🚨 Shock

Shock is a life-threatening condition of circulatory failure leading to inadequate tissue perfusion and cellular hypoxia. It is classified into hypovolaemic, cardiogenic, distributive (septic, anaphylactic, neurogenic), and obstructive types. Rapid recognition and targeted management are crucial to prevent multi-organ failure and death.

Key signs include hypotension (systolic BP <90 mmHg or MAP <65 mmHg), tachycardia, tachypnoea, altered mental status, and oliguria. Clinical features vary by type: cool/clammy skin in hypovolaemic/cardiogenic, warm/flushed in early septic shock. Always consider the underlying cause.

A: Ensure airway patency, consider early intubation if GCS dropping. B: Assess breathing rate, effort, oxygen saturation; administer high-flow oxygen. C: Assess pulse, blood pressure, capillary refill, JVP, and auscultate heart sounds. Insert two large-bore IV cannulae. D: Assess conscious level (AVPU/GCS), pupillary response, and focal neurology. E: Expose patient fully, check temperature, look for sources of bleeding/infection.

Persistent hypotension despite fluid resuscitation, worsening altered mental status, increasing lactate, oliguria, or signs of multi-organ dysfunction. Failure to respond to initial interventions or rapid deterioration are critical indicators for escalation.

Bedside: Pulse oximetry, continuous cardiac monitoring, blood pressure monitoring, blood glucose, arterial blood gas (lactate, pH). Bloods: FBC, U&Es, LFTs, coagulation screen, Group & Save, cardiac enzymes, blood cultures (if sepsis suspected). Imaging: Chest X-ray, ECG, focused ultrasound (FAST scan in trauma, ECHO in cardiogenic shock).

Secure airway and provide high-flow oxygen. Establish IV access and administer intravenous fluids (e.g., crystalloids) as appropriate for the type of shock, guided by clinical response. Consider vasopressors (e.g., noradrenaline) if fluid resuscitation is insufficient. Treat the underlying cause: antibiotics for sepsis, blood products for haemorrhage, inotropes for cardiogenic shock, relieve obstruction.

Immediate senior medical review (Registrar/Consultant) for any patient in shock. Critical care (HDU/ICU) admission is almost always required for ongoing monitoring, vasopressor support, and complex management. Surgical or specialist consultation may be needed depending on the underlying cause (e.g., trauma, ruptured aneurysm).

Remember the '4 Ds' of shock: Decreased perfusion, Decreased oxygen delivery, Decreased cellular function, Death. Sepsis is a common cause of distributive shock in the UK. Always consider anaphylaxis if there's a history of allergen exposure and widespread rash/bronchospasm. Early lactate measurement is crucial for prognosis and guiding resuscitation.