- Project: Ghana Emergency Medicine Collaborative - Document Title: Shock - Reviews shock, which can occur with a low blood pressure and hypoperfusion and can occur without shock. Shock treatment goals are to maintain cardiac output and tissue perfusion through adequate fluid resuscitation and vasoconstriction or inotropic support when needed.

1. Project: Ghana Emergency Medicine Collaborative
Document Title: Shock
Author(s): Patrick Carter (University of Michigan), MD 2012
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CLASS
I
II
III
IV
BVL
< 15%
15 - 30%
30 - 40%
> 40%
AMOUNT
750 cc
750 - 1500 cc
1500 - 2000 cc
> 2000 cc
PULSE
<100
> 100
>120
>140
BP
No change
Narrowed pulse
pressure
Consistent decrease
in SBP
Decreased SBP and
narrowed pulse pressure or
no DBP
RESP
No change
20-30
30-40
>35
CNS
No change
Anxiety
Anxious, confused
Confused. lethargic
Urine
>30cc per hr
20-30cc per hr
5-15cc per hr
negligible
TX
Replace fluid
loss
2L NS IV
2 L NS IV, usually requires
blood transfusion
Rapid transfusion of blood
and NS, requires immediate
intervention to stop
hemorrhage
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No Response
Vitals
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Transient
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return to previous
Estimated Blood
loss
10-20%
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ongoing likely
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Need for more
Fluid
Low
High
High
Need for Blood
Type and cross
Type specific
O neg
Need for surgery
Possible
Likely
Highly likely
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B 9'5+3+<'2<"Q:=.<'2+3.2"?5'7<6'2<"
B C@"2."5'+=.2+'"7n'5"#YA"i"CNdR"(.2+3D'5"+<75)2;"7"
*7+.=5'++.5"W4.5'=32'=-532'R"0.=7632'R"'<(X"72D"
)<57<'"<."^e9"
B [.78b""^e9"o"SP"
B >.2+3D'5"7D5'278"32+F`(3'2(:b""Q:D5.(.5)+.2'"!cc"
6;"CN"
AJ"

35. V758:"[.78"035'(<'D"?-'57=:"
B ,'=)(",-.(/"?5'7<6'2<"e8;.53<-6R"H3*'5+"'<"78l"
4Vh^R"#cc!"
B ,<FD:"<-7<"'G7632'D"F+'".@"72"'758:";.78"D35'(<'D"
<-'57=:"78;.53<-6"<."<5'7<"=7)'2<+"I3<-"+'=)("+-.(/"W7+"
D'12'D"%:"5'@57(<.5:"-:=.<'2+3.2".5"87(<7<'"o"JX"
B #SA"=7)'2<+"572D.68:"7++3;2'D"<."'3<-'5"<5'7<6'2<"756"
.5"<."+<72D75D"5'+F+(3<7).2"756+"W!Ac"*+l"!AAX"
B >.2<5.8"756"<5'7<'D"I3<-"+<72D75D"(75'"72D"7D63_'D"<."
C>j"
B ?5'7<6'2<"756"@.88.I'D"=5.<.(.8"32"V0"@.5"S"-.F5+"72D"
<-'2"7D63_'D"<."C>j"
B d32D32;+f$F<(.6'"
B ?5'7<6'2<";5.F="5'('3*'D"6.5'"F3D+"(.6=75'D"<."
(.2<5.8";5.F="WP"i"*+l"AlP"iX"
B AlU"D7:+"8'++"32"-.+=3<78"@.5"<5'7<6'2<";5.F="
B #"@.8D"8'++"(75D3.=F86.275:"(.6=83(7).2+"@.5"<5'7<6'2<"
;5.F="
B D&).2?&'#&8*12$0',0'+$#".),"7'$/'EFGFH'
AP"

36. V758:"[.78"035'(<'D"?-'57=:"
H3*'5+"V"'<"78l"V758:";.78YD35'(<'D"<-'57=:"32"<-'"<5'7<6'2<".@"+'*'5'"+'=+3+"72D"
+'=)("+-.(/"4"V2;8"h"^'Dl"#cc!bAJPb!ASUY!ATTl"
"
AS"

37. e27=-:87()(",-.(/"
B e27=-:87G3+"
B ,'*'5'"+:+<'63("
-:='5+'2+3)*3<:"5'7().2"
B >-757(<'53g'D"%:"
6F8)+:+<'6"32*.8*'6'2<""
B C;V"6'D37<'D"
B e27=-:87(<.3D"5'7().2"
B >8323(788:"32D3+)2;F3+-7%8'"
@5.6"727=-:87G3+"
B 0.'+"2.<"5'EF35'"7"
+'2+3)g32;"'G=.+F5'"
Justin Beck, Flickr
B 4.<"C;V"6'D37<'D"
AT"

38. e27=-:87()(",-.(/"O">8323(78"
^723@'+<7).2+"
• >8323(78",='(<5F6"
– d35+<",:6=<.6+b""
• H3+/"@7(<.5+"@.5"@7<78"
727=-:87G3+""
– 95.;5'++3.2b""
• H'.((F55'2('"57<'+"
– ,'*'5'",:6=<.6+b"""
• ^.+<"(.66.2"(7F+'+"
• 95F53<F+"
• d8F+-32;"
• j5)(7537"
•
•
•
•
•
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i3;-<-'7D'D2'++"
• e8<'5'D"6'2<78"+<7<F+"
• H'+=357<.5:"D3+<5'++"
• >35(F87<.5:"(.887=+'"
– 9..58:"(.2<5.88'D"7+<-67"""
– 95'*3.F+"727=-:87G3+""
"
– JcYScp"@.5"32+'(<"+)2;+"
– #cYJcp"@.5"57D3.(.2<57+<"
7;'2<+"
– !cY#cp"@.5"='23(38832"
"
– e2)%3.)(+"
– C2+'(<+"
– d..D""
AU"

39. e27=-:87()(",-.(/"Y"037;2.+3+"
• >8323(78"D37;2.+3+"
– 0'12'D"%:"735I7:"(.6=5.63+'R"-:=.<'2+3.2R".5"
32*.8*'6'2<".@"(F<72'.F+R"5'+=357<.5:R".5"[C"+:+<'6+"
B ^38DR"8.(783g'D"F5)(7537"(72"=5.;5'++"<."@F88"727=-:87G3+"
B ,:6=<.6+"F+F788:"%';32"I3<-32"Sc"632F<'+".@"'G=.+F5'"
B d7+<'5".2+'<".@"+:6=<.6+"L"6.5'"+'*'5'"5'7().2"
B K3=-7+3("=5'+'2<7).2".((F5+"32"F="<."#cp".@"=7)'2<+"
B ,:6=<.6+"I388"5'<F52"AYJ"-.F5+"7n'5"323)78"5'7().2"-7+"(8'75'D"
• i../"@.5"'G=.+F5'"<."D5F;R"@..DR".5"32+'(<"
• i7%+"-7*'"2."5.8'"
A]"

40. e27=-:87()(",-.(/"Y"?5'7<6'2<"
• eK>q+"
– H'+=357<.5:"(.6=5.63+'"5'EF35'"366'D37<'"
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•
•
•
•
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V=32'=-532'"@.5"e27=-:87G3+f,-.(/"
,'(.2D"832'"?-'57=3'+"
– >.5)(.+<'5.3D+"
– Q!"72D"Q#"%8.(/'5+"
Jc"

41. e27=-:87()(",-.(/"Y"?5'7<6'2<"
• V=32'=-532'"
– clA"6;"C^".5",>".@"!b!ccc"D38F).2"@.5"727=-:87G3+""
– H'='7<"'*'5:"PY!c"632"7+"2''D'D"
– >7F).2"3@"=7)'2<".2"%'<7"%8.(/'5+"DF'"<."
F2.==.+'D"78=-7"+)6F87).2"72D"5'+F8<72<"+'*'5'"
-:='5<'2+3.2"
– d.5">N"(.887=+'"W3l'l"(75D37("755'+<XR"!"6;"CN".@"
!b!cRccc"W+76'"7+"e>i,"0.+'X"
– C@"5'@57(<.5:"-:=.<'2+3.2"72D"+-.(/R"+<75<"CN"D53="
J!"

42. e27=-:87()(",-.(/"Y"?5'7<6'2<"
• >.5)(.+<'5.3D+"
– ^'<-:8=5'D23+.8.2'"!#P"6;"CN""
– 95'D23+.2'"Sc"6;"9$"
• e2)-3+<7632'+"
– Q!"%8.(/'5Y"03=-'2-:D57632'"#PYPc"6;"CN"
– Q#"%8.(/'5Y"H723)D32'"Pc"6;"CN"
• K5.2(-.D387<.5+"
– e8%F<'5.8"2'%F83g'5"
– e<5.*'2<"2'%F83g'5"
– ^7;2'+3F6"+F8@7<'"#";"CN".*'5"#c"632F<'+""
"
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43. B 0'12'D"7+b"
>75D3.;'23(",-.(/"
B ,K9"m"]c"66Q;"
B >75D37("C2D'G"m"#l#"if6f6#"
B 9F86.275:">7=38875:"Z'D;'"
95'++F5'"W9>Z9X"o"!U"
66Q;"
Patrick J. Lynch, Wikimedia Commons
B ^.5<783<:"=53.5"<."5'='5@F+3.2"
<-'57=:"L"PcYUcp"
B ,3;2+b"
B
B
B
B
B
B
B
>..8R"6._8'D"+/32"
?7(-:=2'7"
9F86.275:"*7+(F875"(.2;'+).2""
Q:=.<'2+3.2"
e8<'5'D"6'2<78"+<7<F+"
4755.I'D"=F8+'"=5'++F5'"
H78'+R"6F56F5"
JA"

44. >75D3.;'23(",-.(/""
• >75D3.;'23(",-.(/"V).8.;:"
– e(F<'"^:.(75D378"C2@75().2"We^CX"
– ,'=+3+"
– ^:.(75D3)+"
– ^:.(75D378">.2<F+3.2"
– e(F<'"e.5)("C2+F`(3'2(:"
– e.5)(".@"^3<578",<'2.+3+"
– Q:='5<5.=-3(">75D3.6:.=7<-:"
JJ"

45. >75D3.;'23(",-.(/"
• $n'2"5'+F8<+"@5.6"6:.(75D378"3+(-'637"
I3<-"8.++".@"8'n"*'2<53(F875"WiNX"@F2().2"
– >8323(78"+-.(/"'2+F'+"7n'5"8.++".@"Jcp"iN"
• H'+F8)2;"(75D37(".F<=F<"5'DF().2"8'7D+"
<."87()("7(3D.+3+"72D"-:=.G37"
• ,<5./'"*.8F6'"3+"5'DF('D""
– ?7(-:(75D37"D'*'8.=+"7+"(.6='2+7).2"@.5"
D'(5'7+'D",N"<."6732<732"(75D37(".F<=F<""
– C+(-'637"72D"32@75().2"I.5+'2+"(5'7)2;"
D.I2I75D"+=3578"
JP"

46. >75D3.;'23(",-.(/"Y"037;2.+3+"
• Vt["
• >MH"
• i7%.57<.5:b""
– >.6=8'<'"K8..D">.F2<"
– >-'63+<5:"972'8"WV8'(<5.8:<'+R"Kj4f>HX"
– >75D37("'2g:6'+"W^:.;8.%32R">tR">tY^KR"?5.=.232X"
– >.7;F87).2"+<FD3'+"
• V(-.(75D3.;576"
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47. >75D3.;'23(",-.(/"Y"?5'7<6'2<"
• ?5'7<6'2<"[.78+"
– e35I7:"(.2<5.8"W3@"2'('++75:X"
– C6=5.*32;"6:.(75D378"=F6="@F2().2"
– H'='5@F+3.2"W3@"7*7387%8'X"
– 95'*'2)2;"@F5<-'5"6:.(75D378"D767;'"
• ^.23<.532;""
– >75D37("6.23<.5"
– 9F8+'"$G36'<5:"
• ,F==8'6'2<78".G:;'2R"CN"7(('++"
• C2<F%7).2"D'(5'7+'+"=5'8.7D"72D"(7F+'+"
-:=.<'2+3.2"""
– ^7:"2''D"<.";3*'"F3D"%.8F+"<."(.6='2+7<'"3@"32<F%7)2;"
JT"

48. >75D3.;'23(",-.(/"Y"?5'7<6'2<"
• e^C"
– e+=3532R"K'<7Y%8.(/'5R"^.5=-32'R"Q'=7532"
– 43<5.;8:('532"@.5"=732"(.2<5.8"W7*.3D"32"32@'53.5"^CX"
– C@"2."=F86.275:"'D'67R"67:"<5:"CN"F3D"@.5"K9"+F==.5<"
– C@"=F86.275:"'D'67"
• 0.=7632'"O"I388"x"QH"72D"<-F+"(75D37("I.5/"
• 0.%F<7632'"O"^7:"D5.="%8..D"=5'++F5'"DF'"<."='53=-'578"
*7+.D387<7).2"
• >.6%327).2"<-'57=:"67:"%'"6.5'"'a'()*'"
– H'='5@F+3.2"?-'57=:"W3@",?V^C"72D"7*7387%8'"32"<-'"(8323(78"
+'y2;X"
• >75D37("(7<-'<'53g7).2"I3<-"32<'5*'2).2""
• ?-5.6%.8:)(+"
"
JU"

49. 4'F5.;'23(",-.(/"
• H'+F8<+"@5.6"+=3278"(.5D"32&F5:"I3<-"+-.(/"
87+)2;"@5.6"!YA"I''/+"
• i.++".@"+:6=7<-')("<.2'"72D"5'+F8<72<"
F2.==.+'D"*7;78"<.2'"
• 0'(5'7+'D"*7+.6.<.5"<.2'""
• H'+F8<+"32"-:=.<'2+3.2"72D"%57D:(75D37"
• 97)'2<+"67:"5'6732"78'5<R"I756R"72D"D5:"
D'+=3<'"<-'"-:=.<'2+3.2"
• ,=3278"+-.(/"
– ?'6=.575:"8.++".@"+=3278"5''G"7()*3<:"
%'8.I"7"<.<78".5"2'75"<.<78"+=3278"(.5D"
32&F5:"
– 4.<"<-'"+76'"7+"2'F5.;'23("+-.(/R"<-'"
<'56+"75'"2.<"32<'5(-72;'7%8'"
gunkyboy, Wikimedia Commons
J]"

50. 4'F5.;'23(",-.(/Y"?5'7<6'2<"
• eRKR>+"
– H'6'6%'5">Y+=32'"=5'(7F).2+"
– Q3;-">Y+=32'"32&F53'+"5'EF35'"6'(-723(78"*'2)87).2""
• >AY>JY>P"O"9-5'23("4'5*'"322'5*7).2"
• d8F3D"5'+F+(3<7).2"
– t''="^e9"7<"UPY]c"66"Q;"@.5"15+<"T"D7:+"
– ^32363g'"+'(.2D75:"(.5D"32&F5:"
– C@"(5:+<788.3D"3+"32+F`(3'2<"F+'"*7+.=5'++.5+"
• ,'75(-"@.5".<-'5"(7F+'+".@"-:=.<'2+3.2"
– $n'2R",>C"5'+F8<+"@5.6"<57F67"L"5f."Q'6.55-7;3(",-.(/"
• d.5"%57D:(75D37"
– e<5.=32'"
– 97('67/'5""
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51. $%+<5F()*'",-.(/"
•
•
•
•
?'2+3.2"92'F6.<-.57G"
>75D37("?76=.27D'"
9F86.275:"V6%.83+6"
,'*'5'"e.5)(",<'2.+3+"
P!"

52. $%+<5F()*'",-.(/"
B ?'2+3.2"=2'F6.<-.57G"
Delldot, Wikimedia Commons
Source:
www.meddean.luc.edu/lumenMedEd/medicine/
pulmonar/cxr/pneumo1.htm
B e35"<57=='D"32"=8'F578"+=7('"I3<-"!"
I7:"*78*'R"735f=5'++F5'"%F38D+"F="
B ^'D37+)2F6"+-3n'D"36='D32;"
*'2.F+"5'<F52"
B >-'+<"=732R",$KR"D'(5'7+'D"%5'7<-"
+.F2D+"
B 4."<'+<+"2''D'Df(8323(78"D37;2.+3+"
B ?5'7<6'2<b"4''D8'"D'(.6=5'++3.2"
@.88.I'D"%:"(-'+<"<F%'"
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53. $%+<5F()*'",-.(/"
9'53(75D3F6"
K8..D"
V=3(75D3F6"
Aceofhearts1968, Wikimedia Commons
B >75D37("<76=.27D'"
B K8..D"32"='53(75D378"+7("=5'*'2<+"
*'2.F+"5'<F52"<."72D"(.2<57().2".@"
-'75<"
B V).8.;:b""?57F67R"9'53(75D3)+R"^C"
B K'(/q+"<537Db""
B Q:=.<'2+3.2R"6Fz'D"-'75<"+.F2D+R"hN0"
B 037;2.+3+b"i75;'"-'75<">MHR"'(-."
B ?5'7<6'2<b"9'53(75D3.('2<'+3+"
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54. $%+<5F()*'",-.(/"
• 9F86.275:"'6%.83+6"
– N35(-.I"<537Db""
• Q:='5(.7;F87%8'"
• N'2.F+"32&F5:"
• N'2.+<7+3+"
– ,3;2+b""
• ?7(-:=2'7""
• ?7(-:(75D37"
• Q:=.G37"
– i.I"53+/b"0YD36'5"
– Q3;-'5"53+/b">?"(-'+<".5"Nk"
+(72"
– ?5'7<6'2<b""Q'=7532"
Hellerhoff, Wikimedia Commons
• >.2+3D'5"<-5.6%.8:)(+"3@"+-.(/"
@5.6"9V"
PJ"

55. $%+<5F()*'",-.(/"
B e.5)("+<'2.+3+"
B H'+3+<72('"<."+:+<.83("'&'().2"(7F+'+"D'(5'7+'D"
(75D37("@F2().2"
B >-'+<"=732"I3<-"+:2(.='"
B ,:+<.83("'&'().2"6F56F5"
B 0'123)*'"D37;2.+3+"I3<-"'(-."
B N7+.D387<.5+"W4?[X"I388"D5.="=5'++F5'"
B ?5'7<6'2<b"e.5)("*78*'"+F5;'5:"
PP"

56. Z-3(-"=5'++.5"+-.F8D"C"(-..+'r"
! Q:=.*.8'63("+-.(/"
– Fluids and Blood
! >75D3.;'23("+-.(/"
– Dobutamine - !1 agonist
! Increases squeeze and
heart rate
! 4'F5.;'23("+-.(/"
– Fluids, phenylephrine, Levophed,
look for another type of shock if
it is persistent
! e27=-:87()("+-.(/"
– Fluids and epinephrine
! ,'=)("+-.(/"
– Neosynephrine - alpha agonist
! Increases SVR by
arteriolar constriction
– Norepinephrine/Levophed - alpha
and beta agonists
! 0.=7632'"
– Low Dose - increases renal blood
supply
– Medium Dose - beta effects
(increases heart rate and squeeze)
– High Dose - alpha effects
(arteriolar constriction)
PS"

57. kF'+).2+r"
Dkscully, Flickr
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