Emergency Medicine

Critical Care Emergencies 21

SHOCKED PATIENT

(a) remember that in healthy adults the only signs associated

with loss of up to 30% of the circulatory blood volume

(i.e. 1500 mL) may be a tachycardia and a narrowed pulse

pressure

(b) thus, a consistent fall in SBP indicates that at least 30% of the

blood volume has already been lost

(c) full cross-match takes 45 min, a type-specific cross-match

takes 10 min, and O rhesus-negative blood is available

immediately

(d) use a blood warmer and macropore blood filter for multiple

transfusions

• give fresh frozen plasma 8–10 units and platelets after trans-
  fusing 8–10 units of blood or more, i.e. in a 1:1 ratio for a
  ‘massive blood transfusion’
  (e) aim for haemoglobin 70–100 g/L, or haematocrit >30%.

4 Consult the surgical, vascular or gynaecological team immediately if there is
suspected blood loss causing shock (e.g. ruptured spleen, AAA or ectopic
pregnancy).

5 Admit the patient to theatre, intensive care unit (ICU) or a high-dependency
unit (HDU) depending on the underlying cause, and response to treatment.

Septic shock

DIAGNOSIS

1 Sepsis is a heterogeneous clinical entity defined by physiological changes
k nown as the systemic inf lammator y response syndrome (SIRS) in response
to a pre su me d i n fe c t iou s ae t iolog y, w h ic h i s mos t u su a l ly bac ter i a l, or f u nga l,
viral or parasitic.
(i) More than 85% of the causes originate from the chest, abdominal
or genitourinary systems, skin and vascular access.
(ii) Worldwide sepsis is one of the most common reasons for
admission to an ICU, and up to 20–50% of patients with sepsis
die.

2 Definitions used in sepsis include:
(i) SIRS
Two or more of:
(a) temperature >38°C or < 36°C
(b) tachycardia with heart rate >90/min
(c) respiratory rate >20/min or PaCO 2 <32 mmHg (<4.3 kPa)
(d) WBC >12  109 /L, <4  109 /L or >10% immature
neutrophils (band forms).
(ii) Sepsis
When SIRS is the result of a confirmed infectious process.