20 Critical Care Emergencies
SHOCKED PATIENT(ii) Internal:
(a) pancreatitis ‘third spacing’, bowel obstruction.
4 Ask about external bleeding, previous episodes of bleeding, chest, abdomi-
nal or back pain, drugs taken including non-steroidal anti-inf lammatory
drugs (NSAIDs) or warfarin, allergies, alcohol use and travel abroad.
(i) Enquire about non-specific symptoms of lethargy, breathlessness,
light-headedness, syncope and altered mental status such as
confusion, particularly in the elderly.
5 Check the vital signs and include a postural blood pressure if SBP is normal.
6 Look for signs of anaemia with pale skin creases and conjunctivae, and for
signs of dehydration such as dry mucous membranes, reduced tissue turgor
or sunken eyes.
(i) Assess the JVP which should be low.
7 Examine for specific causes according to the history. Include a per rectal
exam for unrecognized gastrointestinal bleeding.
8 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.
9 Send blood for FBC, coagulation profile, ELFTs, lipase, lactate and cross-
match blood according to the suspected cause.
(i) Check a venous or arterial blood gas.
10 Perform an ECG and request a CXR.
11 Insert a urethral catheter to measure the urine output.
(i) Oliguria suggests ongoing renal hypoperfusion.
(ii) Check a urinary -hCG pregnancy test in pre-menopausal
females.
12 Organize a rapid bedside ultrasound to look for a ruptured AAA, ectopic
pregnancy or free f luid in the peritoneal cavity.MANAGEMENT
1 Commence high-dose oxygen via a face mask. Maintain the oxygen satura-
tion above 94%.
2 Compress or pack any external haemorrhage such as epistaxis (see p. 402) or
wound bleeding (see p. 220).
3 Begin immediate f luid replacement:
(i) Give 20 mL/kg normal saline i.v. rapidly and repeat, aiming for a
urine output of 0.5–1 mL/kg per h
(a) then gradually correct any dehydration (rehydration), and
include daily maintenance amounts.
(ii) Give cross-matched blood when it is available, if the patient is
shocked due to blood loss