Undifferentiated shock

Definition

  1. SBP <90 in nl pt
  2. SBP<100 with h/o HTN or age >60
  3. ABG = lactate > 4 or base def < -4
  4. MAP = SVR x CO

Types

Type Skin HR Oth
Hypovolemic cold inc
Obstructive cold inc
Cardiogenic cold inc/dec  ?dysth
Distributive warm inc
Neurogenic warm dec

Undifferentiated Hypotension Algorithm

Check:

  1. HR (age appropriate)
    1. <40 and >150-180 --> likely HR = Primary etiology
    2. Pace or Shock
  2. Volume Status - LVEDP (approx by CVP, IVC, etc.)
    1. History of volume loss
    2. Lung Exam
    3. Mucous membrane
    4. Ultrasound IVC (RUQ window or AAA)
    5. Hemeacuu, Guaic
  3. Contractility (weak heart)
    1. Bounding/thready pulse, hyperdynamic precordium
    2. Cardiac Ultrasound
  4. Low SVR - Vasodilation is the final answer, if all else is negative expect bounding pulse
  1. HR
    1. Too high (>180) or too low
      1. Tx with cardioversion/defib or pace
  2. Volume
    1. Plasma vs. RBC loss
      1. Evaluate CVP, IVC, UOP
      2. Check for GI, intraperitoneal, lung, retroperitoneal loss/sequestration
  3. Contractility
    1. Dx with ultrasound
      1. Will have high afterload
        1. May be due to STEMI, CHF
  4. Forward flow
    1. Valvular dysfunction (MR) or obstruction
      1. Evaluate via auscultation, ultrasound
        1. Consider PE, HOCM
  5. SVR
    1. Pathologic vasodilation
      1. Warm extremities, bounding pulse
        1. Consider sympathetic dysregulation/neurogenic shock
    2. Cool extremities and "normal" BP
      1. Consider vasoconstriction and treat as hypotension from the top

Lack of Response to Normal Tx (DDX)

  1. Cardiac tamponade
  2. Tension PNTX
  3. Adrenal insuffic
  4. Toxin
  5. Allergic Rx
  6. Occult bleeding (ectopic, A/P)
  7. PE
  8. DIC

Source

2/06 DONALDSON (Adapted from Tintinalli)

Morchi 2010