Shock, Sepsis and the Unconscious Patient

Recognising Shock
Causes of altered level of consciousness - assess

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

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

Venous thromboembolism: If suspected start anticoagulation 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 and stabilise breathing

C - assess and stabilise circulation

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

Recognising shock

Main symptoms and signs

• Pulse weak and 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!