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Application example

The face of shock

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Youtube link

  • https://youtu.be/7GLNJ5bwNy4

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Rebecca

  • 35 year-old female brought to the ER by ambulance after being found in her home unconscious by her 10 year old daughter returning from school. Recent history of “stomach upset” according to the patient’s daughter.
  • Examination: Drowsy/difficult to rouse; peripherally shut down with slow capillary refill to extremities, very dry mucous membranes. Respirations are deep and sighing, she has a funny odour. Patient has been incontinent of urine
  • VS: 36.9-130-26-90/60-100% by EMS, now 30 min later 36.9-138-28-80/46-100%
  • Foley catheter inserted for 500 ml very pale urine. Urine drug screen negative.
  • ABG/lab results:
  • pH 7.05 (7.35-7.45)
  • pCO2 11 mmHg (35-45)
  • PO2 187 mmHg (>80)
  • Bicarb 6.0 mmol/L (22-28)
  • Lytes:
  • K 5.7 mmol/L (3.5-5)
  • Na 141mmol/L (135-145)
  • Cl 96 mmol/L (95-105)

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Let’s analyze

VS

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Let’s analyze

ABGs

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Let’s analyze

Lytes

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Quick Reminder: Shock

  • Fundamentally a lack of oxygen at the cellular level
  • Inability of circulatory system to supply adequate oxygen and nutrients to tissues d/t:

1) ineffective cardiac pump (cariogenic = “engine won’t work”)

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2) ineffective circulatory system (distributive = “vessels too big” [i.e., you’re trying to put out a fire by attaching a fire hose to the kitchen tap] = anaphylactic, neurogenic, septic)

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3) inadequate blood volume (hypovolemic = empty tank)

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3 Stages of Shock

  • Compensatory
    • Specific to each type of shock
    • Priority is to treat underlying disorder
    • Relies upon mechanisms of homeostasis
  • Progressive
  • Irreversible

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Hypovolemic Shock

  • Causes: loss of fluid or blood from body, third spacing of fluid or blood
  • Self-preservation = compensation through homeostatic mechanisms
  • Survival mechanism: vasoconstriction and fluid retention should maintain BP until “leak” is identified and rectified

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Compensatory Stage

  • BP can be normal (except early Septic shock)
  • HR & RR
  • Cold peripheries, clammy
  • Urinary output but NOT < 30mls
  • Diminished bowel sounds
  • Anxious, restless
  • If resp. alkalosis develops = confusion & aggression

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What is the underlying mechanism?

  • Am I seeing shock? What stage?
  • What type and what is the etiology?
  • What’s missing here?

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  • AND WHAT CAN I DO IN THE MEANTIME?
  • Continuous cardiac monitoring and 12 lead ECG
  • IV access
  • Full assessment including neurological assessment
  • Do I have the people, equipment and medications I may need on hand?
  • Check BS

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Blood sugar

  • All patients who are difficult to rouse or show any change in LOC should have BS checked
  • All patients whose “clinical picture” has not yet revealed itself (you’re still wondering what’s going on) should have BS checked
  • Always quick glucometer reading followed by lab specimen
  • Rebecca’s BS is 32

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Let’s go through what we know

  • High BS
  • Increased UO
  • Dry mucous membranes
  • Tachy, hypotensive, tachypnic
  • Funny smell
  • Recent history of “upset stomach”

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DKA

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Try an ISBAR report

  • I - introduce
  • S - situation
  • B - background
  • A - assessment
  • R - recommendation

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Recommendation

  • IV NS bolus to rehydrate and bring up her BP
  • Insulin drip to bring down her BS, with q1h glucometer readings
  • Continuous cardiac monitoring
  • Consider if Calcium gluconate is needed to protect heart from hypokalemia (how can that be if her K is 5.7??? Should we correct the hyperkalemia??? NO)
  • Critical recommendation- observe K, repeat q 1 h, do not treat high K as insulin will drive K into the cell and K will drop (often leading to hypokalemia)
  • Must be seen immediately by MD/NP

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A good youtube on DKA as medical emergency

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