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(The information is an adapted version of the original text, taken from an instruction based on the principles of evidence-based medicine).
None.
1. Signs of insufficient perfusion are:
a) violation of the state of consciousness;
b) delayed/rapid capillary filling;
c) hypoxia (blood saturation less than 94%);
d) decreased urination;
d) respiratory rate more than 20/min in adults or higher in children (see Table 1 Normal vital signs);
e) hypotension depending on age (lowest acceptable systolic blood pressure index):):
f) tachycardia (depending on age), regardless of temperature (see Appendix 4);
e) brady- or tachycardia;
g) cold/marble or hyperemic skin.
2. Possible etiological causes of shock:
a) hypovolemia (insufficient use of fluids, excessive loss of fluids (for example, bleeding, syndrome of inadequate release of antidiuretic hormones, excessive urination due to hyperglycemia, vomiting, diarrhea);
b) sepsis
violation of thermoregulation:
c) anaphylaxis (hives, nausea/vomiting, swelling of soft tissues and mucous membranes, whistling sounds during breathing);
d) signs of heart failure (hepatomegaly, pathological respiratory murmurs – wheezing, swelling of the limbs, expansion of the jugular veins).
Shock due to potential injury (see instructions of the “Injury” section).
1. Medical history:
a) history of gastrointestinal bleeding;
b) heart disease;
c) stroke;
d) fever;
g) nausea/vomiting, diarrhea;
e) frequent or absent diuresis;
f) episodes of loss of consciousness;
e) allergic reactions;
g) disorders of the immune system (malignant neoplasms, transplants, asplenia);
c) endocrine disorders;
and) the presence of a catheter in the central vein;
and) other risks of infectious diseases (spina bifida or other anatomical abnormality of the genitourinary system).
2. Overview:
a) airway/breathing (airway edema, wheezing, whistling, pulse oximetry, respiratory rate);
b) blood circulation (heart rate, blood pressure, capillary filling);
c) abdomen (hepatomegaly);
d) hydration of mucous membranes;
d) skin (turgor, rash);
e) neurology (SCG, sensorimotor deficiency).
3. Definition of shock type:
a) cardiogenic;
b) distributive (neurogenic, septic, anaphylactic);
c) hypovolemic;
d) obstructive (e.g. pulmonary embolism, cardiac tamponade, strained pneumothorax).).
1. Check vital signs.
2. Oxygen therapy – the goal is to achieve a blood saturation level of 94-98%.
3. Cardiomonitoring.
4. Pulse oximetry and capnometry (index less than 25 mm Hg may be a sign of poor perfusion).
5. Glucometry, if necessary, appropriate treatment (if the indicator is below 3.3 mmol/l (60 mg/dL).
6. ECG.
7. Determine the level of lactate if possible (an indicator above 2 mmol/l is a pathology).
8. Provide i.v. access – in case of failure after two attempts or within 90 seconds, it is necessary to provide i.v. access.
9. IV liquid (30 ml/kg isotonic liquid; maximum 1 liter) for less than 15 minutes, using a method of taking fluid into a syringe and injecting it through an IV catheter (mainly in children). It can be repeated three times, depending on the general condition of the patient.
10. If a history of adrenal insufficiency or long-term steroid dependence, provide:
a) hydrocortisone succinate, 2 mg/kg (maximum dose – 100 mg) IV/IM (priority method)
OR
b) methylprednisolone, 2 mg/kg iv (maximum dose – 125 mg)
11. Vasopressors (if not responding to infusion therapy)
a) cardiogenic, hypovolemic, obstructive shock:
b) distributive shock (except for anaphylactic shock):
12. Norepinephrine is the first-line choice drug in the treatment of neurogenic shock.
13. With anaphylactic shock – see. Manual “Anaphylaxis and allergic reaction.”
14. Send information about the patient’s condition to the emergency room.
15. Consider empirical antibiotics if septic shock is suspected in case the transport time to the emergency department is more than 1 hour, if it is possible to obtain a blood culture in advance, take a bacteriological blood test and/or if the EMF coordinates with the hospital admission department regarding the choice of antibiotic therapy.
16. For fever, use antipyretic drugs:
a) paracetamol (15 mg/kg, the maximum dose is 1000 mg);
b) ibuprofen (10 mg/kg, maximum dose 800 mg).
Recognition of cardiogenic shock – if the patient’s condition worsens after infusion therapy, wheezing appears or hepatomegaly develops, the presence of cardiogenic shock should be suspected and infusion therapy should be stopped.
1. Early aggressive infusion of fluids is the foundation in the treatment of suspected shock.
2. Patients with a tendency to shock:
a) with impaired immunity (patients undergoing chemotherapy or with congenital/acquired immunity disorder);
b) with adrenal insufficiency (Addison’s disease, congenital adrenal hyperplasia, chronic or recent steroid use);
c) with a history of solid organ or bone marrow transplantation;
d) infants;
e) elderly persons.
3. In most adults, tachycardia is the first sign of compensatory shock and can last for hours. Tachycardia may be a late sign of shock in children, in this state children are close to cardiovascular collapse.
4. Hypotension indicates non-compensatory shock, which can develop into cardiopulmonary collapse within minutes.
5. Hydrocortisone succinate (if available) is the preferred drug for methylprednisolone and dexamethasone in a patient with adrenal insufficiency because it has a dual glucocorticoid and mineralocorticoid effect:
a) patients who do not have a history of adrenal dysfunction may have adrenal suppression due to severe disease, so hydrocortisone should be used in the presence of treatment-resistant shock;
b) patients with adrenal insufficiency can carry an emergency dose of hydrocortisone, which can be administered IV or IV.
Reduced perfusion, which is manifested by an altered mental state or a violation of capillary filling or pulse, a decrease in diuresis (less than 1 ml/kg/h) indicates:
a) cardiogenic, hypovolemic, obstructive shock: capillary filling longer than 2 seconds, weak peripheral pulse, cool limbs;
b) distributive shock: sharp capillary filling limiting peripheral pulse.