0071643192.pdf

■ Narrow pulse pressure
■ Cool and clammy skin, diminished turgor (late and not as commonly seen
as in children)
■ Mental status changes: Anxiety, agitation, confusion, lethargy
■ Hypotension (late)
■ Dry mucous membranes
■ Decreased urine output

A 45-year-old male is brought to the ED by ambulance after a 2-day history

of abdominal pain and bloody diarrhea. Upon presentation he is lethargic

and has a HR of 140 bpm and a BP of 90/60. What is the best indicator for

shock in this patient?

Diminished end organ perfusion is the single best indicator of shock. Clinical

markers include mental status changes, decreased urine output, and increased

base deficit or lactate production.

SHOCK

Shock occurs when there is inadequate tissue oxygenation to meet demand.
Shock may be thought of as belonging to one of four categories: hypo-
volemic, cardiogenic, obstructive, or distributive. Some emergency physi-
cians like to add a fifth category, dissociative shock, in which the ability to use
O 2 is impaired (carbon monoxide or cyanide poisoning).

RESUSCITATION
TABLE 1.14. Guidelines for Correlating Volume Loss With Patient Appearance

HEMORRHAGECLASS ESTIMATEDVOLUMELOSS SIGNS/SYMPTOMS

I <15% (750 mL) No change in VS or patient

demeanor

II 15–30% (750–1500 mL) ↑HR

↑RR

↓Pulse pressure

Cool, clammy skin

Anxiety, agitation

III 30–40% (1500–2000 mL) Further ↑in HR and RR

↓BP

Impaired peripheral circulation

Confusion, agitation

IV >40% (>2000 mL) Marked ↑in HR and RR

Circulatory collapse

Confusion, lethargy