Trauma Care 2: Shock Evaluation Overview Portal
Initial Evaluation: BP, heart rate, respiratory rate, temperature, neck vein evaluation, ECG, CBC, ABGs, electrolytes, creatinine, arterial blood lactate level, vital signs, urinary output, and neurologic, mental status exams
Cardiac Causes
| Abnormal Rate |
Symptoms
|
Treatment
|
| Tachyarrhythmia | ||
| Bradyarrhythmia | ||
| Decreased Preload or Vascular Infarction | Symptoms
|
Treatment
|
| Right Ventricular Infarction | chest pain, JVD, right-sided gallops, hypotension associated with inferior infarctions, clear lungs, ST elevation in right precordial leads (RV4) | vigorous fluid therapy to raise left ventricle filling pressure, dobutamine, intra-aortic balloon pump, consider angioplasty or bypass surgery, thrombolytic therapy |
| Massive Pulmonary Embolus | hypoxemia, chest pain, pulmonary hypertension, acute right ventricular failure, tachycardia, ECG changes, shortness of breath, hemoptysis | IV fluids, oxygen, thrombolytic therapy, anticoagulation, embolectomy, extraction thrombectomy, pressors to support BP |
| Tension Pneumothorax | anxious, chest or back pain, unilateral absent breath sounds, dyspnea, tracheal deviation, tachypnea | chest tube placement, oxygen, volume replacement, BP support, pleural tap with large-bore needle into second or third anterior intercostal space |
| Cardiac Tamponade | anxious, distant heart sounds, tachycardia, jugular venous distension, pulsus paradoxus >10 mm Hg, ECG changes. Hypotension is a late finding. | pericardiocentesis, rapid fluid infusion, pericardiostomy or pericardial window, dopamine |
| Mitral Stenosis | shortness of breath, tachycardia, jugular venous distension, possible diastolic murmur or opening snap, hypoxia, pulmonary rales, AF | oxygen, control arrhythmias, diuretics, morphine sulfate, balloon valvuloplasty, or surgical intervention |
| Cardiac Myxoma | syncope with mitral stenosis often associated with emboli, fever, and weight loss | surgery |
| Superior Vena Cava Syndrome | distended neck veins, facial edema, tachypnea, mediastinal mass on chest x-ray | supportive medical therapy, tissue diagnosis, radiation, or chemotherapy |
| Thoracic Aortic Dissection (Decreased Preload Due to Hypovolemia or Obstruction Due to Tamponade) | pain similar to MI, pain severe at onset, neurologic abnormalities and pulse deficits may occur, aortic regurgitation, pericardial rubs or tamponade | if hypertensive, lower the BP, decrease contractile force of left ventricle, administer beta blocker, and depending on location of dissection, consider surgery |
| Impaired Contractility/ Excessive Preload | Symptoms |
Treatment |
| Acute MI with Cardiogenic Shock is the Most Common Cause of Shock with a Contractile Dysfunction (Mortality Rates of 50% to 80%) | hypotension, pulmonary congestion, oliguria, mental obtundation, pallor, sweating, tachycardia; to cause shock the area of necrosis is > than 35% to 40% | cardiac catheterization, angioplasty, intra-aortic balloon pump, revascularization surgery, dopamine or dobutamine |
| Ventricular Septal Rupture -- occurs 3 to 7 days post MI | chest pain, tachycardia, new murmur | IV fluids, intra-aortic balloon pump, BP support, surgical interventions, afterload reduction, digitalis, diuretics |
| Ruptured Chordae/Papillary Muscle -- Acute Onset of CHF, usually 1 to 7 days after infarction | loud systolic murmur along left sternal border | immediate surgery if unstable or in 4 to 6 weeks if the patient is stable, afterload reduction, diuretics, ACE inhibitors, digitalis, intra-aortic balloon pump |
| Mitral Regurgitation | anxious, cyanosis, pulmonary rales, S3 gallop, new heart murmur tachycardia, hypoxemia, acidemia | oxygen, diuretics, ACE inhibitors, morphine sulfate, nitrate preparations, intra-aortic balloon pump, coronary reperfusion |
| Aortic Regurgitation | shortness of breath, diastolic murmur, narrowed pulse, pulmonary rales, tachycardia, hypoxemia | intropic support, BP support, oxygen, surgical intervention |
| Dilated Cardiomyopathy | signs of left and right ventricular hypertrophy, Q waves without infarction, possible pericardial effusion, signs and symptoms of CHF | oxygen, supportive care including BP support, ACE inhibitors, diuretics, possible beta blockers |
| Myocarditis | fever, dyspnea, edema, fatique, palpitations, and pleuropericardial pain, ST and T wave changes | mainly supportive, digitalis, diuresis, afterload reduction |
| Prosthetic Valve Dysfunction | change in cardiac function and change in heart murmur | surgical valve replacement |
| Excessive Afterload |
Symptoms
|
Treatment
|
| Aortic Stenosis | shortness of breath, pulmonary rales, jugular venous distension, hypoxia, late-peaking systolic murmur, diminished carotid pstroke, possible thrill | inotropic and BP support, oxygen, balloon valvuloplasty, valve replacement surgery, control arrhythmias |
| Hypertrophic Cardiomyopathy (Preload may also be reduced.) | dyspnea, angina, syncope, palpitations, mitral regurgitation murmur, elevated pulmonary venous pressures, systolic murmur, positive thrill, and bifid carotid pulse | control arrhythmias, consider beta blocker and calcium antagonist therapy |
| Coarctation of the Aorta | delayed and weaker femoral pulses, rib notching on chest x-ray, symptoms of left ventricular hypertrophy, systolic bruit in supper chest | surgical repair |
Non-Cardiac Causes
| Volume Loss | Symptoms |
Treatment |
| Hemorrhage: Most common cause of shock | anxious, skin cool, clammy, tachycardia, lethargy, obtundation (common in trauma, GI losses) | volume replacement with fluids and blood products, endoscopy, surgical intervention |
| Gastrointestinal Fluid Losses | anxious, skin cool, clammy, tachycardia, lethargy, obtundation (consider with poor intake), persistent vomiting and diarrhea | fluid support, management of electrolyte abnormalities |
| Generalized Fluid Losses (Burns, Heat Stroke) | tachycardia, lethargy, obtundation (consider with diaphoresis in heat stroke or burn patients) | treat underlying cause (burn or heat prostration), fluid support |
| Diabetic Ketoacidosis | elevated blood sugar, acidosis, elevated ketone levels, dehydration, altered mental status, vomiting, abdominal pain | (Vol III -- END/M2 Diabetic Ketoacidosis) fluid replacement, monitor and manage electrolyte abnormalities, insulin administration, correction of acidosis (Vol III -- END/M6 Acid-Base) |
| Renal Losses (Diabetes Insipidus) | polydipsia, polyuria, excessive thirst, failure to concentrate urine, hyponatremia | salt restriction, thiazide diuretics, ADH replacement, DDAVP, chlorpropamide |
| Decreased Vascular Resistance | Symptoms |
Treatment |
| Septic Shock | hypothermia or hyperthermia, respirator alkalosis and/or metabolic acidosis, oliguria or anuria, rigors, hypernea, other end-organ dysfunction | (Vol III -- IN3 Sepsis in Adults) Identify source of infection; fluid support; cultures and initiation of antibiotic therapy; possibly steroid therapy |
| Anaphylactic Shock | anxious, vascular collapse with peripheral vasodilatation, angioedema, respiratory compromise or distress | (Vol III -- AIR8 Anaphylaxis) epinephrine, antihistamines, airway management, IV fluids, oxygen, corticosteroids to prevent return of symptoms |
| Neurogenic Shock | bradycardia, loss of peripheral vascular tone (seen with significant CNS or spinal cord injury) | if possible, correct neurologic abnormality; IV fluid support |
| Addisonian Crisis | weight loss, anorexia, hypovolemia, hypotension, weakness, azotemia, hyponatremia, hyperkalemia | (Vol III -- ENd/M1 Adrenal Crisis) glucocorticoid replacement, fluid support, mineral corticoid replacement, correct hypoglycemia |
| Myxedema (Severe Hypothyroidism) | lethargy to unresponsiveness, hypothermia, hypotension, bradycardia, hypoventilation, hyponatremia | (Vol III - END/M4 Thyroid Storm) assisted ventilation, thyroid hormone replacement, fluid support, glucocorticoid replacement, electrolyte correction |
| Drug Overdose (Vol III -- TOX1 Systematic Approach) | variable -- seen with drugs that cause alteration of vascular tone or cardiac function (commonly seen with anesthetics, barbituates, glutethimide, phenothiazines) | fluid support, airway and ventilatory support if needed, reverse drug effect if possible |