Shock (2023)

Shock

by Joseph Ciano

You have a new patient!

A 55-year-old male enters your Emergency Department with sudden onset of shortness of breath with chest pain. He states his symptoms began several hours ago, and he is now feeling generally weak and dizzy. Vital signs on initial assessment are: 125 beats/min, 86/40 mmHg, 24 breaths/min, 37.5°C, and 93% SpO2 on room air. You are concerned by the patient’s vital signs and begin to organize your medical team for treatment of the patient.

What do you need to know?

Importance

Shock is a true emergency. Shock has a wide array of clinical causes (e.g., sepsis, hemorrhage, pulmonary embolism), categories, and different hemodynamic physiologies. The mortality rate of untreated shock is high, but it varies depending on the specific cause and type of shock. For example, the mortality rate of septic shock is 26% and is almost 50% for cardiogenic shock [1]. This means that rapid identification and treatment of shock matters in order to improve outcomes.

Epidemiology

Because shock has many different causes and no single accepted test for diagnosis, it is difficult to measure its prevalence accurately. The different causes of shock may also vary across different country contexts. A systematic review defining shock as a systolic blood pressure under 90 mmHg estimated 0.4-1.3% of patients arrive at the Emergency Department in shock [2]. Other studies have shown variable rates among the different shock categories, but the obstructive shock is typically the least common type of shock [3,4].

Pathophysiology

Shock is a state of circulatory collapse where the body is unable to adequately perfuse tissues to meet the body’s metabolic demands. Shock is characterized by global hypoperfusion and hypoxia. The four major categories of shock are hypovolemic, distributive, cardiogenic, and obstructive shock. Each category of shock has differences in hemodynamics, causes, and treatments. If left untreated, shock will lead to multiorgan system dysfunction and failure.  Shock is often associated with hypotension (systolic blood pressure under 90 mmHg), but shock can occur with a “normal blood pressure”. For example, a systolic blood pressure of 100-120 mmHg in conjunction with other signs and symptoms could be considered a relative hypotensive state and indicate shock in a chronically hypertensive patient. The chart below summarizes the different types of shock.

Type of shock

Hemodynamics

Potential causes

Potential treatments

Hypovolemic

↓preload

↑SVR

↓CO

Dehydration, vomiting/diarrhea, burns, hemorrhage (GI bleed, traumatic wound, etc.)

IV fluids

Blood products (if due to hemorrhage)

Distributive

↓preload

↓SVR

↓/↑CO

Sepsis, anaphylaxis, adrenal insufficiency, neurogenic shock

IV fluids +/- antibiotics and vasopressors.

Treat underlying cause.

Epinephrine (anaphylaxis)

Norepinephrine (sepsis or neurogenic)

Phenylephrine (neurogenic)

Cardiogenic

↑preload

↑SVR

↓CO

Heart failure, tachy/bradyarrythmias, myocardial infarction, valve failure, myocarditis, cardiomyopathy,

beta-blocker overdose

Dobutamine or Epinephrine

Treat underlying cause

Obstructive

↓preload

↑SVR

↓CO

Tension pneumothorax, cardiac tamponade, pulmonary embolism

IV fluids

Treat underlying cause.

Tension Pneumothorax

Needle decompression then tube thoracostomy

Cardiac tamponade-Pericardiocentesis then pericardial window

Pulmonary embolism-Anticoagulation, consider thrombolytics or surgical embolectomy

(CO= Cardiac Output; SVR= Systemic Vascular Resistance)

Medical History

Key questions to ask on history-taking

Since shock has a multitude of causes, the patient’s history helps us identify shock and guides us in determining the underlying cause. Certain nonspecific presenting symptoms, such as generalized weakness, syncope, or altered mental status, can be seen in all types of shock as these symptoms indicate hypoperfusion. History-taking should be symptom based and also include review of the past medical history, past surgical history, medications, allergies, and drug or alcohol use. The mnemonic “OPQRST” (Onset of symptoms, Provoking/Palliating factors, Quality, Radiation, Severity, Timing) can be used to assist in gathering symptom-based information from the patient.

Being able to narrow down the potential causes will help decide which laboratory and imaging investigations to order and what initial treatments are indicated. Suggestions for key questions to ask are illustrated in the table below. 

Type of shock

Presenting symptoms that may indicate shock

Key questions to ask based on cause of shock

Hypovolemic

Weakness

Syncope

Altered mental status

Vomiting/diarrhea

Hematemesis

Hematochezia/Melena

Burn injury

Trauma/fall

Dehydration

  • Last PO intake? Diuretic usage? Recent travel?

 

Vomiting/diarrhea

  • How many times? Presence of blood? Recent travel? Fevers?

 

Hemorrhage (GI bleed, traumatic wound, etc.)

  • How much blood loss? Any anticoagulant use?

 

Distributive

Weakness

Syncope

Altered mental status

Fever, chills

Cough

Difficulty breathing

Dysuria

Lip/tongue swelling

Rash

Sepsis

  • Fevers, cough, dyspnea, dysuria, skin changes, headaches, neck stiffness, chest or abdominal pain?

 

Anaphylaxis

  • Known inciting factor or allergies? Angioedema?

 

Adrenal insufficiency

  • Steroid use? Medication changes? TB history?

 

Neurogenic shock

  • Spinal trauma? Focal weakness/numbness?

 

Cardiogenic

Weakness

Syncope

Altered mental status

Chest pain

Back or shoulder pain

Palpitations

Difficulty breathing Orthopnea

Peripheral edema

Heart failure, Cardiomyopathy, Valve failure

  • Medication changes? Chest pain? Body edema or dyspnea?

 

Tachy/bradyarrythmias

  • Syncope? Palpitations/heart fluttering?

 

Myocardial infarction

  • Chest or back pain? Diaphoresis?

 

Obstructive

Weakness

Syncope

Altered mental status

Difficulty breathing

Chest pain

Penetrating chest trauma

Unilateral leg pain/edema

Tension pneumothorax

  • Chest trauma?

 

Cardiac tamponade

  • Chest trauma? History of renal disease, HIV, or cancer history?

 

Pulmonary embolism

  • Sudden onset dyspnea or chest pain? Leg pain or swelling? Use of hormones? Recent travel, hospitalizations, or surgeries? Cancer history?

 

Identifying “red flags”

Shock can sometimes be subtle without marked hypotension or tachycardia, so it is important to be vigilant for red flags detected on history-taking to aid in early identification.  Some red flags include altered mental status or confusion, syncope, or chest pain. These symptoms may indicate hypoperfusion of the brain or heart and can point towards shock. Belonging to a special patient group, such as an elderly or neonatal patient, an immunosuppressed patient, or a pregnant patient, may be associated with a more atypical presentation of shock or less favorable patient outcomes.  

Physical Examination

Key physical exam features

Shock is a state of global hypoperfusion, so many physical exam features will reflect this (e.g., delirium, comatose state, tachypnea, etc.). However, shock exists along a continuum of severity and is impacted by patient age, medications, comorbidities, the cause of shock, and other factors. Hypotension and tachycardia are often regarded as key findings of shock, but these vital sign changes may not be present on initial examination depending on where the patient is in the timeline of their shock, as well as other factors described above. For this reason, it is important to look at the combination of the patient’s physical exam findings, rather than a single finding to assist in the diagnosis of shock [1]. Refer to the chart below for physical exam findings seen in shock.

shock - physical exam findings chart

Identifying “red flags”

Similar to patient history-taking, it is important to identify “red flags” during physical examination to aid in the early identification and treatment of shock. Some red flags on physical examination include hypotension with a MAP below 65mmHg, severe bradycardia, low urine output, delirium or altered mental status, and angioedema of lips or tongue [5]. A MAP below 65mmHg indicates severe hypoperfusion that requires prompt aggressive intravenous fluid or vasopressor administration. Bradycardia below 45bpm in shock may indicate poor cardiac output and a lack of physiologic ability to increase cardiac output properly in a shock state. Low urine output and altered mental status are signs of renal and cerebral hypoperfusion, respectively. Angioedema can occur in anaphylactic shock and can pose an acute airway emergency.

Alternative Diagnoses

Shock can have a variety of causes and clinical presentations that can range from the subtle to the severe. Determining the patient’s type of shock and specific diagnosis responsible for the shock state is dependent on details from the patient history, physical exam, and diagnostic testing (discussed more in next section). See the chart below for a list of differential diagnoses for the different categories of shock. Use this table in conjunction with the tables provided in the previous sections to assist in differentiating shock types and causes.

Shock Type

Differential diagnosis 5,6

Hypovolemic

  • GI losses (gastroenteritis, colitis, fistulas)
  • Skin burns
  • Renal losses (excess diuretic use, diabetes insipidus)
  • Hemorrhage (e.g., GI bleed, traumatic wound, aortic aneurysmal rupture, ruptured ectopic pregnancy, coagulopathy, etc.)

Distributive

  • Sepsis
  • Anaphylaxis
  • Adrenal insufficiency (primary vs secondary causes)
  • Thiamine deficiency (beriberi)
  • Pancreatitis
  • Thyroid storm
  • Toxins (salicylates, cyanide, carbon monoxide)
  • Neurogenic shock (trauma, spinal anesthesia)

Cardiogenic

  • Tachyarrhythmia or bradyarrhythmia
  • Left ventricular failure/Cardiomyopathy
    • Ischemic (myocardial infarction)
    • Nonischemic (postpartum, Takotsubo, myocarditis, myocardial contusion,
  • Ca channel/beta-blocker overdose, autoimmune)
  • Valve dysfunction
    • Endocarditis, post MI papillary muscle rupture, prosthetic valve problem
  • LV outflow obstruction
    • Hypertrophic obstructive cardiomyopathy (HOCM), aortic stenosis
  • Device malfunction (ECMO, Ventricular assist device)

Obstructive

  • Tension pneumothorax
  • Cardiac tamponade
  • Pulmonary embolism
  • Auto PEEP (“breath stacking”) in obstructive lung disease patient

Acing Diagnostic Testing

There is no single diagnostic test to rule in or rule out shock. The diagnosis of shock is based on a constellation of diagnostic test results in combination with the history and physical exam of the patient. Whenever possible, diagnostic testing should be based on the presumed cause of shock (e.g., CT pulmonary angiogram for pulmonary embolism, EKG for myocardial infarction, etc.). The table below summarizes different bedside tests, laboratory tests, and imaging tests to consider ordering in patients with shock.  Rational and use behind these tests is discussed in more detail in sections that follow the table.

Bedside tests

Laboratory tests

Imaging tests

  • EKG
  • Point of care testing, if available (pregnancy, glucose, arterial or venous blood gas testing)

 

  • Serum lactate
  • CBC with differential
  • Serum chemistry (BUN, creatinine, electrolytes)
  • Hepatic function panel
  • Coagulation studies
  • Type and screen
  • Venous or arterial blood gas testing
  • Cultures (blood, urine, wound)
  • Pregnancy test
  • Urinalysis
  • Cortisol level
  • Chest X-ray
  • CT of chest/abdomen/pelvis as supported by history + physical
  • Ultrasound (lung, heart, abdomen)

 

Bedside Tests

The EKG is a basic screening test helpful in all shock patients to assess for cardiac dysrhythmias, myocardial infarction, or EKG interval disturbances from medication overdoses. The EKG is clearly valuable in potential cardiogenic shock patients, but it is also helpful in obstructive shock (e.g., low voltage QRS in cardiac tamponade, EKG changes in pulmonary embolism).

Point of care pregnancy testing can help rule out a ruptured ectopic pregnancy.  Glucose testing screens for hypoglycemia which can be seen in septic shock, GI losses with decreased oral intake, and adrenal insufficiency. Point of care blood gas testing can aid in the assessment of the patient’s acid-base and blood gas status which can assist in immediate therapeutic decisions at the bedside. 

Laboratory Tests

Lactate is a common test ordered and trended in shock.  Lactate is a nonspecific marker for poor perfusion and anaerobic metabolism. An elevated lactate >2mmol/L can occur in all types of shock as it indicates poor perfusion, but it does not necessarily mean the patient has a diagnosis of shock. Increasing lactate levels have been associated with increased mortality in many shock types [1].

CBC and type and screen testing are helpful in hemorrhagic shock to measure hemoglobin and prepare for the need for blood product transfusion. The CBC can assess the white blood count which can be helpful in septic shock, especially when trended overtime. Serum chemistry, a hepatic function panel, and coagulation studies screen for signs of end-organ damage (e.g., acute kidney injury, transaminitis (“shock liver”), coagulopathy, etc.).

Blood gas testing is valuable as a screening test in any type of shock to evaluate acid-base and blood gas balance. Urinalysis testing and cultures, blood cultures, and wound cultures do not change management in the emergency department, but they are helpful in identifying sources of infection in septic shock which can be utilized to make antibiotic therapy more targeted as part of the patient’s larger plan of care. Cortisol testing can be beneficial in making the diagnosis of adrenal insufficiency.

Imaging Tests

The chest X-ray is another basic screening test that can be performed as a portable test in the unstable shock patient.  The chest X-ray screens for pneumonia (septic shock), cardiomegaly (cardiogenic and obstructive shock), tension pneumothorax (diagnosis should be made clinically prior to X-ray), pulmonary edema (cardiogenic shock), hemothorax (hemorrhagic shock), amongst other relevant findings.

CT imaging can be used to identify the source of infection or bleeding in septic and hemorrhagic shock, respectively.  However, it should be used after reviewing the risks and benefits in an unstable shock patient.  For example, CT imaging may involve the patient travelling to a less monitored setting outside of the emergency department with less resources and tools for resuscitation.  Contrast-induced nephropathy is another risk to consider when ordering CT imaging with IV contrast in shock patients who likely have hypo-perfused kidneys.  Conversely, CT imaging can lead to a definitive diagnosis (e.g., acute appendicitis, retroperitoneal bleed, ruptured spleen, etc.) that can direct management [1].

Ultrasound is an incredibly valuable bedside diagnostic modality in shock.  Ultrasound can be used to determine the patient’s type of shock through a physiologic assessment of the heart, lungs, and abdomen.  Specific diagnostic information that can be gathered by ultrasound includes the cardiac ejection fraction, presence of a large pericardial effusion with right ventricular compression (cardiac tamponade),  right ventricular dilation (may indicate pulmonary embolism), Inferior vena cava (IVC) dilation or collapse, presence of abdominal free fluid in trauma (hemoperitoneum), abdominal aortic aneurysm presence, absence of bilateral lung sliding (pneumothorax), pulmonary edema (cardiogenic shock if diffuse, infectious if localized), and pleural effusions (infectious or hemothorax depending on the historical context). Organized ultrasound protocols exist that aim to assess these body systems in an algorithmic manner.  One example is the RUSH protocol (Rapid Ultrasound for Shock and Hypotension) [1,5]. This protocol can be executed using the curvilinear (abdominal) or phase-array (cardiac) probe.  Operator competency is needed to obtain meaningful diagnostic data from bedside ultrasound, but with practice and education, proficiency can be achieved.  See the images below for a visual representation of the RUSH protocol and a summary of ultrasound findings in the different types of shock [5,7].

Ultrasound findings in shock

Risk Stratification

Since shock has many potential causes and clinical presentations, there is no single risk stratification tool that is broadly applicable to all types of shock.  There are some tools available to assist in early diagnosis of sepsis by identifying risk factors, like the SIRS criteria (Systemic inflammatory response syndrome criteria) and qSOFA score (Quick sequential organ failure assessment score) [8]. These scores are not specific and can be “positive” in conditions other than sepsis, like diabetic ketoacidosis or severe anxiety.  The shock index measurement is another tool that takes into account heart rate and systolic blood pressure to identify occult shock, especially in trauma or acute hemorrhage. A shock index above 0.5-0.7 may point towards occult shock in the presence of normal vital signs [9].   

Shock is ultimately a clinical diagnosis, so clinical assessment of the patient with the history, physical exam, and diagnostic test results are often used in combination with the clinical picture to predict risk.  Clinical factors that may be associated with poorer outcomes are high serum lactate levels not responsive to fluid resuscitation, severe acidosis, low MAP, elderly and neonatal patient populations, and immunosuppressed patients [1,5,8]. 

Management

Initial management in unstable patients

Management of the shock patient starts with the primary survey, or the “ABCs” (Airway, Breathing, Circulation).  The primary survey is an algorithmic approach used for ill patients to help organize patient assessment, identify life-threatening conditions quickly, and treat time sensitive conditions. 

Airway (“A”)

Establishing a definitive airway may be needed to prevent aspiration or as the precursor to mechanical ventilation for respiratory failure.  Listen for any gurgling sounds or poor effort in phonation that may indicate a risk for aspiration.  Since shock is a state of hypoperfusion, many patients may have poor cerebral perfusion, somnolence, and require an invasive airway.  Positive pressure ventilation and many pre-intubation sedation medications can cause hypotension, so strongly consider initiating volume resuscitation or vasopressors to improve hemodynamics prior to performing intubation [1]. 

Assess for any obvious external swelling of the face, lips, or tongue, which may occur in anaphylaxic shock.  Although this angioedema should improve with prompt epinephrine administration, airway management is sometimes needed.  Look for tracheal deviation which can occur in tension pneumothorax.  Be sure to consider cervical spinal fracture and provide a rigid cervical collar for spinal immobilization in the presence of trauma.

Breathing (“B”)

Assistance in respiration is sometimes needed in the shock patient due a primary pulmonary cause of shock (e.g., septic shock due to pneumonia), respiratory compensation for lactic acidosis, or respiratory changes due to toxic overdoses causing shock (e.g., distributive shock from salicylate overdose).  Noninvasive positive pressure ventilation, such as BIPAP or CPAP, or invasive mechanical ventilation with intubation may be required to manage work of breathing and respiratory failure.

Circulation (“C”)

Shock is a state of systemic hypoperfusion, so a key part of treatment often involves some type of volume resuscitation.  Most commonly this involves administration of crystalloid fluids (e.g., normal saline, lactated ringers solution) or blood products.  If the specific type or cause of shock is unclear after assessment of the patient, start with administration of small volume boluses of fluids with frequent reassessments.  A 250-500mL crystalloid fluid bolus is a reasonable initial intervention in the undifferentiated shock patient.  Fluid should be administered rapidly over 5-20minutes to a total of 20-30mL/kg, depending on the cause of shock [1]. Balanced isotonic crystalloid fluids, like lactated ringers solution, may provide a small mortality benefit over normal saline, especially if large volumes of fluid administration are expected [1]. Large volume administration of normal saline can also cause hyperchloremic metabolic acidosis.   For this reason, if lactated ringers solution is readily available and a cost-effective alternative to normal saline, it may be a worthwhile alternative.  Blood products, rather than crystalloid fluids, should be prioritized if hemorrhagic shock is the assumed cause of shock.

Although volume resuscitation is a crucial component of treatment, caution should be taken in aggressive fluid administration in the presence of cardiogenic shock as this may lead to pulmonary edema.  If the patient remains hypotensive after fluid administration with a MAP below 65mmHg, vasopressors should be initiated [1,5].

Medications

Intravenous crystalloid fluids and blood products are common treatments in shock, but depending on the cause of shock, additional medications may be needed.  Some examples are broad spectrum antibiotics in septic shock, steroids in adrenal insufficiency, or thrombolytics in massive pulmonary embolism with obstructive shock.  See the charts below for a list of adjunctive medications along with their doses and uses.   

Common antibiotics used in shock

Drug name

(Generic)

Potential use

Dose

Frequency

Maximum Dose

Cautions / Comments

Piperacillin-Tazobactam

Intra-abdominal, genitourinary, skin/soft tissue, pneumonia infections, febrile neutropenia

3.375-4.5g

(IV)

Q6 hours

4.5gm IV

Common first line broad spectrum antibiotic in septic shock

Cefepime

Intra-abdominal, genitourinary, skin/soft tissue, meningitis, pneumonia infections, febrile neutropenia

1-2g

(IV)

Q8-12 hours

2gm IV

Common first line broad spectrum antibiotic in septic shock.

 

Similar uses as piperacillin-tazobactam

Vancomycin

Severe bacterial infections, especially MRSA, pneumonia, endocarditis, systemic anthrax, meningitis

15-20 mg/kg/

dose (IV)

Q8-12 hours

3gm IV

Common first line broad spectrum antibiotic in septic shock used in combination with cefepime or piperacillin-tazobactam

Ceftriaxone

Meningitis, pneumonia, UTI, endocarditis, typhoid fever, gonococcal infections, pelvic inflammatory disease

1-2g (IV)

Q24 hours

2gm IV

First line medication for bacterial meningitis in adults, also commonly used for UTIs and community-acquired pneumonia

Ciprofloxacin

UTI, intra-abdominal infections, prostatitis, pneumonia, bone/joint infections, typhoid fever, salmonella/shigella infections

200-400mg

(IV)

Q8-12 hours

400mg IV (1000mg PO)

Can prolong QT interval and increase risk for tendon rupture

Metronidazole

Anaerobic coverage for intra-abdominal infections, Pelvic inflammatory disease, C. difficile

500mg (IV)

Q8-12 hours

500mg IV

(500mg PO)

Causes disulfiram-like reaction with alcohol (avoid alcohol with this medication)

Azithromycin

Community-acquired pneumonia, chlamydial infections, COPD exacerbation, MAC treatment, pertussis

500mg then 250mg

(IV)

Q24 hours

500mg IV (1000mg PO)

Can prolong QT interval

Often given IV with ceftriaxone for community acquired pneumonia patients

Common vasopressors used in shock

Drug name

(Generic)

Potential use

Dose

Frequency

Maximum Dose

Cautions / Comments

Norepinephrine (Noradrenaline)

First line vasopressor for most types of shock, especially if loss of vascular tone is primary problem

0.02-1 mcg/kg/min

(IV)

Titrate as needed to maintain MAP >65

See dose

May cause tachyarrhythmia

Epinephrine (Adrenaline)

First line for anaphylactic shock

0.05-2 mcg/kg/min (IV)

0.3-0.5mg (SubQ or IM)

Titrate as needed to maintain MAP >65

See dose

In anaphylaxis, start with 0.3mg subQ/IM dose. This can be repeated every 10min as needed versus starting a continuous infusion.

May cause tachyarrhythmia

Dobutamine

Frequently used in cardiogenic shock due to heavy beta-adrenergic receptor preference

2-20

 mcg/kg/min (IV)

Titrate as needed to maintain MAP >65

See dose

May cause tachyarrhythmia

Phenylephrine

Pure alpha-adrenergic receptor agonist used as a 2nd or 3rd line vasopressor in shock

10-200 mcg/min (IV)

Titrate as needed to maintain MAP >65

See dose

May cause reflex bradycardia and headache

Consider use when tachydysrhythmias are present

Vasopressin

Often used as a 2nd or 3rd line vasopressor after norepinephrine or epinephrine

0.01-0.04 units/min (IV)

Titrate as needed to maintain MAP >65

See dose

Primarily causes vasoconstriction, similar to phenylephrine

Common additional adjunctive medications used in shock

Drug name

(Generic)

Potential use

Dose

Frequency

Maximum Dose

Cautions / Comments

Acetaminophen

Fever or pain

325-1000mg PO or IV

Q4-6 hours

4gm daily

Be careful with dosing this common medication to avoid overdose

Ibuprofen

Fever or pain

200-800mg PO

Q4-6 hours

3200mg daily

Can cause GI upset and increase risk for peptic ulcer disease

Morphine

Moderate-severe Pain

2.5-10mg (IV)

Q2-6 hours

n/a

Risk of respiratory depression, addiction and abuse, hypotension

 

Use naloxone for reversal

Hydrocortisone

Adrenal crisis, vasopressor-refractory hypotension in shock

100-300mg (IV)

Q6-8 hours

1200mg daily for septic shock adjunct

Start at 100mg IV for adrenal insufficiency

 

Taper dose over 5-7 days for septic shock adjunctive treatment

Dexamethasone

Adrenal crisis, vasopressor-refractory hypotension in shock

0.03- 0.15 mg/kg/

day

Q6-12 hours

0.15mg/kg

daily for adrenal insufficiency

Alternative to hydrocortisone

Alteplase

Massive PE with obstructive shock

100mg (IV)

Single dose over 2 hours

100mg

Bleeding is main side effect

Procedures

Some patients in shock may need emergent procedures as part of their treatment plan.  The chart below summarizes relevant procedures that may be encountered in the care of the shock patient.

Indication or Problem

Procedure

Tension pneumothorax

Needle thoracostomy (Followed by tube thoracostomy)

Cardiac tamponade

Pericardiocentesis (Followed by pericardiotomy)

Persistent hypotension despite intravenous fluids with need for prolonged vasopressor administration

Inability to establish IV access in hemodynamically unstable patient

 

Central venous line placement (Triple lumen catheter)

 

 

Inability to establish IV access in hemodynamically unstable patient

 

Intraosseous line placement (or central venous line)

Respiratory failure or inability to protect airway

Endotracheal tube placement (Intubation)

Empyema, hemothorax, or after needle decompression of tension pneumothorax

Tube thoracostomy (Chest tube placement)

Patient reassessment

Reassessment is an important part of management.  The primary survey (“ABCs”) is conducted on initial evaluation of the patient to guide management, but it can be repeated after therapies have started as clinical changes can occur. Fluid administration too rapidly in a patient with cardiac or renal comorbidities may result in pulmonary edema, requiring fluid administration to be halted.  Patients may develop worsening mental status or hypoxemia overtime due to respiratory muscle fatigue, requiring supplemental oxygen or more aggressive airway management.  Complications can develop after procedures, such pneumothorax after internal jugular central venous line placement or re-expansion pulmonary edema after chest tube placement.  These changes in clinical course are only identified if the patient is reassessed after treatment is initiated. 

Bedside ultrasound can also assist in patient reassessment.  A RUSH exam can be repeated or used as a framework to guide sonographic reassessments.  Some examples of pertinent findings on reassessment include pulmonary B-lines after IV fluid administration (alveolar fluid present), the absence of lung sliding (may indicate pneumothorax), or changes in the IVC size after IV fluid administration (a flat IVC may indicate fluid responsiveness) [5,7].  

Special Patient Groups

Pediatrics

Pediatric patients in shock are often well compensated physiologically and may not have hypotension on initial presentation.  For this reason, unexplained tachycardia in the pediatric patient should always raise concern for possible occult or early shock [10]. Hypovolemic shock is the most common type of shock in the pediatric patient population, while obstructive shock is the least common type of shock.  Volume status in infants can be assessed through evaluation of the fontanelles (flat or sunken), the presence or absence of tears, and changes in urine output estimated by the number of wet diapers per day (e.g., less than baseline or baseline) [10]. Similar to adults, shock should be managed aggressively with volume resuscitation with the exception of cardiogenic shock where fluids should be used judiciously and vasopressors used early (e.g., epinephrine).  Septic shock is the most common type of distributive shock in pediatric patients, and volume resuscitation should be aggressive with up to three 20mL/kg fluid boluses given (60mL/kg total) [10]. This should be contrasted with the recommendation of a 20-30mL/kg fluid bolus in adults for most types of shock [1].

Geriatrics

The diagnosis and treatment of shock in geriatric patients may be more challenging due to unique factors associated with this population.  Unlike pediatric patients, elderly patients often do not have a robust physiologic reserve to compensate in a shock state.  Elderly patients often have more comorbidities and take more medications than adults and children which may blunt the tachycardia response or lead to an atypical clinical presentation [11,12]. For example, beta blockers and calcium channel blockers may prevent a tachycardic response in a hypoperfusion state.  Blood pressure may also be “normal” in elderly patients in shock who are chronically hypertensive [11]. For example, blunt trauma patients over 65 years-old with systolic blood pressures below 110mmHg and heart rates above 90 beats/min have an association with an increase in mortality [12]. Elderly patients with sepsis are also less likely to have a fever or leukocytosis than younger adult patients [13]. Do not rely only on vital signs or abnormal investigations to diagnose shock in the elderly patient.

Management of shock in the elderly patient should involve more gentle volume resuscitation with small fluid boluses (e.g., 250-500mL) and frequent reassessments for response or a change in clinical status (e.g., pulmonary edema).  Have a low threshold to start blood products in elderly hemorrhagic shock patients to avoid excess crystalloid fluid administration and volume overload [12]. Consider drug-drug interactions and the impact of baseline comorbidities (e.g., chronic renal insufficiency) when prescribing antibiotics or other therapies for the elderly patient in shock [13].     

Pregnant patients

Pregnant patients have physiologic and hormonal changes that make certain causes of shock more likely than others.  Some common causes of shock to consider in the pregnant patient include pulmonary embolism, hyperemesis gravidarum, peripartum or postpartum hemorrhage, pyelonephritis, and peripartum cardiomyopathy amongst other causes.  

Other pregnancy-related factors include a higher circulating plasma and blood volume in pregnancy, hypercoagulability due to hormonal changes, and risk of vena caval compression by the growing uterus [14]. Volume resuscitation in pregnancy should accommodate for the pregnant patient’s increase in blood and plasma volume. It is recommended that a 50% additional volume of fluids be given to the pregnant patient in shock to account for this [14]. Standard vasopressors administered in shock, like norepinephrine (noradrenaline), dopamine, and vasopressin, may decrease uterine blood flow from vasoconstriction but have limited data on use in pregnancy.  However, these medications are typically given in pregnant shock patients as the benefit of restoring normal maternal perfusion and hemodynamics outweighs any potential risk to the fetus [14]. Treatment of the pregnant shock patient should also incorporate positioning the patient in the left lateral decubitus position.  This avoids compression of the inferior vena cava by the gravid uterus which could reduce cardiac preload [14].

Other patient groups

Other patient groups that may have more nonspecific or atypical findings in shock are immunosuppressed patients, such as those on chemotherapy for malignancies, post-splenectomy patients, post-transplant patients on immunomodulators, or patients on chronic steroid therapy [5,8]. Diagnosing shock in these special patient groups starts with identifying risk factors and keeping occult shock on the differential diagnosis list.  These patient groups should, similar to typical adult patients, receive aggressive and early volume resuscitation, vasopressors when needed, and adjunctive therapies as appropriate (e.g., broad spectrum antibiotics for septic shock). 

When to admit shock patients

All patients with a diagnosis of shock should be admitted due to the high morbidity and mortality associated with shock [1]. Many patients may need to go to a hospital ward with a high level of monitoring, such as an intensive care unit, due to risk of hemodynamic decompensation [1].  Although some causes of shock are “reversible”, such as tube thoracostomy for tension pneumothorax, these patients should be admitted for further monitoring and treatment due to high risk for poor outcomes.

Revisiting your patient

A 55-year-old male enters your Emergency Department with sudden onset of shortness of breath with chest pain. He states his symptoms began several hours ago, and he is now feeling generally weak and dizzy. Vital signs on initial assessment are: 125 beats/min, 86/40 mmHg, 24 breaths/min, 37.5°C, and 93% SpO2 on room air. You are concerned by the patient’s vital signs and begin to organize your medical team for treatment of the patient.

You identify that your patient is hypotensive, tachycardic, tachypneic, and appears to be in a shock state. You quickly perform a primary survey and note that the airway is patent, lungs are clear bilaterally, and distal extremities are cool with bounding pulses. Two large bore peripheral IV lines are placed, comprehensive laboratory investigations are drawn and sent, supplemental oxygen is applied, and 2 liters of normal saline are administered rapidly. 

A 12-lead EKG demonstrates sinus tachycardia without acute ischemic abnormalities. A bedside ultrasound exam shows diffuse pulmonary A lines (no alveolar fluid) with good lung sliding bilaterally, no pericardial effusion, and a dilated inferior vena cava.  The right ventricle appears dilated and hypokinetic. You diagnose the patient with obstructive shock, likely due to massive pulmonary embolism. You rule out tension pneumothorax and cardiac tamponade as alternative diagnoses with your physical exam and bedside ultrasound findings.  Thrombolytics are promptly administered. The patient’s vital signs slowly stabilize, and he is admitted to the medical intensive care unit for continued monitoring and care.

Author

Joseph CIANO

Joseph CIANO

Dr Ciano is an Emergency Medicine Physician from New York, USA. He completed his Emergency Medicine Residency in Brooklyn, NY and a Fellowship in Global Emergency Medicine in the Northwell-LIJ Health System. He is interested in building the educational infrastructure of EM in countries where Emergency Medicine is not yet recognized as a field and in countries that are in the early stages of this process. He has partnered with international NGOs in Emergency Medicine educational projects and works as a visiting Emergency Medicine faculty member in West Bengal, India. He is excited to collaborate with the other authors of the iEM Education Project to contribute to the world of FOAM-ed.

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Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Shock (2023)," in International Emergency Medicine Education Project, May 8, 2023, https://iem-student.org/2023/05/08/shock-2023/, date accessed: October 1, 2023

2018 version of this topichttps://iem-student.org/shock/

References

  1. Nicks BA, Gaillard JP. Approach to Nontraumatic Shock. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. Accessed January 31, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=218079826
  1. Gitz Holler J, Bech CM, Henriksen DP, et al. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: A systematic review. PLoS One. 2015;10(3): e0119331. doi: 10.1371/journal.pone.0119331.
  1. Gitz Holler J, Jensen HK, Henriksen DP, et al. Etiology of Shock in the Emergency Department: A 12-Year Population-Based Cohort Study. Shock. 2019;51(1):60-67. doi:10.1097/SHK.0000000000000816
  1. Bloom JE, Andrew E, Dawson LP, et al. Incidence and outcomes of nontraumatic shock in adults using emergency medical services in Victoria, Australia. JAMA Netw Open. 2022;5(1): e2145179. doi:10.1001/jamanetworkopen.2021.45179
  1. Farkas J. Approach to shock. EMCrit Project. https://emcrit.org/ibcc/shock/ . Published November 29, 2021. Accessed January 31, 2023.
  1. Doerschug KC, Schmidt GA. Shock: Diagnosis and Management. In: Oropello JM, Pastores SM, Kvetan V. eds. Critical Care. McGraw Hill. Accessed February 07, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=1944&sectionid=143516997
  1. Weingart SD, Duque D, Nelson B. The RUSH exam: Rapid ultrasound for shock and hypotension. EMCrit Project. https://emcrit.org/rush-exam/. Accessed February 8, 2023.
  1. Puskarich MA, Jones AE. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. Accessed February 08, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=220292051
  1. Shock index. MDCalc. https://www.mdcalc.com/calc/1316/shock-index. Accessed February 8, 2023.
  1. Orsborn J, Braund C. Emergencies & Injuries. In: Bunik M, Hay WW, Levin MJ, Abzug MJ. Current Diagnosis & Treatment: Pediatrics, 26e. McGraw Hill; 2022. Accessed February 22, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=3163&sectionid=266216337
  1. Levine M. Geriatric trauma and medical illness: Pearls and pitfalls. emDocs. http://www.emdocs.net/geriatric-trauma-medical-illness-pearls-pitfalls/ Published August 21, 2016. Accessed February 22, 2023.
  1. Fleischman RJ, Ma O. Trauma in the Elderly. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. Accessed February 22, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=221180950
  1. Clifford KM, Dy-Boarman EA, Haase KK, Maxvill K, Pass SE, Alvarez CA. Challenges with Diagnosing and Managing Sepsis in Older Adults. Expert Rev Anti Infect Ther. 2016;14(2):231-241. doi:10.1586/14787210.2016.1135052
  1. Burns BD, Fisher ES. Resuscitation in Pregnancy. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. Accessed February 23, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=206322334

Acknowledgement

The patient image was created with the assistance of DALL·E 2 by iEM editorial team.

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Question Of The Day #100

question of the day
Which of the following is the most appropriate next step in management for this patient’s condition?

This patient arrives to the Emergency department with 1 week of melena and fatigue.  His medication list includes an antiplatelet and an anticoagulant medication.  There is tachycardia and melena noted on examination.  This patient likely has an upper GI bleed based on his signs and symptoms with peptic ulcer disease as the most common cause.  The patient’s anticoagulation serves as a risk factor for GI bleeding and is an important contributing factor in this scenario.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Gastroenterology consultation for emergent endoscopy (Choice B) is not necessary as the patient is not acutely unstable.  He may need a diagnostic and therapeutic endoscopy during an inpatient admission, but the GI consultants do not need to be called emergently for this procedure.  An acutely unstable upper GI bleed patient, such as a patient with hemodynamic instability, requiring intubation for airway protection, receiving multiple blood product transfusions, or with brisk (rapid) bleeding on exam should prompt GI consultation for an emergent endoscopy for source control.  Surgery consultation for gastrectomy (Choice C) is not a first-line treatment for upper GI bleeding.  Gastroenterology should first perform a diagnostic and therapeutic endoscopy for most upper GI bleed patients.  Surgical esophageal transection, gastrectomy, colectomy, and other surgical procedures are last resort measures to control GI bleeding.  Administration of IV Ceftriaxone (Choice D) is not needed in this scenario and should not be given routinely in upper GI bleeds.  This patient has no infectious signs or symptoms.  Antibiotics, such as Ceftriaxone or quinolones, should be given to upper GI bleed patients with chronic liver disease (i.e., cirrhosis), or presumed gastroesophageal variceal bleeds.  Antibiotics have been found to have a mortality benefit in this patient population with GI bleeds. 

The best next step in management is to treat the patient’s tachycardia with normal saline (Choice A) for volume resuscitation.  This patient may eventually need blood products, but crystalloid IV fluids are okay to start until the Complete Blood Count results return.  This patient is not in overt hemorrhagic shock, so blood products can be held until there is evidence that the hemoglobin is below 7g/dL.  Reversal of the patient’s anticoagulation with Vitamin K and fresh frozen plasma may also be needed depending on the INR level.  Reversal can wait until coagulation studies are complete since the patient is not acutely unstable. An unstable patient should have their anticoagulant reversed immediately. Correct Answer: A

References

 
 
Cite this article as: Joseph Ciano, USA, "Question Of The Day #100," in International Emergency Medicine Education Project, August 12, 2022, https://iem-student.org/2022/08/12/question-of-the-day-100/, date accessed: October 1, 2023

Question Of The Day #99

question of the day

Complete Blood Count

Result

(Reference Range)

BUN

36.2

5 -18 mg/dL

Creatinine

1.1

0.7 – 1.2 mg/dL

Hemoglobin

9.2

13.0 – 18.0 g/dL

Hematocrit

27.6

39.0 – 54.0 %

Which of the following is the most appropriate advice for this patient’s condition?

This patient arrives to the Emergency department after a single hematemesis episode.  On exam he has a borderline low blood pressure and tachycardia.  The laboratory results demonstrate an elevated BUN and a low hemoglobin and hematocrit.  The patient’s vital signs in combination with the laboratory values point towards a diagnosis of an upper GI bleed with early signs of hemorrhagic shock.  The history of alcohol abuse also should raise concern for possible gastro-esophageal variceal bleeding as the cause of the GI bleed.

Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Although this patient is not acutely unstable, his vital signs are abnormal and he should receive volume resuscitation and close observation in the Emergency department.  After initial resuscitation and treatment, it is sometimes difficult to know the best disposition for the patient (admit versus discharge).  The Glasgow-Blatchford Score isa validated risk satisfaction tool used to assist in determining the disposition of patients with an upper GI bleed.  The scoring criteria and instructions on how to use the score are below.

Glasgow-Blatchford Score

 

A validated risk stratification tool for patients with upper GIB

Scoring Criteria

Numerical Score

BUN (mg/dL)

<18.2

18.2-22.3

22.4-28

28-70

>70

 

0

+2

+3

+4

+6

Hemoglobin (g/dL) for men

>13

12-13

10-12

<10

 

0

+1

+3

+6

Hemoglobin (g/dL) for women

>12

10-12

<10

 

0

+1

+6

Systolic blood pressure (mmHg)

>110

100-109

90-99

<90

 

0

+1

+2

+3

Other criteria

Pulse >100 beats/min

Melena present

Syncope

Liver disease history

Cardiac failure history

 

+1

+1

+2

+2

+2

Instructions:

Low risk= Score of 0.  Any score higher than 0 is high risk for needing intervention: transfusion, endoscopy, or surgery. Consider admission for any score over 0. 

This patient has a Glasgow-Blatchford score of 15, and should not be discharged home.  A plan to discharge with gastroenterology follow up in 1 week (Choice A) or discharge with instructions to return if there are repeat hematemesis episodes (Choice B) should not be followed. This patient may have future hematemesis episodes in the Emergency department, be at risk for aspiration, require endotracheal intubation, and become more hypotensive.  A Sengstaken-Blakemore tube (Choice C) is a specialized oro-gastric tube with a gastric and esophageal balloon.  Placement of this tube is considered an invasive procedure that is only used after a patient has been endotracheally intubated to prevent aspiration.  Once placed correctly, the balloons in the tube can be inflated to tamponade any bleeding variceal vessels in the distal esophagus or stomach.  This tube is used as a last resort measure prior to endoscopic treatment for presumed gastro-esophageal variceal bleeds. 

The best advice for this patient would be to admit the patient for monitoring and endoscopy (Choice D).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #99," in International Emergency Medicine Education Project, August 5, 2022, https://iem-student.org/2022/08/05/question-of-the-day-99/, date accessed: October 1, 2023

Question Of The Day #98

question of the day
Which of the following is the most likely cause for this patient’s condition?

This man presents to the Emergency department with epigastric pain and hematemesis.  His exam shows hypotension, tachycardia, pale conjunctiva, and a tender epigastrium and left upper quadrant.  This patient likely has an upper GI bleed based on his signs and symptoms. 

Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Risk factors for GI bleeds include alcohol use, anticoagulant use, NSAID (non-steroidal anti-inflammatory drug) use (i.e., ibuprofen, aspirin, naproxen), recent gastrointestinal surgery or procedures, prior GI bleeds, and a history of conditions that are associated with GI bleeds (i.e., gastritis, peptic ulcers, H. Pylori infection, ulcerative colitis, Chron’s disease, hemorrhoids, diverticulosis, or GI tract cancers).  Fatty meals (Choice A) can trigger gastroesophageal reflux disorder (GERD) symptoms or biliary colic symptoms from cholelithiasis.  However, fatty meals do not increase the risk for GI bleeding.  Physiological stress, such as sepsis or bacteremia (Choice B), can increase the risk for GI bleeding.  This patient does not have any infectious exam signs or symptoms that would support the presence of bacteremia. Acetaminophen use (Choice D) can cause liver failure if taken in excess, but acetaminophen does not cause GI bleeding.  NSAIDs, unlike Tylenol, are associated with GI bleeding. 

Systemic steroid use (Choice C) can increase the risk for GI bleeding and is the likely cause of this patient’s upper GI bleed. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #98," in International Emergency Medicine Education Project, July 29, 2022, https://iem-student.org/2022/07/29/question-of-the-day-98/, date accessed: October 1, 2023

Question Of The Day #97

question of the day
Which of the following is the most appropriate next step in management for this patient’s condition?

This patient arrives to the Emergency department after multiple episodes of hematemesis.  Her exam shows tachycardia, borderline hypotension, and mild tachypnea.  While in the Emergency department the patient decompensates after more hematemesis episodes and develops altered mental status.  This patient has an upper GI bleed most likely from a gastroesophageal variceal bleed.  Gastro-esophageal (GE) varices are dilated blood vessels at the GE junction that result from portal hypertension.  Variceal bleeding can be catastrophic and cause hemorrhagic shock and problems with airway patency as seen in this scenario.  The management of GE variceal bleeding, like other GI bleeds, begins with management of the “ABCs” (Airway, Breathing, and Circulation).  Unlike in other causes of upper GI bleeds, IV antibiotics and IV octreotide are used in GE variceal bleeds.  IV antibiotics have a mortality benefit when used in this setting.  Early gastroenterology consultation is another important component of GE variceal bleed management for definitive diagnosis and treatment with variceal banding or ligation.  Please see the chart below for further details on general GI bleed causes, signs and symptoms, and ED management.

This patient with a depressed mental status needs to have a definitive airway established to prevent aspiration with bloody vomitus.  IV Pantoprazole (Choice B) is used in upper GI bleeds from peptic ulcers but has no role in this acutely ill variceal bleed patient.  The airway should be established prior to medications, such as pantoprazole are considered.  A cricothyrotomy (Choice D) would establish an airway, but this is an invasive approach to airway management and not the best approach in this patient.  A cricothyrotomy involves piercing a needle or scalpel in the anterior neck (cricothyroid membrane) to establish an airway surgically.  This procedure is performed in special situations where a patient cannot be intubated through the trachea (i.e., angioedema of the lips and tongue, facial mass, facial trauma) and cannot ventilate independently (i.e., depressed mental status).  This patient does not meet the criteria for this invasive procedure.  Endotracheal intubation should be attempted first on this patient.  A Sengstaken-Blakemore tube (Choice A) is a specialized oro-gastric tube with a gastric and esophageal balloon.  Once placed correctly, the balloons on the tube can be inflated to tamponade any bleeding variceal vessels in the distal esophagus or stomach.  This tube should be placed only after intubating a patient and is used as a last resort measure prior to endoscopic treatment.  The best next step in management of this patient is to perform endotracheal intubation (Choice C) for airway protection. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #97," in International Emergency Medicine Education Project, July 22, 2022, https://iem-student.org/2022/07/22/question-of-the-day-97/, date accessed: October 1, 2023

Question Of The Day #96

question of the day
Which of the following is the most appropriate next step in management for this patient’s condition?

This patient arrives to the Emergency department with upper abdominal pain and hematemesis.  The exam demonstrated hypotension, tachycardia, pale conjunctiva, and abdominal ascites. The patient decompensates during the exam requiring endotracheal intubation for airway protection. This patient has an upper GI bleed most likely from gastro-esophageal varices given her history of liver cirrhosis and stigmata of chronic liver disease.  Gastro-esophageal (GE) varices are dilated blood vessels at the GE junction that result from portal hypertension.  Variceal bleeding can be catastrophic and cause hemorrhagic shock and problems with airway patency as seen in this scenario.  The management of GE variceal bleeding, like other GI bleeds, begins with management of the “ABCs” (Airway, Breathing, and Circulation).  Unlike in other causes of upper GI bleeds, IV antibiotics and IV octreotide are used in GE variceal bleeds.  IV antibiotics have a mortality benefit when used in this setting.  First line antibiotics are IV ceftriaxone or IV ciprofloxacin.  Early gastroenterology consultation is another important component of GE variceal bleed management for definitive diagnosis and treatment with variceal banding or ligation.  

An abdominal paracentesis (Choice A) is not the best next step in this unstable cirrhotic patient.  Antibiotics are routinely given in gastro-esophageal variceal bleeds due to their mortality benefit, so there is no need for an emergent paracentesis to evaluate for spontaneous bacterial peritonitis (SBP) with an ascitic fluid sample. IV Tranexamic acid (Choice C) is an anti-fibrinolytic agent with pro-coagulative effects.  Its use is recommended in post-partum hemorrhage and traumatic hemorrhages, but it has no utility in the setting of GI bleed.  Early gastroenterology consultation for endoscopy is preferred over general surgery consultation (Choice D).  Surgery consultants can assist in a TIPS procedure (Transjugular intrahepatic portosystemic shunt) to reduce portal hypertension, esophageal resection, or gastrectomy, but less invasive endoscopic therapies with GI specialists are preferred over these procedures.

IV Ceftriaxone (Choice B) is the best next step in this scenario due to the mortality benefit of antibiotics in chronic liver disease patients with variceal bleeds.      

Please see the chart below for further details on general GI bleed causes, signs and symptoms, and ED management.

    

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #96," in International Emergency Medicine Education Project, July 8, 2022, https://iem-student.org/2022/07/08/question-of-the-day-96/, date accessed: October 1, 2023

Question Of The Day #95

question of the day

Complete Blood Count

Result

(Reference Range)

WBC Count

16.2

4.0 – 10.5 X 103/mL

Hemoglobin

10.8

13.0 – 18.0 g/dL

Hematocrit

32.4

39.0 – 54.0 %

Platelets

220

140 – 415 x 103/mL

Which of the following is the most likely diagnosis for this patient’s condition?

This patient arrives to the Emergency department with bright red bloody stools and lower abdominal pain.  The exam shows fever, tachycardia, and left-sided abdominal tenderness.  The laboratory results provided show leukocytosis and anemia.  This patient likely has a lower GI bleed based on her signs and symptoms.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

All choices provided are causes of lower GI bleeding and are possible in this patient.  However, that patient’s signs, symptoms, and risk profile make certain diagnoses less likely than others.  Diverticulosis (Choice A) is the most common cause of lower GI bleeding.  Diverticulosis often occurs in older patients and should not be associated with pain or fever, which support a diagnosis of an inflammatory or infectious etiology (i.e., diverticulitis, Shigellosis, ulcerative colitis, chron’s disease, etc.).  This patient is young and has fever and leukocytosis, making diverticulosis less likely.  Colon malignancy (Choice B) is also possible but is less likely given the patient’s young age, the presence of fever, and the acute onset of symptoms over 2 days.  Colon malignancy tends to cause slow GI bleeding over a longer period of time, rather than acutely over 2 days.  Ischemic colitis (Choice C), such as mesenteric ischemia, is less likely in a young patient without any cardiac risk factors or recent abdominal surgeries. 

Ulcerative colitis (Choice D) is the most likely diagnosis in this scenario.  Peak incidence for ulcerative colitis occurs in the second and third decades of life, and women are more likely than men to have this diagnosis.  Definitive diagnosis requires a biopsy and colonoscopy, but a CT scan of the abdomen and pelvis can show findings consistent with ulcerative colitis for a new diagnosis.  Treatment of an ulcerative colitis flare includes general supportive care, IV steroids, and IV antibiotics if there is concern for a concurrent infectious process.  Intestinal perforation and toxic megacolon also should be evaluated for with CT imaging.    

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #95," in International Emergency Medicine Education Project, July 1, 2022, https://iem-student.org/2022/07/01/question-of-the-day-95/, date accessed: October 1, 2023

Question Of The Day #94

question of the day

Complete Blood Count

Result

(Reference Range)

WBC Count

4.5

4.0 – 10.5 X 103/mL

Hemoglobin

5.3

13.0 – 18.0 g/dL

Hematocrit

15.9

39.0 – 54.0 %

Platelets

138

140 – 415 x 103/mL

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient arrives to the Emergency Department with bright red bloody stools in the setting of warfarin use.  His exam shows hypotension and tachycardia.  The laboratory results show a low hemoglobin and hematocrit, but no INR or other coagulation studies are provided.  This patient is in hemorrhagic shock due to a lower gastrointestinal bleed.  This patient’s condition may be due to coagulopathy from his warfarin (i.e., supratherapeutic INR), diverticulosis, or other conditions.  Initial management of this unstable patient should include management of the airway, breathing, and circulation (“ABCs”).  This includes aggressive and prompt treatment of the patient’s hypotension and tachycardia and reversal of the patient’s anticoagulation.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

This patient’s platelet level is just below the lower limit of normal, so administration of a platelet transfusion (Choice A) would not be the next best step.  Platelet administration should be considered if the platelet count is below 50,000-100,000, or if a massive transfusion protocol is initiated to prevent coagulopathy.  No INR value is provided in the question stem, but prompt reversal of warfarin should not be delayed for an INR level (Choice D).  Reversal of warfarin should be promptly initiated when a patient is unstable (i.e., hypotensive GI bleed, traumatic wound hemorrhage, intracranial bleed, etc.).  Medication reversal in these settings includes both IV Vitamin K 10mg and IV Fresh Frozen Plasma 10-20cc/kg.  IV Vitamin K helps reverse the Vitamin K antagonistic effect of Warfarin, but it does not acutely provide new Vitamin K-dependent coagulation factors (Factors X, V, II, VII).  IV Vitamin K gives the liver the ‘materials’ needed to regenerate these coagulation factors, but this process takes time.  Fresh frozen plasma contains ‘ready-to-use’ coagulation factors that will help control the hemorrhage acutely.  For this reason, both Vitamin K and FFP are given together in an unstable patient.  An alternative to fresh frozen plasma (FFP) is prothrombin complex concentrate (PCC), which is a concentrated version of coagulation factors.  PCC is not broadly available in all countries, and is generally more expensive than FFP. 

The management of stable patients with a supratherapeutic INR includes holding warfarin doses and sometimes providing PO Vitamin K, depending on the INR level.  Administration of IV Vitamin K only (Choice C) is not the correct treatment in this scenario.  IV Vitamin K and IV Fresh Frozen Plasma (Choice B) is the best next step to reverse this patient’s anticoagulant. 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #94," in International Emergency Medicine Education Project, June 24, 2022, https://iem-student.org/2022/06/24/question-of-the-day-94/, date accessed: October 1, 2023

Question Of The Day #93

question of the day

Which of the following is the most appropriate next step in management?

This patient arrives to the Emergency Department with bright red bloody stools and generalized abdominal pain.  His exam shows hypotension, tachycardia, a diffusely tender abdomen, and pale conjunctiva.  He also takes warfarin daily for anticoagulation.  This patient is in hemorrhagic shock due to a lower gastrointestinal bleed.  This patient’s condition may be due to coagulopathy from his warfarin (i.e., supratherapeutic INR), diverticulosis, ischemic colitis (i.e., mesenteric ischemia), and other conditions.  Initial management of this unstable patient should include management of the airway, breathing, and circulation (“ABCs”).  This includes aggressive and prompt treatment of the patient’s hypotension and tachycardia.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

A CT Angiogram of the abdomen and pelvis (Choice A) may be helpful in clarifying the etiology and site of the patient’s bleeding, but this is not the best next step in management.  The patient’s shock state first should be managed prior to any imaging studies.  Gastroenterology consultation for colonoscopy (Choice B) may be important later in this patient’s management, but it is not the best next step in management. His shock state should be treated prior to calling any consultants. An IV Pantoprazole infusion (Choice C) is helpful in upper GI bleeds due to peptic ulcer disease.  Proton pump inhibitor medications, like pantoprazole, help reduce findings of ulcer bleeding during endoscopy.  Proton pump inhibitor use has been controversial in upper GI bleeds as there is no evidence that their use decreases mortality, decreases blood product requirements, or ulcer rebleeding, but these medications are often given due to their generally small risk profile.

 

The best next step for this patient in hemorrhagic shock is administration of packed red blood cells (Choice D).  He also should have reversal of his warfarin with IV Vitamin K and fresh frozen plasma to prevent continued bleeding.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #93," in International Emergency Medicine Education Project, June 17, 2022, https://iem-student.org/2022/06/17/question-of-the-day-93/, date accessed: October 1, 2023

Question Of The Day #92

question of the day

Which of the following is the most likely cause of this patient’s condition?

This elderly patient arrives to the Emergency Department with painless hematochezia.  His exam shows borderline hypotension, tachycardia, and a normal abdominal exam.  This patient most likely has a lower gastrointestinal bleed based on his signs and symptoms.  A brisk (fast) upper GI bleed is also possible but is less likely.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

All choices listed above are potential causes of bright red bloody stools.  Peptic ulcer disease (Choice C) is the most common cause of upper GI bleeding worldwide, not lower GI bleeding.  However, a profusely bleeding peptic ulcer can cause rapid blood transit through the GI tract to form hematochezia rather than melena.  The patient lacks any risk factors or symptoms of peptic ulcer disease, such as upper abdominal pain, hematemesis, NSAID use, or prior H. pylori infection.  Ischemic colitis, or mesenteric ischemia (Choice A), is often associated with abdominal pain and cardiac risk factors (i.e., atrial fibrillation).  Colon cancer (Choice B) is also possible, but typically colon malignancy causes slow, chronic bleeding, rather than acute large volume bloody stools with signs of shock as in this patient.  The most common cause of lower GI bleeding worldwide is diverticulosis (Choice D).  This is the most likely diagnosis in this patient with painless hematochezia.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #92," in International Emergency Medicine Education Project, June 10, 2022, https://iem-student.org/2022/06/10/question-of-the-day-92/, date accessed: October 1, 2023

Question Of The Day #91

question of the day

Which of the following is the most likely cause of this patient’s condition?

This patient arrives to the Emergency Department with upper abdominal pain and hematemesis.  He occasionally takes ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), which is a risk factor for GI bleeding. His examination shows tachycardia.  This patient likely has an upper gastrointestinal bleed given his signs and symptoms.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding.  

All choices listed above are potential causes of upper GI bleeding, with the exception of GERD (Choice D).  Erosive gastritis and esophagitis can cause an upper GI bleed, but GERD is not a cause of upper GI bleed.  The patient lacks risk factors for esophageal varices (Choice A), such as chronic liver disease, cirrhosis, or alcohol abuse.  Gastric malignancy (Choice B) is possible, but less likely given the patient’s young age and lack of risk factors mentioned in the question stem for gastric malignancy (i.e., prior H. pylori infection, tobacco smoking, chronic gastritis, weight loss, lymphadenopathy, etc.).  The most common worldwide cause of upper GI bleeding is peptic ulcer disease (Choice C).  For this reason, Choice C is the best answer.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #91," in International Emergency Medicine Education Project, June 3, 2022, https://iem-student.org/2022/06/03/question-of-the-day-91/, date accessed: October 1, 2023

Approach to the trauma patient – ABCDE of trauma care

Approach to the trauma patient – ABCDE of trauma care

Case

Jane Doe, 22-year-old female, was in a major car crash and is approaching the trauma bay via an ambulance. You are aware that the patient’s condition is critical, so you do a quick run-through in your head about the approach that you will have to care for them once they arrive to your emergency department. What should your approach to a trauma patient be?

The ABCDE of Trauma Care

The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a clinically proven approach to any critically ill patient that needs emergent care and treatment. It has been proven to improve patient outcomes, optimize team performance and save time when patients are in life-threatening conditions [1]. This approach is applicable to all patients (both adults and children), regardless of their underlying condition. However, the ABCDE approach is not applicable to patients who are in cardiac arrest, in which case the cardiopulmonary resuscitation guidelines should be used [2].

With the ABCDE approach, initial assessment and treatment are performed simultaneously. Once the entire survey is completed, reassessment should be conducted until the patient is stable enough for the care team to be able to move on to the secondary survey and look for a definitive diagnosis.

A - Airway

First, the care team should assess if the patient’s airway is patent. If the patient responds to the team in a normal voice, then that is a good sign that the airway is intact. It is important to note that airway obstruction can be complete or partial, and can be caused by upper airway obstruction or reduced level of consciousness.

Signs of complete airway obstruction are lack of respiration despite great effort. Signs of partial airway obstruction include:
– Changes in the patient’s voice
– Snoring or gurgling
– Stridor (noisy breathing)
– Increased breathing effort

Assess the patient’s airway by looking for rocking chest wall motion and any signs of maxillofacial trauma or laryngeal injury. Perform the head-tilt and chin-lift maneuver to open the airway (note that caution should be conducted in patients with C-spine injury). If there is anything that is noticeably obstructing the airway, suction or remove it. If possible, remove foreign bodies that are causing airway obstruction. Provide high-flow oxygen to the critically ill patient and perform definitive airway if needed [1].

B – Breathing

Generally, airway and breathing are examined simultaneously. Determine if breathing is intact by assessing the respiratory rate, inspecting the chest wall movement for symmetry, depth, and respiratory pattern. Additionally, assess for tracheal deviation and use of respiratory muscles. Percuss the chest for dullness or resonance, auscultate for breath sounds and apply a pulse oximeter [1].

Injuries that impact breathing should be immediately recognized, and life-threatening injuries should be addressed and managed [3]. For example, tension pneumothorax must be promptly relieved by needle thoracocentesis, bronchospasms should be managed with inhalation and assisted ventilation should be considered if breathing continues to be insufficient [1].

C – Circulation

Conditions that threaten the patient’s circulation and can be fatal include shock, hypertensive crises, vascular emergencies such as aortic dissection and aortic aneurisms. These conditions should be immediately identified and managed [1].

Circulation can be assessed by looking at the general appearance of the patient, including signs of cyanosis, pallor, flushing and diaphoresis. Assess for any obvious signs of hemorrhage, blood loss and level of consciousness. Additionally, capillary refill time and pulse rate should be assessed. Auscultate the chest for heart sounds, and blood pressure measurement and electrocardiography should be performed as soon as possible [1].

Additionally, assess for signs of hypovolemia and shock. If these are identified, obtain an intravenous access and infuse saline to restore circulating volume [1]. If there are life-threatening conditions that are compromising the patient’s circulation, promptly identify and treat them as needed. For example, tension pneumothorax should be immediately treated with needle decompression and cardiac tamponade can be relived with pericardiocentesis.

D - Disability

The main disability in the primary survey to be assessed for is the brain. Abnormal neurological status can be caused by primary brain injury or systemic conditions that effect brain perfusion, such as shock, hypoxia, intoxication etc. Assess the level of consciousness by using the Glasgow Coma Scale [4], look for pupillary response and limb movement.

The best way to prevent injury to the brain is to maintain adequate airway, breathing and circulation. Glucose levels can be assessed at bedside for decreased level of consciousness due to low blood glucose levels, and corrected with oral or infused glucose [1].

E – Exposure

The exposure portion of the ABCDE approach involves assessment of the whole-body to avoid any signs of missing injuries. During this part of the management, undress the patient fully and examine the back for any signs of C-spine precautions. Additionally, check for clues for any signs of underlying conditions, such as:

  • Signs of trauma (i.e. burns, gunshot wounds, stab wounds)
  • Rashes
  • Causes of sepsis (i.e. infected wounds, gangrene)
  • Toxins and drugs (i.e. needle track marks, chemicals, patches)
  • Other wounds such as bite marks, insect bites, embedded ticks
  • Iatrogenic causes (i.e. catheters, tubes, implants, surgical sites and scars)

Concluding Remarks

The ABCDE approach to the critically ill patient is a strong and proven clinical tool for initial assessment and treatment of patients in medical emergencies. Widespread knowledge of this skill is critical for healthcare workers and any team providing emergent care to trauma patients. 

*Note that this is a general approach to the trauma patient. Always consult your care team for adequate management of trauma patients and resort to reliable resources for more information on the ABCDE approach. 

References and Further Reading

  1. Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine5, 117.
  2. Koster, R. W., Baubin, M. A., Bossaert, L. L., Caballero, A., Cassan, P., Castrén, M., … & Sandroni, C. (2010). European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation81(10), 1277-1292.
  3. Subcommittee, A. T. L. S., & International ATLS Working Group. (2013). Advanced trauma life support (ATLS®): the ninth edition. The journal of trauma and acute care surgery74(5), 1363-1366.
  4. Sternbach, G. L. (2000). The Glasgow coma scale. The Journal of emergency medicine19(1), 67-71.
Cite this article as: Maryam Bagherzadeh, Canada, "Approach to the trauma patient – ABCDE of trauma care," in International Emergency Medicine Education Project, January 19, 2022, https://iem-student.org/2022/01/19/abcde-of-trauma-care/, date accessed: October 1, 2023