View source for Undifferentiated shock

{{AdultPage|undifferentiated shock}}
==Overview==
*Inadequate perfusion of the tissues
*Goal to increase the flow of oxygenated blood to the tissues
*MAP<50 in dog studies brain will become ischemic and patients might presents as an altered mental status <ref>Plöchl, W, D J Cook, T A Orszulak, and R C Daly. 1998. Critical cerebral perfusion pressure during tepid heart operations in dogs. The Annals of thoracic surgery, no. 1. http://www.ncbi.nlm.nih.gov/pubmed/9692450</ref>  

==Undifferentiated [[Hypotension]] Algorithm<ref>Morchi R. Diagnosis Deconstructed: Solving [[Hypotension]]in 30 Seconds. Emergency Medicine News. 2015.</ref>==
Check/manage the following in order:

[[File:Hypotension.png|thumbnail|Algorithm for the Evaluation of [[Hypotension]](By Dr. Ravi Morchi)]]

*Pulse (assess based on patient's age)
**Too [[bradycardia|slow]] or too [[tachycardia|fast]] (to the point where CO is affected)?
***If so, HR is likely primary etiology of hypotension
***Pace or cardiovert
*Volume status
**What is the LV end-diastolic volume?
***Approximated by the [[IVC ultrasound|IVC diameter]] or CVP
***If low:
****Assess for [[hemorrhage|blood]] loss versus [[hypovolemia|fluid loss]]
*****[[FAST exam|FAST]] for intra-abdominal bleed
*****US for ruptured [[Aortic ultrasound|AAA]]
*****Guaiac for [[GI bleed]]
*****[[CXR]] for [[hemothorax]]
****Treat with [[IVF]] and/or [[pRBCs]] depending on cause
*Contractility
**Is the myocardium severely depressed in its contractile function ([[cardiogenic shock]])?
***Assess via [[Ultrasound: In Shock and Hypotension|ultrasound]]
***Treat with inotrope (e.g. [[epinephrine]], [[dopamine]]
**Is forward flow occurring?
***Assess for valvular dysfunction ([[mitral regurgitation|MR]], [[aortic regurgitation|AR]])
***Assess for obstruction ([[PE]], [[tamponade]]) 
*Systemic Vascular Resistance
**Pathologic vasodilation (decreased SVR) suggested by:
***Warm extremities
***Bounding pulse
**Treated based on likely etiology of distributive shock (see below)

==Differential Diagnosis==
{{Shock DDX}}

==Evaluation==
{{Shock index}}

===Consider RUSH to CVS===
*[[RUSH exam]]
*[[calcium chloride|Calcium]] bolus as inotrope
*[[Vasopressin]]
*[[Steroids]], stress-dose, mineralocorticoids

==Management==
*Treat underlying type

{{Vasopressor table}}

===Causes of non-response to vasopressors<ref>Anand Swaminathan, "Occult Causes of Non-Response to Vasopressors", REBEL EM blog, July 13, 2017. Available at: https://rebelem.com/occult-causes-of-non-response-to-vasopressors/.</ref>===
*[[Acidosis]]
**Dx: Blood gas, BMP
**Tx: treat underlying cause, consider bicarbonate gtt
*[[Hypothyroidism]]
**Dx: Clinical, TSH
**Tx: [[levothyroxine]]
*[[Anaphylaxis]]
**Dx: History
**Tx: [[Epinephrine]], [[methylene blue]], ECMO
*[[Adrenal insufficiency]]
**Dx: Clinical, cortisol level, [[hyperkalemia]] + [[hyponatremia]]
**Tx: [[Hydrocortisone]] 100-200mg
*[[Hypocalcemia]]
**Dx: ionized calcium, [[prolonged QTc]]
**Tx: [[Calcium chloride]] or [[calcium gluconate]]
*[[Hemorrhagic shock|Occult bleeding]]
**Dx: Clinical (consider [[GI bleed]] and retroperitoneal hematoma)
**Tx: Transfusion, treat coagulopathy, surgery/IR interventions
*[[Toxicology (main)|Toxicologic]]
**Dx: Clinical (consider [[beta blocker toxicity]], [[calcium channel blocker toxicity]], [[TCA overdose]], etc)
**Tx: Depends on etiology (glucagon, hyperinsulin euglycemia therapy, sodium bicarbonate, ECMO, etc)
*2nd cause of shock
**Dx: Clinical, consider [[RUSH exam]]
**Tx: Address underlying cause

==Disposition==
*All patients with shock require ICU admission
*Early identification and treatment of reversible causes is critical
*Reassess frequently for response to interventions
*Consider transfer to higher level of care if cause cannot be identified or adequately treated

==See Also==
*[[Ultrasound in Shock and Hypotension]]
*[[Pediatric shock]]

== Calculators ==
{{Shock_Index_Calculator}}

{{MAP_Calculator}}

==External Links==
*[http://pemplaybook.org/podcast/approach-to-shock/ Pediatric Emergency Playbook Podcast: Approach to Shock]

==References==
<references/>

==Videos==
{{#widget:YouTube|id=rOADTgtWuD4}}
{{#widget:YouTube|id=uZgusFEwmmk}}
[[Category:Critical Care]]
[[Category:Cardiology]]