18 Critical Care Emergencies
SHOCKED PATIENT(ii) Look at the skin for sweating, pallor or mottling and feel if it is
cold or clammy
(a) check the capillary refill time (CRT) by pressing on a nailbed
(held at the level of the heart) for 5 s. Observe the time taken
to refill the blanched area with blood. Over 2 s is prolonged
and suggests hypoperfused or cool peripheries.
6 Estimate preload volume status to help determine the cause, and to monitor
treatment effect.
(i) Low preload with non-visible jugular venous pressure (JVP)
occurs in hypovolaemic and distributive shock states.
(ii) High preload with raised JVP occurs in cardiogenic and
obstructive shock.
7 Establish venous access with two large-bore (14- or 16-gauge) cannulae into
the antecubital veins and attach a cardiac monitor and pulse oximeter to the
patient.
8 Send blood for full blood count (FBC), coagulation profile, electrolyte and
liver function tests (ELFTs), lipase, cardiac troponin I (cTnI) or troponin T
(cTnT), lactate, blood cultures from two sites and a group and save (G&S) or
cross-match blood according to the suspected cause.
(i) Check a venous or arterial blood gas.
9 Perform an ECG, and arrange immediate review by a senior ED doctor.
(i) Look for acute changes suggesting an acute coronary syndrome,
or for an arrhythmia
(a) acute changes may be the cause or the effect of the shock state.
(ii) A normal ECG effectively rules out cardiogenic shock.
10 Request a CXR to look for cardiomegaly, pneumothorax, consolidation,
pulmonary oedema and atelectasis.
11 Insert a urethral catheter to measure the urine output, and check a urinalysis for
blood, protein, nitrites and sugar. Send for microscopy and culture if positive.
(i) Oliguria suggests ongoing renal hypoperfusion.
(ii) Check a urinary -human chorionic gonadotrophin (hCG)
pregnancy test in pre-menopausal females.
12 Organize a rapid bedside ultrasound to look for a ruptured abdominal aortic
aneurysm (AAA), ectopic pregnancy, cardiac tamponade or free f luid in the
peritoneal cavity.MANAGEMENT1 Commence high-dose oxygen via a face mask. Maintain the oxygen satura-
tion above 94%.
2 Begin immediate f luid replacement:
(i) Give 20 mL/kg normal saline i.v. rapidly and repeat until JVP is
3–5 cm above sternal angle