The Shocked Patient

“Shock is a life-threatening condition of circulatory failure. The effects of shock are initially reversible, but rapidly become irreversible, resulting in multiorgan failure (MOF) and death.”
— UpToDate.com

CMP 1 – Anaphylaxis

CMP 4 – Septic patient

CMP 5 – Shocked Patient

EM Curriculum: (click to view)

Background

Shock is defined as acute circulatory failure with inadequate or inappropriately distributed tissue perfusion resulting in generalised cellular hypoxia.

Shock can be classified into different causes - the acronym "PROVED?" can be used (Life in the Fast Lane).

  • Cardiogenic (Pump)

  • Rhythm abnormalities (some purists exclude dysrhythmia as a cause of cardiogenic shock)

  • Obstructive

  • Hypovolemia (Volume)

  • Endocrine causes (often mixed classification, but a useful subheading to make sure endocrine causes aren’t missed!)

  • Distributive (due to vasodilation)

  • ? = is it real? (check the BP measurement, is the arterial line in an artery, is the transducer at the correct height?)

“As you know, my motto is maximally aggressive care, ALWAYS! Maximally aggressive curative care and maximally aggressive palliative care.”
— Scott Weingart (@emcrit)

Irrespective of the cause, the inadequate delivery of oxygen results in a failure of aerobic metabolism which leads to end organ dysfunction.

Looking only at patients with severe sepsis (defined as SIRS + Infection + Organ Dysfunction) the overall mortality rate for patients admitted is 35% – approximately 5 times higher than for ST elevation myocardial infarction and stroke – and is responsible for approximately 37,000 deaths and 100,000 hospital admissions in the United Kingdom (UK) per year. (R.Daniels  2011)

Therefore it is essential that we identify these patients and were appropriate involve critical care and outreach, however it also worth identifying that for some patients escalation of care is not appropriate and they should receive appropriate comfort and dignity.

Further Reading:

  • Daniels R. Surviving the first hours in Sepsis: getting the basics right (an Intensivist’s perspective). Journal of Antimicrobial Chemotherapy 2011; 66(Suppl ii): 11-23

LEARNING OUTCOMES FROM COMPLETING THE TASKS

  • Describe what is meant by shock.

  • Differentiate between the various causes of shock.

  • Recognise the physical signs and symptoms of shock.

  • Formulate a differential diagnosis for the shocked patient.

  • Recall the tasks involved in the resuscitation and treatment of the causes of shock.

  • Compose a standard management plan for anaphylaxis in the Emergency Department.

  • Formulate a management plan for angioedema in the Emergency Department.

LEARNING OUTCOME FROM FACE-TO-FACE TEACHING

  • Consolidate knowledge on formulating a differential diagnosis in a patient in shock.

  • Consolidate knowledge on the treatment of shock.

  • Review the sepsis guidelines.

  • Review the evidence of fluid resuscitation in the management of different causes of shock.

  • Appreciate that major trauma is a significant cause of shock and explain the therapies for managing shock in these cases.

TASKS

Complete the following before the face to face session:

Task 1: The Diagnosis of Shock

Duration: 60 mins

This module covers in great detail the pathophysiology of shock and it's differential diagnoses. It is on the new RCEM Learning website which replaces EnlightenMe, so if this is your first visit take a look around at some of the other content which is matched to the RCEM curriculum.

Task 2: SePSIS Management

Duration: 15 mins

The latest version of our ED management tool for Sepsis is in line with the update definitions of sepsis (note the removal of SIRs Criteria). This video by Martin Wiese summarises the latest version.

Be aware that new International Consensus Definitions of Sepsis were released in Feb 2016 - we have summarised these in an infographic which we have added. Once they have been adopted into routine clinical practice in the UK we will update this task further.

Task 3: The ProMISe Study: EGDT RIP?

Duration: 30 mins

Early goal directed therapies in Sepsis have been a recent hot topic, and three large studies (ProMISe, ARISE, ProCESS) have recently look at their effectiveness. This page from St. Emlyn's summarises the ProMISe trial, which was conducted in the UK.

Task 4: Anaphylaxis

Duration: 60 mins

This great module is very ED specific and covers various presentations of anaphylaxis and angioedema with the management of both.

Task 5: Lactate = LactHate

Duration: 30 mins

This excellent article from St Emlyns will challenge your understanding of lactate and shock. Prepare for some dogmalysis.

#EM3 Content

Lightning Learning:

Simulations:

EMERGENCY PROTOCOLS

You should familiarise yourself with relevant Local Guidelines, but for East Midlands Trainees we are aiming to host these on the website shortly (although this may password protected).

In the meantime please review your local guidelines relevant to shock.

CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

“A 72 year old man has returned from a holiday abroad, he has been unwell for 3 days now with increasing shortness of breath. He has been red called to resus as a possible sepsis...”
“A 25 year old lady has returned from her holiday in Australia, she too has become short of breath. She also has noticed some pains in her calf...”

ADDITIONAL RESOURCES

Septris:

The Sepsis Management Game: how high can you score? Despite being american this game highlights the goals in the early management of shocked patients, you score points by making the correct interventions early.

DNUK e-learning:

COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form.

Updated: 27th July 2016