1. Acute Medicine: Shock Hypovolaemic Shock
Invxs FBC - ↑Hct in acute alcoholic binge due to diuresis. Hct is an Inaccurate
Definition – inadequate tissue and organ perfusion leading to a hypoperfusion state & eventual marker of bld loss acutely.
cellular hypoxia and its attendant sequelae. GXM 6 units
U/E/Cr
S/S: Hypotension, ↓urine output, tachycardia, diaphoresis, AMS Troponin T & Cardiac enzymes
Coagulation profile with DIVC screen (PT/PTT, pltlet, D-dimer)
Types of Shock ABG – metab acidosis, ↑lactate, base deficits are poor Px factors
‘White’ shock ‘Red’ shock UPT - ?ectopic pregnancy? Ask for LMP
Examine abdomen for pulsatile AAA
Types Hypovolaemic Cardiogenic Neurogenic Septic Anaphylactic
Causes Haemorrhage AMI Spinal injury Infxns Fluid Rx 1 L crystalloid fast infusion w/in 1 hr
Assess response
Burns Dysrhythmia
Subsequent colloid or whole blood infusion
Ruptured ectopic
pregnancy ± CVP line Used to guide fluid Rx, esp in CCF patients
Severe GE
Acute pancreatitis
S/S Pallor Pallor Warm skin Fever, rigors Fever, rigors Cardiogenic Shock
Cold clammy skin Cold clammy N/↓ heart Warm skin Warm skin ECG Manage accordingly – refer acute coronary syndrome &
↑peri vas Ω skin rate Trop T & cardiac enzymes ACLS notes
↑peri vas Ω Neuro deficit
Invxs ↓ Hct (late) Cardiac FBC
enzymes Bld C/S Neurogenic Shock
ECG Hx/PE Trauma – site, mechanism, force
Neuro exam, DRE – document initial neurological deficits
Also, Obstructive Shock due to tension pneumothorax, cardiac tamponade or pulmonary Immobilize Immobilize spine in neutral position
embolism Invxs C-spine X-ray (AP & lat) – ensure visualization up to C7/T1 junction
± Swimmer’s view (visualize C7/T1 jn) & open mouth view (visualize C1/2
Management injury)
Thoracic & lumbar spine X-ray (AP & lat)
General Mx ± CT scan
Airway Maintain airway – consider intubation if necessary ± MRI later
Breathing 100% O2 via non-rebreather mask Fluid Rx Titrate fluid resus with urine output
Circulation 2 large bore (14-16G) cannulae ± vasopressors if BP does not respond to fluid challenge
± Inotropic support ± IV methyl 30 mg/kg over 15mins, followed by 5.4mg/kg/h for nxt 23 hrs
o IV dopamine 5-10μg/kg/min prednisolone Indications – non-penetrating spinal cord injury & w/in 8 hrs of injury
o IV dobutamine 5-10μg/kg/min (esp for cardiogenic shock) Contraindications
o IV norepinephrine 5-20μg/kg/min (esp for septic shock) o <13YO
Monitoring Pulse oximetry o pregnancy
ECG o mild injury of the cauda equina / nerve root
BP o abdominal trauma present
Heart rate o major life-threatening morbidity
Urine output – catheterize patient Disposition Refer Ortho / NeuroSx

2. Obstructive Shock
nd
Tension Decompression: insert 14G cannula over 2 intercostals space in mid-
Septic Shock
Pneumothorax clav. Line
Sepsis = ≥ 2 of the following present:
Cardiac IV fluid bolus 500ml N/S o
o Temp >38 or <36 C
tamponade ± IV dopamine infusion 5μg/kg/min o HR > 90bpm
Prepare for pericardiocentesis o RR > 20 breaths/min OR PaCO2<32mmHg
Pul Embolism Invx o
3 3
WCC>12000/mm , <4000/mm ,or >10% immature forms
FBC Hx / PE Identify site of infxn – UTI (indwelling cathether), gallbladder dz, peritonitis,
GXM 6 units pneumonia, appendicitis, immunocompromised state
U/E/Cr
Invx FBC - ↑ TW
DIVC screen (D-dimer)
U/E/Cr
ABG
DIVC screen – PT/PTT, pltlet, fibrinogen, D-dimer
o ↓ PaO2 & N/↓ PaCO2
Bld C/S (2 different sites)
o widened alveolo-arterial P02 gradient (AaPO2 >20mmHg)
Capillary bld glucose
ECG (may be normal)
ABG
o non-specific ST depression & T wave inversion
CXR – pneumonia, ARDS
o Sinus tachycardia
ECG
o Right heart strain
Urine dipstick – UTI
Right axis deviation
Urine C/S
Transient RBBB
Fluid Rx Rapid infusion 1-2L crystalloids
T wave inversion in V1-3
P pulmonale ± CVP line insertion
S1Q3T3 ± Inotropic if no response to fluid Rx
o Exclude DDxes – MI, pericarditis support Noradrenaline (drug of choice) - 1μg/kg/min OR
CXR (may be normal) Dopamin 5-20μg/kg/min
rd
o Westermark sign – oligaemic lung fields Empirical ABx Immunocompetent w/o obvious 3 gen cephalosporin (IV ceftriaxone
o Pul infarcts – wedge shape opacities w apex pointing source 1g) OR
towards the hilum Quinolones (ciprofloxacin 200mg)
o Atelectasis Immunocompromised w/o Anti-pseudomonal ABx (IV ceftazidime
o Pleural effusions obvious source 1g) OR
o Raised diaphragm Quinolone
o Consolidation PLUS aminoglycoside (Gentamicin
o ‘Plump’ pul. arteries 80mg)
o Exclude DDxes – pneumothorax, pneumonia, L heart Gram-positive (burns, FB / lines IV cefazolin 2g
failure, tumour, rib #, massive pleural effusion, lobar present) IV vancomycin 1g if hx of IVDA,
collapse indwelling cath. Or penicillin allergy
± Spiral CT, Echo, MRI, lung scintigraphy, pulmonary angiogram (gold Anaerobic source (intra-abdo, IV metronidazole 500mg +
std) biliary, female genital tract, ceftriazone 1g + IV gentamicin 80mg
aspiration pneumonia)
Rx
Pain relieve – use Opioids with caution
Fluid Rx & inotropic support if haemodynamically unstable
Anticoagulation Rx:
o IV heparin 5000U bolus or SC fraxiparine (0.4ml if <50kg;
0.5ml if 50-65kg; 0.6ml if >65kg)
o Convert to Oral warfarin later
± Thrombolysis
o Intra pul. arterial urokinase fro 12-24 hrs
Surgical
o Complete IVC ligation or partial caval interruption

3. Anaphylactic Shock
Definitions
Urticaria – oedematous & pruritic plaques w pale centre & raised edges
Angioedema – oedema of deeper layers of the skin. Non-pruritic. May be a/w numbness & pain
Anaphylaxis – severe systemic allergic rxn to an Ag. Ppt by abrupt release of chemical
mediators in a previously sensitized patient
Anaphylactoid rxn – resembles anaphylactic rxn, but due to direct histamine release from mast
cells w/o need for prior sensitization
Common causes
Drugs – penicililns & NSAIDS commonest, aspirin, TCM, sulpha drugs
Food – shellfish, egg white, peanuts
Venoms – bees, wasps, hornets
Environment – dust, pollen
Infections – EBV, HBV, coxsackie virus, parasites
Stop Pptant Stop administration of suspected agent / flick out insect stinger with tongue
blade
Gastric lavage & activated charcoal if drug was ingested
Airway Prepare for intubation or cricothyroidectomy – ENT/Anaesthesia consult
Fluid Rx 2L Hartman’s or N/S bolus
Drug Rx Adrenaline Normotensive – 0.01ml/kg (max 0.5ml) 1:1000 dilution
SC/IM
Hypotensive – 0.1ml/kg (max 5ml) 1:10,000 dilution IV
over 5 mins
Glucagon Indications: failure of adrenaline Rx OR if adrenaline is
contraindicated eg IHD, severe HPT, pregnancy, β-blocker
use
0.5-1.0mg IV/IM. Can be repeated once after 30mins
Antihistamines Diphenhydramine 25mg IM/IV
Chlorpheniramine 10mg IM/IV
Promethazine 25mg IM/IV
Cimetidine For persistent symptoms unresponsive to above Rx
200-400mg IV bolus
Nebulised for persistent bronchospasm
bronchodilator Salbutamol 2:2 q20-30mins
Corticosteroids Hydrocortisone 200-300mg IV bolus, q 6hr
Digitally signed by DR WANA
HLA SHWE
DN: cn=DR WANA HLA SHWE,
c=MY, o=UCSI University,
School of Medicine, KT-
Campus, Terengganu,
ou=Internal Medicine Group,
email=wunna.hlashwe@gmail.
com
Reason: This document is for
UCSI year 4 students.
Date: 2009.02.19 09:32:18
+08'00'