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Vaccination Referrals from ED
Blunt Chest Wall Trauma/Rib Fractures
Fracture Management Guidelines (Paediatric)
Fracture Management Guidelines (Adult)
Hypothermia
Care Of Burns In Scotland (COBIS) Paediatric Guidance
Paediatric Febrile Neutropenia Guidance
PAEDIATRIC HYPOGLYCAEMIA MANAGEMENT in NON DIABETIC CHILDREN
Management of Anaphylaxis (Paediatrics)
Management of Prolonged Seizures (Convulsive Status Epilepticus) in Children
Acute Wheeze or Asthma in Paediatrics
Medical Emergencies in Eating Disorders (MEED)
Emergency Department
Vasopressors and Inotropes/Chronotropes
Shock
Level 1 CCU Medical Area
Pericardiocentesis
Major Haemorrhage Protocols (DGRI & GCH)
Major Haemorrhage
Suspected Anaphylaxis
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Shock
Last updated 4th March 2024
Introduction
- Hypoperfusion (shock) has a number of different causes with very different treatments. The treatment will depend what the cause(s) is/are.
- You MUST perform an ABCDE assessment to determine the cause(s).
- You MUST inform your/the patient’s responsible Consultant if any shock is not rapidly improving and you are considering any Critical Care interventions.
- The following categories of shock are recognised
Hypovolaemic Shock
- Reduced circulating volume leads to less pre-load and so less stroke volume and cardiac output and blood pressure.
- The treatment is fluid / blood replacement and stopping the volume loss.
- Do not give more than to restore the patient to EUVOLAEMIA. Don’t overdo it.
- Consider up to 30ml/kg crystalloid.
- In Trauma, use blood products and accept permissive hypotension in adults (not paediatrics) pending damage-control surgery unless there is a major head injury where a normal BP should be targeted.
- Vasopressors or inotropes have limited / no use in hypovolaemic shock.
Cardiogenic Shock
- Low heart rate and/or contractility.
- This may be a primary heart disease issue or as a result of another process such as sepsis or toxicology / electrolyte imbalance causing reduced contractility.
- Treat these first.
- Inotropes that improve cardiac contractility may be indicated (or chronotropes that more affect the heart rate), ask your consultant first.
- Handbook section on Vasopressors and Inotropes/Chronotropes
Obstructive Shock
- You should examine the chest
- Look for signs of DVT (to consider PE), Tension pneumothorax, and have a suspicion in the right types of patients (post-cardiac-surgery / penetrating trauma / aortic dissection) for cardiac tamponade.
- These causes have very different treatments (and are unlikely to benefit from vasopressors/inotropes as the primary treatment).
Distributive Shock
- Anaphylaxis, Neurogenic and Septic shock all cause vasodilation where the blood is ‘distributed’ away from the central organs that need perfusing, resulting in cardiac, cerebral and renal hypoperfusion.
- Resuscitate with fluid to EUVOLAEMIA
- Then start vasopressors after discussing with your consultant
- Some pathological processes may also require inotropes
- Handbook section on Vasopressors and Inotropes/Chronotropes
Cytotoxic Shock
- We won’t cover here as is rather specialist, but comes in the setting of toxic drugs such as cyanide.
Shock Tips
- There may be multiple types of shock in one patient, so in a patient not responding to initial appropriate management, consider alternative causes.
- Consider the patient with their past history and how they will tolerate your usual management
- For example a patient with severe heart failure will not tolerate 30ml/kg of fluid. Use 250ml boluses of fluid for any hypovolaemia and then use inotropes +/- vasopressors, again after discussing with your consultant.
Content updated by Alex McDonald