You are asked to help resuscitate a 75 year old man who has just arrived in the emergency department. He has a blood pressure of 80/45 mmHg, HR 140/min, and a temperature of 38.5°C after 2 litres of normal saline resuscitation.The only history available is of significant cardiac disease.
Outline your approach to the management of his haemodynamic profile.
Consider mixed aetiology for shock
• Cardiogenic (cardiac history, severe sepsis, rhythm)
• Distributive shock (sepsis)
• Obstructive shock (PE, tamponade) – less likely but will probably get mentioned.
Maybe give less marks for this than the other causes
Establishing relative contribution of each to the hypotension
• Clinical Signs
• Distributive; warm and dilated (if adequate filling), temperature, potential source sepsis
• LVF; tachycardia, bibasal crepitations, gallop
• RVF; JVP, hepatomegaly, oedema
• Escalating monitoring
• Minimal: ECG, NIBP, SpO2
• ABP, CVP progressing to Central Venous O2 Sat / TTE / PICCO / PAC as indicated
• Laboratory Investigations directed at cause
• Lactate, Troponin, ECG, CXR, Sepsis screen, UA
• Collateral history
• Optimise preload
• Optimize preload (low from redistribution
• Optimize contractility
• Rhythm; rate control / normalization (cardioversion?)
• Inotropic support
• Dobutamine / Milrone / Levosimenden / Adrenaline / Nor Ad (increases coronary art perfusion pressure) Caution with inodilators while still hypotensive
• Reversible / Specific factors
• Exclude / treat ischaemia (heparin / angio , revascularisation etc.)
• Optimize preload
• Vasopressor support
• Adjuncts: Vasopressin / Steroid (infusion or bolus)
• Mixed pathology issues
• Risk of Noradrenaline alone is an increased afterload with worsening cardiogenic shock / peripheral perfusion
• Start with inotrope and then add vasopressor; dobutamine / norad combination
• Adrenaline may a safer choice (inotrope + vasoconstriction)
This is a question about undifferentiated shock. The question really should read "how do you assess a patient in a non-specific shock state, and maintain their organ perfusion while looking for a cause?" It would probably be useful to mention a rapid focused bedside echo. Obvious hints in terms of fever and a history of crusty coronaries have been given. The examiners would mainly be looking for a systematic approach to diagnosis and treatment, without overcommitment to any specific diagnosis.
The following is really just a rearrangement of the college answer. A standard template of shock assessment should exist; it can be applied here with minimal variation.
Decisive management for this mixed shock state:
Jones, Alan E., et al. "Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients*." Critical care medicine 32.8 (2004): 1703-1708.