Emergency Medicine

Critical Care Emergencies 19

SHOCKED PATIENT

(a) omit fluids if JVP is already raised, and or the patient has

pulmonary oedema

(b) aim for a urine output of 0.5–1 mL/kg per h.

(ii) Give cross-matched blood when it is available, if the patient is

shocked due to blood loss:

(a) use O-negative blood if the situation is desperate. Aim for

haemoglobin 70–100 g/L, or haematocrit >30%.

3 Optimize afterload:
(i) Give a vasopressor such as adrenaline if vasodilated from
anaphylaxis (see p. 27) or sepsis (see p. 21).

4 Treat sepsis:
(i) Give broad-spectrum antibiotics early if septic shock is suspected,
after taking a minimum of two sets of blood cultures from
different sites (see p. 21).

5 Admit the patient to ICU, HDU, theatre or coronary care depending on the
underly ing cause, and response to treatment.

Hypovolaemic shock

DIAGNOSIS

1 This follows haemorrhage or non-haemorrhagic f luid loss that results in a
reduced circulatory volume with inadequate end-organ tissue perfusion.

2 Causes of haemorrhagic shock include (see a lso p. 17):
(i) Trauma with external bleeding:
(a) arterial laceration, compound fracture, limb avulsion,
massive scalping injury.
(ii) Trauma with internal bleeding:
(a) haemothorax, haemoperitoneum from liver, spleen or
mesenteric injury, retroperitoneal from aortic, pelvic or renal
injury, closed long-bone or pelvic fracture.
(iii) Non-traumatic, external bleeding:
(a) epistaxis, massive haemoptysis, haematemesis either fresh or
coffee-grounds, rectal bleeding either melaena or fresh red,
vaginal bleeding either pregnancy-related or non-pregnant,
or gross haematuria.
(iv) Non-traumatic, internal bleeding:
(a) haemothorax, haemoperitoneum including ruptured AAA or
ectopic pregnancy, retroperitoneal bleeding including ruptured
AAA or spontaneous from warfarin or bleeding diathesis.

3 Causes of non-haemorrhagic shock from f luid loss include:
(i) External:
(a) vomiting, diarrhoea, polyuria from renal disease, diabetes
insipidus or diabetes mellitus, burns, extensive skin disease
including erythroderma, hyperthermia, fistulae.