Shock

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

The relative incidence and mortality of shock varies greatly depending on the population and the cause.

Consider using MAP as a surrogate for perfusion.

Consider using MAP as a surrogate for perfusion.

Specific causes of Shock may include the following:

  • Anaphylaxis: which causes about 20 deaths per year in the UK.

  • Sepsis: severe sepsis (be aware the classification of severe sepsis is no longer in use) is estimated to affect 0.3% of the US population/year with a mortality of 28.6%.

  • Cardiogenic shock has an even higher mortality of 50-90%.

  • Haemorrhage.

However it is worth understanding the mechanisms behind the cause of shock as this is what guides the management. The mechanisms of shock are:

  1. Hypovolaemic (e.g. Bleeding)

  2. Distributive (e.g. Anaphylaxis, Sepsis etc.)

  3. Cardiogenic (e.g. Arrythmias)

  4. Obstructive (e.g. Cardiac Tamponade)

  5. Dissociative (e.g. Cyanide Poisoning)

GI Bleeds

These warrant specific mention as acute upper gastrointestinal (GI) haemorrhage commonly presents to emergency departments (ED). In the UK they account for approximately 25,000 admissions per year.

Mortality rates are high (10-14%), particularly in the elderly, and have not changed in last fifty years. However, patient populations are now older with greater comorbidity.

Remember: Identifying why a patient is shocked is important, but not all Shock is SEPSIS.

LEARNING OUTCOMES FROM COMPLETING THE TASKS

  • Recognise sepsis as a cause of shock

  • Formulate a management plan for sepsis as per surviving sepsis guidelines

  • Recognise and manage anaphylaxis as a cause of shock

  • Recognise and formulate a management plan for an upper GI bleed as per ED guidelines

Tasks

Complete the following before the face-to-face session:

Task 1: Sepsis 3.0

Duration: 12 mins

With the new definitions of SEPSIS (known as SEPSIS 3.0) how we identify patients at risk of sepsis has changed. The SIRs criteria no longer feature and we have adopted the concept of RED FLAG Sepsis. This Video by Martin Wiese explains the latest changes to the UHL sepsis management tool:

Remember to think SEPSIS, but that not all sick patients have SEPSIS – consider the SEPSIS Mimics and seek senior advice if you have any concerns. You may also want to watch our video on the correct preparation and administration of Meropenem using the Aseptic Non Touch Technique (ANTT®).

Task 2: Anaphylaxis

Duration: 50 mins

This module covers Emergency Department presentations of anaphylaxis and other causes of angioedema very well. It also covers ALS guidelines and explains mast cell tryptase levels. It is from the new RCEMLearning website which has loads of content mapped to the RCEM curriculums and is all free! If it is you first visit there take the time to look at some of the other content too.

Task 3: Upper GI Bleed

Duration: 50 mins

Complete this module that covers upper GI bleeding in great detail and is very specific to the Emergency Department. Please click on the screenshot or link below to access.

#EM3 Content

Lightning Learning

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 74 year old male patient presents to the Emergency Department acutely unwell. He lives in a residential home and usually requires minimal care, however he has been found confused and unwell this morning....”
“58 year old man brought in by ambulance to the Emergency Department Resus after vomiting bright red blood...”

ADDITIONAL RESOURCES

Here are some extra resources to review if you want more information:

Sepsis:

 

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: 5th January 2017