Undifferentiated shock

Definition

1. SBP <90 in normal pt
2. SBP <100 with h/o HTN or age >60
3. Lactate > 4 or base def < -4

Types

Type	Skin	HR	Oth
Hypovolemic	cold	inc
Obstructive	cold	inc
Cardiogenic	cold	inc/dec	?dysth
Distributive	warm	inc
Neurogenic	warm	dec

Undifferentiated Hypotension Algorithm

Check/manage the following in order:

1. Pulse (assess based on pt's age)
   1. Too slow or too fast (to the point where CO is affected)?
      1. If so, HR is likely primary etiology of hypotension
      2. Pace or cardiovert

1. Volume Status
   1. What is the LV end-diastolic volume?
      1. Approximated by the IVC diameter or CVP
      2. If low:
         1. Assess for blood loss versus fluid loss
            1. FAST for intra-abdominal bleed
            2. US for ruptured AAA
            3. Guaiac for GI bleed
            4. CXR for hemothorax
         2. Treat with IVF and/or pRBC depending on cause

1. Contractility
   1. Is the myocardium severely depressed in its contractile function (cardiogenic shock)?
      1. Assess via ultrasound
      2. Treat w/ inotrope
   2. Is forward flow occurring?
      1. Assess for valvular dysfunction (MR, AR)
      2. Assess for obstruction (PE, tamponade)

1. Systemic Vascular Resistance
   1. Pathologic vasodilation (decreased SVR) suggested by:
      1. Warm extremities
      2. Bounding pulse
   2. Treated based on likely etiology (see Distributive Shock

Lack of Response to Normal Treatment (DDX)

1. Cardiogenic
   1. Acute valvular Regurgitation/VSD
   2. CHF
   3. Dysrhythmia
   4. Ischemia/Infarction
   5. Myocardial contusion
   6. Myocarditis
2. Obstructive
   1. Air embolism
   2. Aortic Stenosis
   3. Tamponade
   4. PE
   5. Tension PTX
3. Distributive
   1. Adrenal Crisis
   2. Anaphylaxis
   3. Neurogenic
   4. Sepsis
   5. Toxicologic
4. Hypovolemic
   1. Hemorrhage (traumatic and non-traumatic)
   2. Severe dehydration

See Also

• Ultrasound in Shock and Hypotension
• Cardiogenic Shock

Source

• Tintinalli)
• Morchi, Undifferentiated Hypotension and Shock, All LA Conference, 05/06/2010