Shock management

1. hemorrhage
   1. trauma, rupture AAA, ruptured ectopic pregnancy
2. most common cuase + reversible
3. fluid loss
   1. vomiting (eg GI obstruction), diarrhea (eg cholera), burns, pools of sequestered fluids ('third spacing' eg in pancreatitis)
4. heat exhaustion
   1. treat w/ tepid sponging + fanning (avoid ice and immersion); reusc w/high sodium lvl (such as 0.9% saline +/- hydrocorisone 100mg IV); stop cooling when T <39
5. TREATMENT
   1. fluid replacement
      1. 0.9% saline or colloid initially. If bleeding, use blood (also if exsanguinating, severe hemm or >1L of fluid req to maintain BP)
   2. treat underlying cause
   3. correct electrolyte abnorms (acidosis often responds to fluid replace)

1. type-1 IgE mediated hypersensitivity reaction
   1. release of histamine + other agents -> capillary leak; wheeze; cyanosis; edema; (larynx, lids, tongue, lips); urticaria
      1. more common in atopic ppl
   2. precipitants
      1. drugs, (eg penicillin, contrast media), latex, stings, eggs, fish, peanuts, strawberries, semen (rare)
2. signs/symps
   1. itching, sweating, diarreha + vomiting, erythema, urticaria, edema; wheeze, laryngeal obstruction, cyanosis, tachycardia, hypotension

Annotations:

• septic shock from endotoxin-induced vasodilat may be SUDDEN and SEVERE with shock + coma but no signs of infection (fever, WCC up)
• sepsis: SIRS occuring in presence of infection severe sepsis: sepsis w/evidence of organ hypoperfusion eg hypoxemia, oliguria, lactic acidosis, or altered cerebral function septic shock: severe sepsis w/hypotension (systolic &lt;90mmHg) despite adequate fluid resusc or the req for vasopressors/inotropes to maintain BP

1. manage
   1. give abx w/in 1hr (preferably after blood culture)
      1. if no clue to source, give IV co-amoxiclav 1.2g/18h or merpenem 1g/8h, or gentamicin (do lvls, reduce in renal fail) + antipseudomonal penicillin
   2. give colloid or crystalloid by IVI. refer to ITu if poss for monitoring +/- inotropes
      1. Aim for CVP 8-12 mmHg, mean pressure >65 mmHg, urine >35ml?h
         1. low dose steroids may help if hypotensive despite fluids + vasopressors as may recombinant human-activated prot C
2. SIRS def (click on me)

   Annotations:

   • SIRS- involving cytokine cascades. free radical production + the release of vasoactive mediators. defined as  T &gt;38 or &lt;36 Tachycardia &gt;90bpm RR &gt;20breaths/min or PaCO2 &lt;4.3 kPa WBC &gt;12x10^9/L or &lt;4x10^9/L or &gt;10% immature forms