Introduction:

• It is condition in which there is acute circulatory failure leading to inadequate end organ tissue perfusion

Diagnosis:

• Cold, clammy peripheries
• Systolic BP- <90mmHg (Mean arterial BP <60mmHg)
• Oliguria (<20ml/hr)
• Altered sensorium
• Abnormal lab values: Elevated serum lactate, metabolic acidosis

Management:

• Overall goal is to reverse the tissue hypoperfusion as quickly as possible
• Start IV line with 2 large bore canulae
• IV Normal saline 500ml- Fast (Continue fluid rescuscitation if required. If still hypotensive, shift to ICU start dopamine/ noradrenaline)
• Establish airway- Intubate and ventilate if necessary
• Monitor vitals
• Hourly urine output- Aim at urine output- 0.5-1ml/kg/hr
• Sodium bicarbonate to maintain pH >7.2
• Ensure hemoglobin is >10gm/dL
• Investigations-
  • ABG
  • ECG- Acute coronary event
  • Chest X Ray- Cardiomegaly, Pneumothorax, Pneumonia, Pulmonary edema, atelectasis
  • Cardiac enzymes
  • 2D Echo
  • CBC, Electrolytes, LFT, RFT, Coagulation profile
  • Blood culture if septic shock is suspected
  • Cross match blood
  • Insert Foley's catheter to measure the output
  • Urine routine with ketone bodies
  • Pregnancy test
  • Bedside USG
• Further management depending on type
• Treatment of cause

Differentiation of each type of shock:

Septic Shock:

Management:

• IV Antibiotics
• Identify the septic focus and treat
• Fluids: NS- 20ml/kg within 1st 30min up to 50-100ml/kg till volume replacement is adequate
• Vasopressors to be considered to maintain vital organ perfusion
• Refer "Febrile neutropenia"

Cardiogenic shock:

Causes: Acute coronary syndrome, myocarditis, cardiomyopathy, acute valve dysfunction, arrythmia, cardiac tamponade, pulmonary embolism

Management:

• Vasopressors
  • Dopamine: 5 microgm/kg/min to 15 microgm/kg/min 
  • Dobutamine: 5 microgm/kg/min to 20 microgm/kg/min
  • Noradrenaline: 10-15microgm/min
  • Adrenaline: 0.1microgm/kg/min- 0.3 microgm/kg/min
• Bradyarrythmias: Atropine and pacing
• Tachyarrythmias: DC shock, IV arrythmics
• Treatment of cause

Hypovolemic shock:

Causes: Gastroenteritis, decreased oral intake, blood loss, heat related intravascular volume depletion, fluid sequestration in abdomen

Management:

• RL- 500ml in first 30min, continue RL/NS till urine output is established or BP is restored
• Blood transfusion- If there is acute blood loss
• If urine output is not established even after adequate hydration, impending ATN should be suspected. Give IV. Frusemide- 20mg IV Stat or IV Mannitol 200ml stat to open up the kidneys
• Tackle if there is any active bleeding- Refer massive bleeding protocol

Anaphylactic shock:

Clinical features: Lacrimation, pruritus- urticaria, nausea/ vomiting, abdominal pain, hypotension, dyspnea, stridor, seizures, cardiac arrest

Management:

• Inj. Adrenaline- 1:1000- 1 ml (1mg/1ml) SC/IM Stat, repeat every 20 min as required (Children 0.01ml/kg/dose- 1in1000-IM/SC)
• Volume expansion- 500-1000ml- NS over 30min 
• Inj. Hydrocortisone- 500mg- IV stat and then 6hrly till recovery
• Inj. Avil- 1amp- IV stat- and then 6hrly till recovery
• Inhaled beta 2 agonists for bronchospasm- Salbutamol
• Inj. Aminophylline- 250mg diluted in 20ml D5%, given as slow infusion over 20min. 
• Intubation if there is impending respiratory collapse
• If laryngeal edema prevents intubation, plan for emergency tracheostomy
• Admit for 6-8hrs and discharge with Tab. Prednisolone- 50mg-OD and T. Loratadine- 10mg- OD