cannot be obtained and/or vasopressors indicated

      • Administer 1L LR bolus followed by maintenance fluid (goal = 30 mL/kg over 3 hours) before starting vasopressors

      • MAP < 65 s/p fluid resuscitation: Start noradrenaline (Levophed) at 0.2 mcg/kg/hr and titrate to MAP > 65

  • Anaphylactic shock

    • Administer 0.3 mg epinephrine 1:1000 injected in outer thigh q 10 min

    • Administer diphenhydramine 50 mg IV, ranitidine 50 mg IV, methylprednisolone 1 mg/kg IV

    • Administer albuterol 2.5 mg nebulized solution

  • Septic shock

    • Initial CBC shows bandemia

    • Obtain blood culture from two distinct venipuncture site and any indwelling devices

    • Start linezolid (Zyvox) IV 600 mg BID, Zosyn 3.375 g IV q8h

    • Suspected infection source

      • CNS (e.g. meningitis): CSF cell count, protein, glucose, Gram stain, and culture

      • Respiratory tract: Start chest physiotherapy, suctioning for pneumonia

      • Intra-abdominal: Obtain abdominal CT +/- stool culture

      • Urinary tract: Change catheter and consult urology if urinary tract obstruction suspected

      • Skin and soft tissue: Debride necrotic tissue, drain abscess and/or effusion

      • Bone: Obtain MRI +/- bone culture

      • Indwelling device: Discontinue or replace access site

  • Myxedema coma/adrenal crisis

    • Obtain TSH, free T4 serum cortisol, ACTH, aldosterone, renin

    • Administer levothyroxine 300 mcg IV, followed by 75 mcg qd

    • Administer triiodothyronine 10 mcg intravenously, followed by 5 mcg q8h

    • Administer hydrocortisone 100 mg IV q8h until adrenal insufficiency excluded

    • Consult endocrine

  • Neurogenic shock

    • Obtain CT at level of traumatic spinal cord injury (TSCI)

    • Presenting within 8 hours of isolated, non-penetrating TSCI: Consider methylprednisolone 30 mg/kg IV bolus followed by 5.4 mg/kg infusion x 23 hours

    • Consult neurology

Notes

  • Potential distributive shock etiologies

    • Infectious

      • Septic shock (e.g. pneumonia)

      • Group A streptococcal infection (e.g. skin necrosis)

    • Non-infectious

      • Anaphylactic shock (characterized by allergen exposure followed by facial edema, inspiratory stridor, hives)

      • Endocrine etiologies including adrenal crisis, myxedema coma due to hypothyroidism

      • Neurogenic shock

  • Antibiotics: Zyvox, Zosyn, aZithromycin for pan coverage

    • Linezolid: Gram positive coverage including MRSA (neurotoxicity risk limits use to < 2 weeks)

    • Zosyn

      • Covers anaerobes and gram negative organisms including pseudomonas

      • Does NOT cover Legionella

      • Does NOT cover organisms with inducible beta-lactamase activity that is chromosomally mediated, i.e. ESCHAPPM (Enterobacter, Serratia, Citrobacter freundii, Hafnia, Aeromonas, Proteus vulgaris, Providencia, Morgananii)

    • Azithromycin: Covers Legionella

    • Moxifloxacin: Covers Legionella and ESCHAPPM organisms

    • Antifungal: Mycofungin 100mg IV qd if disseminated fungal infection is present

Hypovolemic shock

Pt with h/o pancreatitis, intestinal obstruction, polyuria presents with blood loss s/p crush injury. Reports N/V, diarrhea s/p completing a marathon. Orthostatic hypotension, tachycardia, acute weight loss, dry mucous membranes, bleeding cool/mottled extremities, delayed capillary refill, weakness, crush injury, and agitation/confusion on exam.

  • Obtain CBC, CMP, serial troponin, ABG, lactic acid, PT/PTT/INR

  • Obtain urine sodium, creatinine, osmolality

  • Urine sodium <20 mEq/L, FENA <0.2, urine osmolality >450 mOsmol/kg

  • Strict I&O’s; monitor for oliguria

  • Bedside U/S shows IVC diameter <1.5cm

  • Establish access using two large-bore IVs

  • Administer 2L LR bolus; give additional boluses until MAP>65

  • Massive blood loss, hemoglobin <7: Adminster PRBCs

Notes

  • Third-spacing may occur due to intestinal obstruction, crush injury, fracture, and acute pancreatitis

  • Low urine sodium and elevated urine osmolality strongly suggest tissue hypoperfusion; exceptions include

  • Patients with polyuria due to hypoaldosteronism, diuretic abuse, etc.

  • Metabolic alkalosis due to vomiting

  • FENA = ([Plasma creatinine × urinary sodium] / [plasma sodium × urinary creatinine]) × 100

  • Do NOT administer vasopressors