Project: Ghana Emergency Medicine Collaborative Document Title: Shock Author(s): Patrick Carter (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/

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CLASS I II III IV

BVL < 15% 15 - 30% 30 - 40% > 40%

AMOUNT 750 cc 750 - 1500 cc 1500 - 2000 cc > 2000 cc

PULSE <100 > 100 >120 >140

BP No change Narrowed pulse pressure

Consistent decrease in SBP

Decreased SBP and narrowed pulse pressure or no DBP

RESP No change 20-30 30-40 >35

CNS No change Anxiety Anxious, confused Confused. lethargic

Urine >30cc per hr 20-30cc per hr 5-15cc per hr negligible

TX Replace fluid loss

2L NS IV 2 L NS IV, usually requires blood transfusion

Rapid transfusion of blood and NS, requires immediate intervention to stop hemorrhage

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Rapid Response Transient Response

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Vitals Return to normal Transient improvement with return to previous

Remain Abnormal

Estimated Blood loss

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Severe >40%

Need for more Fluid

Low High High

Need for Blood Type and cross Type specific O neg Need for surgery Possible Likely Highly likely

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B  ,'=)(",-.(/"?5'7<6'2<"e8;.53<-6R"H3*'5+"'<"78l"4Vh^R"#cc!"B  ,<FD:"<-7<"'G7632'D"F+'".@"72"'758:";.78"D35'(<'D"<-'57=:"78;.53<-6"<."<5'7<"=7)'2<+"I3<-"+'=)("+-.(/"W7+"D'12'D"%:"5'@57(<.5:"-:=.<'2+3.2".5"87(<7<'"o"JX"

B  #SA"=7)'2<+"572D.68:"7++3;2'D"<."'3<-'5"<5'7<6'2<"756".5"<."+<72D75D"5'+F+(3<7).2"756+"W!Ac"*+l"!AAX"

B  >.2<5.8"756"<5'7<'D"I3<-"+<72D75D"(75'"72D"7D63_'D"<."C>j"

B  ?5'7<6'2<"756"@.88.I'D"=5.<.(.8"32"V0"@.5"S"-.F5+"72D"<-'2"7D63_'D"<."C>j"

B  d32D32;+f$F<(.6'"B  ?5'7<6'2<";5.F="5'('3*'D"6.5'"\F3D+"(.6=75'D"<."(.2<5.8";5.F="WP"i"*+l"AlP"iX"

B  AlU"D7:+"8'++"32"-.+=3<78"@.5"<5'7<6'2<";5.F="B  #"@.8D"8'++"(75D3.=F86.275:"(.6=83(7).2+"@.5"<5'7<6'2<";5.F="

B  D&).2?&'#&8*12$0',0'+$#".),"7'$/'EFGFH'AP"

V758:"[.78"035'(<'D"?-'57=:"

H3*'5+"V"'<"78l"V758:";.78YD35'(<'D"<-'57=:"32"<-'"<5'7<6'2<".@"+'*'5'"+'=+3+"72D"

+'=)("+-.(/"4"V2;8"h"^'Dl"#cc!bAJPb!ASUY!ATTl"

"

AS"

e27=-:87()(",-.(/"

B  e27=-:87G3+"B  ,'*'5'"+:+<'63("

-:='5+'2+3)*3<:"5'7().2"

B  >-757(<'53g'D"%:"6F8)+:+<'6"32*.8*'6'2<""

B  C;V"6'D37<'D"

B  e27=-:87(<.3D"5'7().2"B  >8323(788:"32D3+)2;F3+-7%8'"@5.6"727=-:87G3+"

B  0.'+"2.<"5'EF35'"7"+'2+3)g32;"'G=.+F5'"

B  4.<"C;V"6'D37<'D"

Justin Beck, Flickr

AT"

e27=-:87()(",-.(/"O">8323(78"

^723@'+<7).2+"

•  >8323(78",='(<5F6"–  d35+<",:6=<.6+b""

•  95F53<F+"•  d8F+-32;"•  j5)(7537"

–  95.;5'++3.2b""•  ?-5.7<"@F882'++"•  e2G3'<:"•  >-'+<");-<2'++"•  ,-.5<2'++".@"%5'7<-"•  i3;-<-'7D'D2'++"

–  ,'*'5'",:6=<.6+b"""•  e8<'5'D"6'2<78"+<7<F+"

•  H'+=357<.5:"D3+<5'++"•  >35(F87<.5:"(.887=+'"

•  H3+/"@7(<.5+"@.5"@7<78"727=-:87G3+""–  9..58:"(.2<5.88'D"7+<-67"""

–  95'*3.F+"727=-:87G3+"""

•  H'.((F55'2('"57<'+"–  JcYScp"@.5"32+'(<"+)2;+"–  #cYJcp"@.5"57D3.(.2<57+<"7;'2<+"

–  !cY#cp"@.5"='23(38832""

•  ^.+<"(.66.2"(7F+'+"–  e2)%3.)(+"–  C2+'(<+"–  d..D""

AU"

e27=-:87()(",-.(/"Y"037;2.+3+"

•  >8323(78"D37;2.+3+"–  0'12'D"%:"735I7:"(.6=5.63+'R"-:=.<'2+3.2R".5"

32*.8*'6'2<".@"(F<72'.F+R"5'+=357<.5:R".5"[C"+:+<'6+"

B  ^38DR"8.(783g'D"F5)(7537"(72"=5.;5'++"<."@F88"727=-:87G3+"

B  ,:6=<.6+"F+F788:"%';32"I3<-32"Sc"632F<'+".@"'G=.+F5'"

B  d7+<'5".2+'<".@"+:6=<.6+"L"6.5'"+'*'5'"5'7().2"

B  K3=-7+3("=5'+'2<7).2".((F5+"32"F="<."#cp".@"=7)'2<+"B  ,:6=<.6+"I388"5'<F52"AYJ"-.F5+"7n'5"323)78"5'7().2"-7+"(8'75'D"

•  i../"@.5"'G=.+F5'"<."D5F;R"@..DR".5"32+'(<"•  i7%+"-7*'"2."5.8'"

A]"

e27=-:87()(",-.(/"Y"?5'7<6'2<"

•  eK>q+"– H'+=357<.5:"(.6=5.63+'"5'EF35'"366'D37<'"

32<F%7).2"

•  CNR">75D37("^.23<.5R"9F8+'"$G36'<5:"

•  CNdq+R"$G:;'2"•  V=32'=-532'"@.5"e27=-:87G3+f,-.(/"•  ,'(.2D"832'"?-'57=3'+"

– >.5)(.+<'5.3D+"– Q!"72D"Q#"%8.(/'5+"

Jc"

e27=-:87()(",-.(/"Y"?5'7<6'2<"

•  V=32'=-532'"– clA"6;"C^".5",>".@"!b!ccc"D38F).2"@.5"727=-:87G3+""

– H'='7<"'*'5:"PY!c"632"7+"2''D'D"

– >7F).2"3@"=7)'2<".2"%'<7"%8.(/'5+"DF'"<."F2.==.+'D"78=-7"+)6F87).2"72D"5'+F8<72<"+'*'5'"

-:='5<'2+3.2"

– d.5">N"(.887=+'"W3l'l"(75D37("755'+<XR"!"6;"CN".@"

!b!cRccc"W+76'"7+"e>i,"0.+'X"

–  C@"5'@57(<.5:"-:=.<'2+3.2"72D"+-.(/R"+<75<"CN"D53="

J!"

e27=-:87()(",-.(/"Y"?5'7<6'2<"

•  >.5)(.+<'5.3D+"– ^'<-:8=5'D23+.8.2'"!#P"6;"CN""

–  95'D23+.2'"Sc"6;"9$"

•  e2)-3+<7632'+"

–  Q!"%8.(/'5Y"03=-'2-:D57632'"#PYPc"6;"CN"

–  Q#"%8.(/'5Y"H723)D32'"Pc"6;"CN"

•  K5.2(-.D387<.5+"–  e8%F<'5.8"2'%F83g'5"–  e<5.*'2<"2'%F83g'5"– ^7;2'+3F6"+F8@7<'"#";"CN".*'5"#c"632F<'+""

"

J#"

>75D3.;'23(",-.(/"

B  ^.5<783<:"=53.5"<."5'='5@F+3.2"

<-'57=:"L"PcYUcp"

B  ,3;2+b"B  >..8R"6._8'D"+/32"

B  ?7(-:=2'7"B  9F86.275:"*7+(F875"(.2;'+).2""

B  Q:=.<'2+3.2"B  e8<'5'D"6'2<78"+<7<F+"

B  4755.I'D"=F8+'"=5'++F5'"B  H78'+R"6F56F5"

B  0'12'D"7+b"B  ,K9"m"]c"66Q;"

B  >75D37("C2D'G"m"#l#"if6f6#"

B  9F86.275:">7=38875:"Z'D;'"

95'++F5'"W9>Z9X"o"!U"

66Q;"

Patrick J. Lynch, Wikimedia Commons JA"

>75D3.;'23(",-.(/""

•  >75D3.;'23(",-.(/"V).8.;:"– e(F<'"^:.(75D378"C2@75().2"We^CX"

– ,'=+3+"– ^:.(75D3)+"

– ^:.(75D378">.2<F+3.2"

– e(F<'"e.5)("C2+F`(3'2(:"

– e.5)(".@"^3<578",<'2.+3+"

– Q:='5<5.=-3(">75D3.6:.=7<-:"

JJ"

>75D3.;'23(",-.(/"

•  $n'2"5'+F8<+"@5.6"6:.(75D378"3+(-'637"

I3<-"8.++".@"8'n"*'2<53(F875"WiNX"@F2().2"

– >8323(78"+-.(/"'2+F'+"7n'5"8.++".@"Jcp"iN"•  H'+F8)2;"(75D37(".F<=F<"5'DF().2"8'7D+"<."87()("7(3D.+3+"72D"-:=.G37"

•  ,<5./'"*.8F6'"3+"5'DF('D""

– ?7(-:(75D37"D'*'8.=+"7+"(.6='2+7).2"@.5"

D'(5'7+'D",N"<."6732<732"(75D37(".F<=F<""

–  C+(-'637"72D"32@75().2"I.5+'2+"(5'7)2;"

D.I2I75D"+=3578"

JP"

>75D3.;'23(",-.(/"Y"037;2.+3+"

•  Vt["•  >MH"•  i7%.57<.5:b""

–  >.6=8'<'"K8..D">.F2<"

–  >-'63+<5:"972'8"WV8'(<5.8:<'+R"Kj4f>HX"

–  >75D37("'2g:6'+"W^:.;8.%32R">tR">tY^KR"?5.=.232X"

–  >.7;F87).2"+<FD3'+"•  V(-.(75D3.;576"

JS"

>75D3.;'23(",-.(/"Y"?5'7<6'2<"

•  ?5'7<6'2<"[.78+"

–  e35I7:"(.2<5.8"W3@"2'('++75:X"–  C6=5.*32;"6:.(75D378"=F6="@F2().2"

–  H'='5@F+3.2"W3@"7*7387%8'X"–  95'*'2)2;"@F5<-'5"6:.(75D378"D767;'"

•  ^.23<.532;""

–  >75D37("6.23<.5"

–  9F8+'"$G36'<5:"

•  ,F==8'6'2<78".G:;'2R"CN"7(('++"

•  C2<F%7).2"D'(5'7+'+"=5'8.7D"72D"(7F+'+"-:=.<'2+3.2"""

– ^7:"2''D"<.";3*'"\F3D"%.8F+"<."(.6='2+7<'"3@"32<F%7)2;"

JT"

>75D3.;'23(",-.(/"Y"?5'7<6'2<"

•  e^C"

–  e+=3532R"K'<7Y%8.(/'5R"^.5=-32'R"Q'=7532"

–  43<5.;8:('532"@.5"=732"(.2<5.8"W7*.3D"32"32@'53.5"^CX"

–  C@"2."=F86.275:"'D'67R"67:"<5:"CN"\F3D"@.5"K9"+F==.5<"

–  C@"=F86.275:"'D'67"

•  0.=7632'"O"I388"x"QH"72D"<-F+"(75D37("I.5/"

•  0.%F<7632'"O"^7:"D5.="%8..D"=5'++F5'"DF'"<."='53=-'578"

*7+.D387<7).2"

•  >.6%327).2"<-'57=:"67:"%'"6.5'"'a'()*'"

–  H'='5@F+3.2"?-'57=:"W3@",?V^C"72D"7*7387%8'"32"<-'"(8323(78"

+'y2;X"

•  >75D37("(7<-'<'53g7).2"I3<-"32<'5*'2).2""•  ?-5.6%.8:)(+"

"JU"

4'F5.;'23(",-.(/"

•  H'+F8<+"@5.6"+=3278"(.5D"32&F5:"I3<-"+-.(/"

87+)2;"@5.6"!YA"I''/+"

•  i.++".@"+:6=7<-')("<.2'"72D"5'+F8<72<"

F2.==.+'D"*7;78"<.2'"

•  0'(5'7+'D"*7+.6.<.5"<.2'""

•  H'+F8<+"32"-:=.<'2+3.2"72D"%57D:(75D37"

•  97)'2<+"67:"5'6732"78'5<R"I756R"72D"D5:"

D'+=3<'"<-'"-:=.<'2+3.2"

•  ,=3278"+-.(/"

–  ?'6=.575:"8.++".@"+=3278"5'\'G"7()*3<:"

%'8.I"7"<.<78".5"2'75"<.<78"+=3278"(.5D"

32&F5:"

–  4.<"<-'"+76'"7+"2'F5.;'23("+-.(/R"<-'"

<'56+"75'"2.<"32<'5(-72;'7%8'"

gunkyboy, Wikimedia Commons

J]"

4'F5.;'23(",-.(/Y"?5'7<6'2<"

•  eRKR>+"–  H'6'6%'5">Y+=32'"=5'(7F).2+"

–  Q3;-">Y+=32'"32&F53'+"5'EF35'"6'(-723(78"*'2)87).2""

•  >AY>JY>P"O"9-5'23("4'5*'"322'5*7).2"•  d8F3D"5'+F+(3<7).2"

–  t''="^e9"7<"UPY]c"66"Q;"@.5"15+<"T"D7:+"

–  ^32363g'"+'(.2D75:"(.5D"32&F5:"

–  C@"(5:+<788.3D"3+"32+F`(3'2<"F+'"*7+.=5'++.5+"

•  ,'75(-"@.5".<-'5"(7F+'+".@"-:=.<'2+3.2"–  $n'2R",>C"5'+F8<+"@5.6"<57F67"L"5f."Q'6.55-7;3(",-.(/"

•  d.5"%57D:(75D37"–  e<5.=32'"–  97('67/'5""

Pc"

$%+<5F()*'",-.(/"

•  ?'2+3.2"92'F6.<-.57G"

•  >75D37("?76=.27D'"

•  9F86.275:"V6%.83+6"

•  ,'*'5'"e.5)(",<'2.+3+"

P!"

$%+<5F()*'",-.(/"

B  ?'2+3.2"=2'F6.<-.57G"

B  e35"<57=='D"32"=8'F578"+=7('"I3<-"!"I7:"*78*'R"735f=5'++F5'"%F38D+"F="

B ^'D37+)2F6"+-3n'D"36='D32;"

*'2.F+"5'<F52"

B  >-'+<"=732R",$KR"D'(5'7+'D"%5'7<-"+.F2D+"

B  4."<'+<+"2''D'Df(8323(78"D37;2.+3+"B  ?5'7<6'2<b"4''D8'"D'(.6=5'++3.2"

@.88.I'D"%:"(-'+<"<F%'"Source: www.meddean.luc.edu/lumenMedEd/medicine/pulmonar/cxr/pneumo1.htm

Delldot, Wikimedia Commons

P#"

$%+<5F()*'",-.(/"

B  >75D37("<76=.27D'"

B  K8..D"32"='53(75D378"+7("=5'*'2<+"*'2.F+"5'<F52"<."72D"(.2<57().2".@"

-'75<"

B  V).8.;:b""?57F67R"9'53(75D3)+R"^C"

B  K'(/q+"<537Db""B Q:=.<'2+3.2R"6Fz'D"-'75<"+.F2D+R"hN0"

B  037;2.+3+b"i75;'"-'75<">MHR"'(-."B  ?5'7<6'2<b"9'53(75D3.('2<'+3+"

K8..D"

9'53(75D3F6"

V=3(75D3F6"

Aceofhearts1968, Wikimedia Commons

PA"

$%+<5F()*'",-.(/"

•  9F86.275:"'6%.83+6"

–  N35(-.I"<537Db""•  Q:='5(.7;F87%8'"•  N'2.F+"32&F5:"•  N'2.+<7+3+"

–  ,3;2+b""•  ?7(-:=2'7""•  ?7(-:(75D37"•  Q:=.G37"

–  i.I"53+/b"0YD36'5"

–  Q3;-'5"53+/b">?"(-'+<".5"Nk"+(72"

–  ?5'7<6'2<b""Q'=7532"

•  >.2+3D'5"<-5.6%.8:)(+"3@"+-.(/"

@5.6"9V"

Hellerhoff, Wikimedia Commons

PJ"

$%+<5F()*'",-.(/"

B  e.5)("+<'2.+3+"B  H'+3+<72('"<."+:+<.83("'&'().2"(7F+'+"D'(5'7+'D"(75D37("@F2().2"

B  >-'+<"=732"I3<-"+:2(.='"B  ,:+<.83("'&'().2"6F56F5"

B 0'123)*'"D37;2.+3+"I3<-"'(-."B N7+.D387<.5+"W4?[X"I388"D5.="=5'++F5'"B  ?5'7<6'2<b"e.5)("*78*'"+F5;'5:"

PP"

Z-3(-"=5'++.5"+-.F8D"C"(-..+'r"

! Q:=.*.8'63("+-.(/"

–  Fluids and Blood

! >75D3.;'23("+-.(/"–  Dobutamine - !1 agonist

! Increases squeeze and heart rate

! 4'F5.;'23("+-.(/"–  Fluids, phenylephrine, Levophed,

look for another type of shock if it is persistent

! e27=-:87()("+-.(/"–  Fluids and epinephrine

!  ,'=)("+-.(/"–  Neosynephrine - alpha agonist

! Increases SVR by arteriolar constriction

–  Norepinephrine/Levophed - alpha and beta agonists

! 0.=7632'"

–  Low Dose - increases renal blood supply

–  Medium Dose - beta effects (increases heart rate and squeeze)

–  High Dose - alpha effects (arteriolar constriction)

PS"

kF'+).2+r"

Dkscully, Flickr PT"