ESMOE: Shock, Sepsis and the Unconscious Patient

Recognising Shock

Causes of altered level of consciousness

Sepsis: Fluid resuscitation & prompt administration of IV broad spectrum antibiotics improves outcome. Pulse may be bounding with pyrexia and flushing.

Hypovolaemia: Hypotension signifies substantial blood loss (more than 35% of circulating volume)

Venous thromboembolism: If suspected start anti-coagulation before sending for tests (ECG, CXR, VQ-scan)

Assess level of consciousness - AVPU

Alert

Responds to Voice

Responds to Pain

Unconscious

Remember:

"Shake & Shout"

"Call a CAB"

"Big 5"

"Forgotten 4"

"Core 1"

Left lateral tilt/recovery position if conscious

Call a Cab

C - chest compressions if no signs of life

A - assess & stabilise breathing

C - assess & stabilise circulation

D - disability ('top to toe' survey, to identify cause)

Recognising shock

Main symptoms and signs

• Pulse weak & fast (>110 bpm)
• BP low (systolic <90 mmHg)

Other symptoms and signs

• Pallor
• Sweatiness or cold & clammy skin
• Rapid breathing
• Anxious, confused
• Unconscious
• Fetal distress

If fever >38 degrees C or history of fever consider:

• Sepsis
• Malaria
• Meningitis
• Pneumonia
• Others (including pyelonephritis, TB etc.)

Causes of altered level of consciousness - assess:

Big 5:

• CNS (how does she respond to questions)
• Respiratory system (resp. rate, lung sounds, oxygen saturation)
• CVS (BP, pulse, heart sounds)
• Hepatic system & GIT (jaundiced, tender liver, bowel sounds, tender abdomen)
• Renal system (renal angle tenderness, urine output, MSU, urea & creatinine)

Forgotten 4:

• Haematological system (pallor, bruising, Hb, platelets, clotting profile)
• Endocrine system (breath -abscess, glucose - diabetes, thyroid enlargement)
• Immune system (temperature, HIV status, stigmata of AIDS)
• Musculoskeletal (deep vein thromboses, thrombophlebitis)
  

Core 1:

• Uterine size, tenderness, cervical os open/closed, uterus in pelvis or in abdomen (ovarian vein thrombosis), foul smelling discharge, vaginal bleeding, others e.g. septic episiotomy

Always start specific therapy for condition leading to shock as soon as possible!