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<p>Assessment of shock</p><p>Straight to the point of care</p><p>Last updated: Feb 14, 2024</p><p>Table of Contents</p><p>Overview 3</p><p>Summary 3</p><p>Theory 4</p><p>Aetiology 4</p><p>Emergencies 6</p><p>Urgent considerations 6</p><p>Diagnosis 11</p><p>Approach 11</p><p>Differentials overview 16</p><p>Differentials 18</p><p>Guidelines 29</p><p>Evidence tables 32</p><p>References 36</p><p>Images 46</p><p>Disclaimer 48</p><p>Assessment of shock Overview</p><p>Summary</p><p>Shock is best defined as a state of reduced end-organ oxygenation caused by an imbalance between tissue</p><p>oxygen delivery and demand resulting in an oxygen debt.</p><p>Oxygen delivery is determined by cardiac output, vascular integrity, and oxygen content of the blood. Oxygen</p><p>content is a composite of haemoglobin and arterial oxygen saturation, and the cardiac output is a product of</p><p>stroke volume and heart rate. Stroke volume is affected by preload (filling), left ventricular contractility (pump</p><p>function), and afterload as measured by the systemic vascular resistance.</p><p>Differences in the preload, afterload, and contractility generally differentiate the aetiologies of shock. These</p><p>are broadly classified into hypovolaemic, cardiogenic, obstructive, and distributive types.[1]</p><p>Basic pathophysiology</p><p>Whatever the aetiology, shock is characterised by release of cytokines and other inflammatory mediators that</p><p>cause a systemic inflammatory response syndrome mediated by tissue hypoxia. This causes alterations in</p><p>flow at the level of the microcirculation that can usually be reversed by intravascular volume resuscitation</p><p>and, as appropriate, vasopressor and inotropic support.[2] [3] [4]</p><p>Outcome</p><p>Shock passes through an early reversible stage of compensated shock where the body's homeostatic</p><p>mechanisms compensate for decreased perfusion by increasing the rate and force of contraction of the</p><p>heart, initially maintaining arterial blood pressure (BP). The circulation is centralised, due to peripheral</p><p>vasoconstriction, so that blood flow to non-vital organs (commonly skin) is reduced. Respiratory rate</p><p>increases to compensate for metabolic acidosis and urine output falls (to conserve fluid volume) as a</p><p>result of release of antidiuretic hormone from the posterior pituitary. These adaptive responses may not be</p><p>apparent to the casual observer. Unrecognised, this evolves to overt shock manifested by decreased BP</p><p>and altered mental status attributable to reduced cerebral blood flow. This usually occurs in the setting of an</p><p>effective loss ≥30% of plasma volume and/or cardiac index of 6 to 12 hours) this causes irreversible cellular damage. This is clinically manifest as multi-organ</p><p>dysfunction and/or failure with increased mortality.</p><p>Mortality from shock varies between 23% and 70%, depending on the type of shock and the duration of</p><p>tissue hypoperfusion.[5] [6] [7]</p><p>O</p><p>VERVIEW</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>3</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Theory</p><p>TH</p><p>EO</p><p>RY</p><p>Aetiology</p><p>Shock can be classified into 4 major types.</p><p>Hypovolaemic</p><p>Associated with decreased cardiac preload (blood return to the right ventricle due to low vascular volume),</p><p>which could be due to:</p><p>Haemorrhage</p><p>• Overt, as in gastrointestinal bleeding or trauma</p><p>• Concealed, such as aortic aneurysm rupture, retroperitoneal bleeding, soft tissue bleeding associated</p><p>with long-bone fractures, or traumatic body cavity bleeds.</p><p>Fluid depletion</p><p>• Gastrointestinal losses, such as diarrhoea, vomiting</p><p>• Insensible losses, such as burns</p><p>• Third-space losses, such as major surgery, pancreatitis, intestinal obstruction</p><p>• Excessive heat or exercise exposure without fluid replacement.</p><p>Decreased preload results in decreased cardiac output due to ineffective heart filling. The physiological</p><p>reaction to this condition is diversion of blood from the splanchnic (peripheral) circulation areas to vital</p><p>organs by increasing systemic vascular resistance (SVR).</p><p>Cardiogenic</p><p>Results from heart pump dysfunction (more commonly left-sided) causing a decrease in cardiac output.</p><p>Compensatory surges in catecholamines lead to increased SVR. However, in some instances (especially</p><p>acute coronary syndrome), decreased SVR may be observed.[8] Early, aggressive management can lead to</p><p>improved outcome.[9] Myocardial infarction, viral and alcoholic cardiomyopathies, congestive heart failure,</p><p>and cardiac valvular lesions are some of the main contributors.</p><p>Patients with a history of hypertension or heart disease who are being treated with a beta-blocker, a calcium-</p><p>channel blocker, or a class 1c anti-arrhythmic such as flecainide may be at risk due to pharmacological</p><p>suppression of cardiac contractility and alteration of electrical depolarisation of automatic myocardial</p><p>contraction mechanisms.</p><p>Obstructive</p><p>Secondary to an obstruction to cardiac flow or filling</p><p>• Flow restriction: pulmonary embolism or severe pulmonary hypertension. Usually accompanied by</p><p>decreased oxygenation with very minimal physical signs.</p><p>• Filling restriction: cardiac tamponade or tension pneumothorax. Classically cardiac tamponade</p><p>presents with raised jugular venous pressure, muffled heart sounds, and low blood pressure. Pulsus</p><p>paradoxus or electrical alternans may also be apparent. Physical findings with tension pneumothorax</p><p>may include decreased unilateral breath sounds, hyper-resonance to percussion on the affected</p><p>side, and tracheal deviation to the opposite side from the pneumothorax. These conditions require</p><p>immediate attention.</p><p>4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Theory</p><p>Distributive</p><p>This is associated with significant vasodilation resulting in relative hypovolaemia (decreased cardiac preload)</p><p>and decreased SVR. The classic description of distributive shock includes an elevated cardiac output.</p><p>However, in a substantial percentage of septic shock patients with secondary distributive shock, depression</p><p>of cardiac contractility is observed.[10] Causes of distributive shock include sepsis, neurogenic shock,</p><p>adrenal insufficiency, anaphylaxis, thiamine deficiency, and arterial-venous fistula.</p><p>Combination</p><p>While the above classification can guide evaluation, a combination of the above processes can co-exist.</p><p>For example, septic shock may include a cardiogenic component (myocardial depression), an obstructive</p><p>component (disseminated intravascular coagulation with systemic microthrombosis), and a hypovolaemic</p><p>element (diffuse capillary leak).[8] Nevertheless, the goals of resuscitation are the same for any type of</p><p>shock: restoring oxygen delivery and reversing the tissue oxygen debt, thus normalising mixed venous</p><p>oxygen levels (SVO₂). Timely resuscitation, restoring the circulating volume,and addressing the underlying</p><p>cause for shock leads to much improved outcomes.[9] [11] [12] [13]</p><p>TH</p><p>EO</p><p>RY</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>5</p><p>https://bestpractice.bmj.com</p><p>Assessment</p><p>ratings</p><p>High The authors are very confident that the true</p><p>effect is similar to the estimated effect.</p><p>Moderate The authors are moderately confident that</p><p>the true effect is likely to be close to the</p><p>estimated effect.</p><p>Low The authors have limited confidence in the</p><p>effect estimate and the true effect may be</p><p>substantially different.</p><p>Very Low The authors have very little confidence in</p><p>the effect estimate and the true effect is</p><p>likely to be substantially different.</p><p>BMJ Best Practice EBM Toolkit: What is GRADE? (https://bestpractice.bmj.com/info/toolkit/learn-ebm/what-</p><p>is-grade/)</p><p>EVID</p><p>EN</p><p>C</p><p>E TA</p><p>B</p><p>LES</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>35</p><p>https://bestpractice.bmj.com/info/evidence-tables/</p><p>https://bestpractice.bmj.com/info/evidence-tables/</p><p>https://bestpractice.bmj.com/info/toolkit/learn-ebm/what-is-grade/</p><p>https://bestpractice.bmj.com/info/toolkit/learn-ebm/what-is-grade/</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock References</p><p>R</p><p>EF</p><p>ER</p><p>EN</p><p>C</p><p>ES</p><p>Key articles</p><p>• van Diepen S, Katz JN, Albert NM, et al. Contemporary management of cardiogenic shock: a scientific</p><p>statement from the American Heart Association. Circulation. 2017 Oct 17;136(16):e232-68. Full text</p><p>(https://www.doi.org/10.1161/CIR.0000000000000525) Abstract</p><p>• Shaker MS, Wallace DV, Golden DBK, et al. Anaphylaxis-a 2020 practice parameter update,</p><p>systematic review, and Grading of Recommendations, Assessment, Development and Evaluation</p><p>(GRADE) analysis. J Allergy Clin Immunol. 2020 Apr;145(4):1082-123. Full text (https://</p><p>www.jacionline.org/article/S0091-6749(20)30105-6/fulltext) Abstract</p><p>• Campbell RL, Li JT, Nicklas RA, et al. Emergency department diagnosis and treatment of anaphylaxis:</p><p>a practice parameter. Ann Allergy Asthma Immunol. 2014 Dec;113(6):599-608. Full text (https://</p><p>www.doi.org/10.1016/j.anai.2014.10.007) Abstract</p><p>• Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International</p><p>guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov</p><p>1;49(11):e1063-143. Full text (https://journals.lww.com/ccmjournal/Fulltext/2021/11000/</p><p>Surviving_Sepsis_Campaign__International.21.aspx) Abstract</p><p>• Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of clinical criteria for sepsis: for the Third</p><p>International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb</p><p>23;315(8):762-74. Abstract</p><p>References</p><p>1. Weil MH, Shubin H. Proposed reclassification of shock states with special reference to distributive</p><p>defects. Adv Exp Med Biol. 1971 Oct;23(0):13-23. Abstract (http://www.ncbi.nlm.nih.gov/</p><p>pubmed/5164840?tool=bestpractice.bmj.com)</p><p>2. De Backer D, Creteur J, Preiser JC, et al. Microvascular blood flow is altered in patients with sepsis.</p><p>Am J Respir Crit Care Med. 2002 Jul 1;166(1):98-104. Abstract (http://www.ncbi.nlm.nih.gov/</p><p>pubmed/12091178?tool=bestpractice.bmj.com)</p><p>3. Vincent JL, De Backer D. Microvascular dysfunction as a cause of organ dysfunction in severe</p><p>sepsis. Crit Care. 2005;9 Suppl 4:S9-12. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/16168075?</p><p>tool=bestpractice.bmj.com)</p><p>4. De Backer D, Creteur J, Dubois MJ, et al. The effects of dobutamine on microcirculatory alterations</p><p>in patients with septic shock are independent of its systemic effects. Crit Care Med. 2006</p><p>Feb;34(2):403-8. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/16424721?tool=bestpractice.bmj.com)</p><p>5. Hochman JS, Boland J, Sleeper LA, et al. Current spectrum of cardiogenic shock and effect of early</p><p>revascularization on mortality. Results of an International Registry. SHOCK Registry Investigators.</p><p>36 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://www.doi.org/10.1161/CIR.0000000000000525</p><p>https://www.doi.org/10.1161/CIR.0000000000000525</p><p>http://www.ncbi.nlm.nih.gov/pubmed/28923988?tool=bestpractice.bmj.com</p><p>https://www.jacionline.org/article/S0091-6749(20)30105-6/fulltext</p><p>https://www.jacionline.org/article/S0091-6749(20)30105-6/fulltext</p><p>http://www.ncbi.nlm.nih.gov/pubmed/32001253?tool=bestpractice.bmj.com</p><p>https://www.doi.org/10.1016/j.anai.2014.10.007</p><p>https://www.doi.org/10.1016/j.anai.2014.10.007</p><p>http://www.ncbi.nlm.nih.gov/pubmed/25466802?tool=bestpractice.bmj.com</p><p>https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx</p><p>https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx</p><p>http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/26903335?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/5164840?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/5164840?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/12091178?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/12091178?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/16168075?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/16168075?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/16424721?tool=bestpractice.bmj.com</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock References</p><p>Circulation. 1995 Feb 1;91(3):873-81. Full text (https://circ.ahajournals.org/content/91/3/873.full)</p><p>Abstract (http://www.ncbi.nlm.nih.gov/pubmed/7828316?tool=bestpractice.bmj.com)</p><p>6. Bone RC. Toward an epidemiology and natural history of SIRS (systemic inflammatory response</p><p>syndrome). JAMA. 1992 Dec 23-30;268(24):3452-5. Abstract (http://www.ncbi.nlm.nih.gov/</p><p>pubmed/1460735?tool=bestpractice.bmj.com)</p><p>7. Gitz Holler J, Jensen HK, Henriksen DP, et al. Etiology of shock in the emergency department:</p><p>a 12-year population-based cohort study. Shock. 2019 Jan;51(1):60-7. Full text (https://</p><p>www.doi.org/10.1097/SHK.0000000000000816) Abstract (http://www.ncbi.nlm.nih.gov/</p><p>pubmed/27984523?tool=bestpractice.bmj.com)</p><p>8. Hochman JS. Cardiogenic shock complicating acute myocardial infarction: expanding the</p><p>paradigm. Circulation. 2003 Jun 24;107(24):2998-3002. Full text (https://circ.ahajournals.org/</p><p>content/107/24/2998.full) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/12821585?</p><p>tool=bestpractice.bmj.com)</p><p>9. Hochman JS, Buller CE, Sleeper LA, et al. Cardiogenic shock complicating acute myocardial</p><p>infarction - etiologies, management and outcome: a report from the SHOCK Trial Registry. SHould</p><p>we emergently revascularize Occluded Coronaries for cardiogenic shocK? J Am Coll Cardiol.</p><p>2000 Sep;36(3 Suppl A):1063-70. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/10985706?</p><p>tool=bestpractice.bmj.com)</p><p>10. Vieillard-Baron A, Caille V, Charron C, et al. Actual incidence of global left ventricular hypokinesia</p><p>in adult septic shock. Crit Care Med. 2008 Jun;36(6):1701-6. Abstract (http://www.ncbi.nlm.nih.gov/</p><p>pubmed/18496368?tool=bestpractice.bmj.com)</p><p>11. Hochman JS, Sleeper LA, Webb JG, et al; SHOCK Investigators. Early revascularization in acute</p><p>myocardial infarction complicated by cardiogenic shock. N Engl J Med. 1999 Aug 26;341(9):625-34.</p><p>Full text (https://www.nejm.org/doi/full/10.1056/NEJM199908263410901#t=article) Abstract (http://</p><p>www.ncbi.nlm.nih.gov/pubmed/10460813?tool=bestpractice.bmj.com)</p><p>12. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis</p><p>and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77. Full text (https://www.nejm.org/doi/</p><p>full/10.1056/NEJMoa010307#t=article) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/11794169?</p><p>tool=bestpractice.bmj.com)</p><p>13. Sebat F, Johnson D, Musthafa AA, et al.</p><p>A multidisciplinary community hospital program for early and</p><p>rapid resuscitation of shock in nontrauma patients. Chest. 2005 May;127(5):1729-43. Abstract (http://</p><p>www.ncbi.nlm.nih.gov/pubmed/15888853?tool=bestpractice.bmj.com)</p><p>14. Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N</p><p>Engl J Med. 2018 Mar 1;378(9):829-39. Full text (https://www.doi.org/10.1056/NEJMoa1711584)</p><p>Abstract (http://www.ncbi.nlm.nih.gov/pubmed/29485925?tool=bestpractice.bmj.com)</p><p>15. Lewis SR, Pritchard MW, Evans DJ, et al. Colloids versus crystalloids for fluid resuscitation in</p><p>critically ill people. Cochrane Database Syst Rev. 2018 Aug 3;(8):CD000567. Full text (https://</p><p>R</p><p>EFER</p><p>EN</p><p>C</p><p>ES</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>37</p><p>https://circ.ahajournals.org/content/91/3/873.full</p><p>http://www.ncbi.nlm.nih.gov/pubmed/7828316?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/7828316?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/1460735?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/1460735?tool=bestpractice.bmj.com</p><p>https://www.doi.org/10.1097/SHK.0000000000000816</p><p>https://www.doi.org/10.1097/SHK.0000000000000816</p><p>http://www.ncbi.nlm.nih.gov/pubmed/27984523?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/27984523?tool=bestpractice.bmj.com</p><p>https://circ.ahajournals.org/content/107/24/2998.full</p><p>https://circ.ahajournals.org/content/107/24/2998.full</p><p>http://www.ncbi.nlm.nih.gov/pubmed/12821585?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/12821585?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/10985706?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/10985706?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/18496368?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/18496368?tool=bestpractice.bmj.com</p><p>https://www.nejm.org/doi/full/10.1056/NEJM199908263410901#t=article</p><p>https://www.nejm.org/doi/full/10.1056/NEJM199908263410901#t=article</p><p>http://www.ncbi.nlm.nih.gov/pubmed/10460813?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/10460813?tool=bestpractice.bmj.com</p><p>https://www.nejm.org/doi/full/10.1056/NEJMoa010307#t=article</p><p>https://www.nejm.org/doi/full/10.1056/NEJMoa010307#t=article</p><p>http://www.ncbi.nlm.nih.gov/pubmed/11794169?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/11794169?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/15888853?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/15888853?tool=bestpractice.bmj.com</p><p>https://www.doi.org/10.1056/NEJMoa1711584</p><p>http://www.ncbi.nlm.nih.gov/pubmed/29485925?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/29485925?tool=bestpractice.bmj.com</p><p>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513027</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock References</p><p>R</p><p>EF</p><p>ER</p><p>EN</p><p>C</p><p>ES</p><p>www.ncbi.nlm.nih.gov/pmc/articles/PMC6513027) Abstract (http://www.ncbi.nlm.nih.gov/</p><p>pubmed/30073665?tool=bestpractice.bmj.com)</p><p>16. Napolitano LM, Cohen MJ, Cotton BA, et al. Tranexamic acid in trauma: how should we use</p><p>it? J Trauma Acute Care Surg. 2013 Jun;74(6):1575-86. Abstract (http://www.ncbi.nlm.nih.gov/</p><p>pubmed/23694890?tool=bestpractice.bmj.com)</p><p>17. Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding</p><p>and coagulopathy following trauma: fifth edition. Crit Care. 2019 Mar 27;23(1):98. Full text (https://</p><p>www.doi.org/10.1186/s13054-019-2347-3) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/30917843?</p><p>tool=bestpractice.bmj.com)</p><p>18. Ker K, Roberts I, Shakur H, et al. Antifibrinolytic drugs for acute traumatic injury. Cochrane</p><p>Database Syst Rev. 2015 May 9;(5):CD004896. Full text (https://onlinelibrary.wiley.com/</p><p>doi/10.1002/14651858.CD004896.pub4/full) Abstract (http://www.ncbi.nlm.nih.gov/</p><p>pubmed/25956410?tool=bestpractice.bmj.com)</p><p>19. CRASH-2 collaborators, Roberts I, Shakur H, Afolabi A, et al. 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Circulation. 2017 Oct 17;136(16):e232-68. Full</p><p>text (https://www.doi.org/10.1161/CIR.0000000000000525) Abstract (http://www.ncbi.nlm.nih.gov/</p><p>pubmed/28923988?tool=bestpractice.bmj.com)</p><p>22. Pilarczyk K, Werdan K, Russ M et al. The German-Austrian S3 guideline "cardiogenic shock due to</p><p>myocardial infarction: diagnosis, monitoring, and treatment". Thorac Cardiovasc Surg. 2020 Dec 24.</p><p>Full text (https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0040-1719155) Abstract</p><p>(http://www.ncbi.nlm.nih.gov/pubmed/33368106?tool=bestpractice.bmj.com)</p><p>23. Werdan K, Boeken U, Briegel MJ et al. Short version of the 2nd edition of the German-Austrian S3</p><p>guidelines "Cardiogenic shock complicating myocardial infarction-diagnosis, monitoring and treatment"</p><p>Anaesthesist. Jan 2021;70(1):42-70. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/32997208?</p><p>tool=bestpractice.bmj.com)</p><p>24. De Luca G, Dirksen MT, Spaulding C, et al. Drug-eluting vs bare-metal stents in primary angioplasty: a</p><p>pooled patient-level meta-analysis of randomized trials. Arch Intern Med. 2012 Apr 23;172(8):611-21;</p><p>discussion 621-2. Full text (https://www.doi.org/10.1001/archinternmed.2012.758) Abstract (http://</p><p>www.ncbi.nlm.nih.gov/pubmed/22529227?tool=bestpractice.bmj.com)</p><p>38 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. 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Khorsandi M, Dougherty S, Bouamra O, et al. Extra-corporeal membrane oxygenation for refractory</p><p>cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis. J Cardiothorac</p><p>Surg. 2017 Jul 17;12(1):55. Full text (https://www.doi.org/10.1186/s13019-017-0618-0) Abstract</p><p>(http://www.ncbi.nlm.nih.gov/pubmed/28716039?tool=bestpractice.bmj.com)</p><p>26. Shaker MS, Wallace DV, Golden DBK, et al. Anaphylaxis-a 2020 practice parameter update,</p><p>systematic review, and Grading of Recommendations, Assessment, Development and Evaluation</p><p>(GRADE) analysis. J Allergy Clin Immunol. 2020 Apr;145(4):1082-123. Full text (https://</p><p>www.jacionline.org/article/S0091-6749(20)30105-6/fulltext) Abstract (http://www.ncbi.nlm.nih.gov/</p><p>pubmed/32001253?tool=bestpractice.bmj.com)</p><p>27. Campbell RL, Li JT, Nicklas RA, et al. Emergency department diagnosis and treatment of anaphylaxis:</p><p>a practice parameter. 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National Institute for Health and Care Excellence. Anaphylaxis: assessment and referral after</p><p>emergency treatment. Aug 2020 [internet publication]. Full text (https://www.nice.org.uk/guidance/</p><p>cg134)</p><p>90. Sampson HA, Mendelson L, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in</p><p>children and adolescents. N Engl J Med. 1992 Aug 6;327(6):380-4. Full text (https://www.nejm.org/</p><p>doi/10.1056/NEJM199208063270603?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub</p><p>%20%200www.ncbi.nlm.nih.gov) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/1294076?</p><p>tool=bestpractice.bmj.com)</p><p>R</p><p>EFER</p><p>EN</p><p>C</p><p>ES</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>45</p><p>https://www.nice.org.uk/guidance/cg134</p><p>https://www.nice.org.uk/guidance/cg134</p><p>https://www.nejm.org/doi/10.1056/NEJM199208063270603?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov</p><p>https://www.nejm.org/doi/10.1056/NEJM199208063270603?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov</p><p>https://www.nejm.org/doi/10.1056/NEJM199208063270603?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov</p><p>http://www.ncbi.nlm.nih.gov/pubmed/1294076?tool=bestpractice.bmj.com</p><p>http://www.ncbi.nlm.nih.gov/pubmed/1294076?tool=bestpractice.bmj.com</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Images</p><p>IM</p><p>AG</p><p>ES</p><p>Images</p><p>Figure 1: Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) criteria</p><p>Created by BMJ, adapted from Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ</p><p>Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on</p><p>Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med.</p><p>1996;22:707-710.</p><p>46 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Images</p><p>Figure 2: Parameters to differentiate between types of shock and examples</p><p>Adapted with permission from 'Rady MY. Bench-to-bedside review: Resuscitation in the emergency</p><p>department. Crit Care. 2005;9:170-176'.</p><p>IM</p><p>AG</p><p>ES</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>47</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Disclaimer</p><p>D</p><p>IS</p><p>C</p><p>LA</p><p>IM</p><p>ER</p><p>Disclaimer</p><p>BMJ Best Practice is intended for licensed medical professionals. BMJ Publishing Group Ltd (BMJ) does not</p><p>advocate or endorse the use of any drug or therapy contained within this publication nor does it diagnose</p><p>patients. As a medical professional you retain full responsibility for the care and treatment of your patients</p><p>and you should use your own clinical judgement and expertise when using this product.</p><p>This content is not intended to cover all possible diagnosis methods, treatments, follow up, drugs and any</p><p>contraindications or side effects. In addition, since such standards and practices in medicine change as</p><p>new data become available, you should consult a variety of sources. We strongly recommend that you</p><p>independently verify specified diagnosis, treatments and follow-up and ensure it is appropriate for your</p><p>patient within your region. In addition, with respect to prescription medication, you are advised to check the</p><p>product information sheet accompanying each drug to verify conditions of use and identify any changes in</p><p>dosage schedule or contraindications, particularly if the drug to be administered is new, infrequently used, or</p><p>has a narrow therapeutic range. You must always check that drugs referenced are licensed for the specified</p><p>use and at the specified doses in your region.</p><p>Information included in BMJ Best Practice is provided on an “as is” basis without any representations,</p><p>conditions or warranties that it is accurate and up to date. BMJ and its licensors and licensees assume no</p><p>responsibility for any aspect of treatment administered to any patients with the aid of this information. To</p><p>the fullest extent permitted by law, BMJ and its licensors and licensees shall not incur any liability, including</p><p>without limitation, liability for damages, arising from the content. All conditions, warranties and other terms</p><p>which might otherwise be implied by the law including, without limitation, the warranties of satisfactory</p><p>quality, fitness for a particular purpose, use of reasonable care and skill and non-infringement of proprietary</p><p>rights are excluded.</p><p>Where BMJ Best Practice has been translated into a language other than English, BMJ does not warrant the</p><p>accuracy and reliability of the translations or the content provided by third parties (including but not limited to</p><p>local regulations, clinical guidelines, terminology, drug names and drug dosages). BMJ is not responsible for</p><p>any errors and omissions arising from translation and adaptation or otherwise.Where BMJ Best Practice lists</p><p>drug names, it does so by recommended International Nonproprietary Names (rINNs) only. It is possible that</p><p>certain drug formularies might refer to the same drugs using different names.</p><p>Please note that recommended formulations and doses may differ between drug databases drug names and</p><p>brands, drug formularies, or locations. A local drug formulary should always be consulted for full prescribing</p><p>information.</p><p>Treatment recommendations in BMJ Best Practice are specific to patient groups. Care is advised when</p><p>selecting the integrated drug formulary as some treatment recommendations are for adults only, and external</p><p>links to a paediatric formulary do not necessarily advocate use in children (and vice-versa). Always check</p><p>that you have selected the correct drug formulary for your patient.</p><p>Where your version of BMJ Best Practice does not integrate with a local drug formulary, you should consult</p><p>a local pharmaceutical database for comprehensive drug information including contraindications, drug</p><p>interactions, and alternative dosing before prescribing.</p><p>Interpretation of numbers</p><p>Regardless of the language in which the content is displayed, numerals are displayed according to the</p><p>original English-language numerical separator standard. For example 4 digit numbers shall not include a</p><p>comma nor a decimal point; numbers of 5 or more digits shall include commas; and numbers stated to be</p><p>less than 1 shall be depicted using decimal points. See Figure 1 below for an explanatory table.</p><p>BMJ accepts no responsibility for misinterpretation of numbers which comply with this stated numerical</p><p>separator standard.</p><p>This approach is in line with the guidance of the International Bureau of Weights and Measures Service.</p><p>Figure 1 – BMJ Best Practice Numeral Style</p><p>48 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://www.bipm.org/en/about-us/</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Disclaimer</p><p>5-digit numerals: 10,000</p><p>4-digit numerals: 1000</p><p>numerals</p><p>of shock Emergencies</p><p>EM</p><p>ER</p><p>G</p><p>EN</p><p>C</p><p>IE</p><p>S</p><p>Urgent considerations</p><p>(See Differentials for more details)</p><p>Hypovolaemic shock</p><p>Loss of body fluid volume due to forms of dehydration such as hyperthermia, burns, excess diuresis,</p><p>prolonged diarrhoea, or lack of usual physiological oral fluid replacement requires fluid replacement either</p><p>orally or intravenously.</p><p>The intravenous use of a balanced crystalloid solution (e.g., lactated Ringer’s [also known as Hartmann’s</p><p>solution]) or normal saline is appropriate for resuscitation in a patient with hypovolaemic shock. Compared</p><p>with normal saline, balanced crystalloids were associated with a modestly reduced rate of a composite</p><p>outcome (of death from any cause, new renal replacement therapy, persistent renal dysfunction) in one</p><p>randomised trial of critically ill patients.[14] Colloid solutions are more expensive than crystalloid solutions</p><p>and, for vascular volume replacement, have not shown superiority over crystalloids.[15]</p><p>Bleeding from any cause requires immediate measures to control the source of the bleeding. Volume</p><p>resuscitation in the form of blood and fluid needs to be instituted immediately. Bleeding following major</p><p>trauma requires coagulation support and monitoring, and the appropriate use of local haemostatic measures,</p><p>tourniquets, calcium, desmopressin, and consideration for tranexamic acid. When indicated, appropriate</p><p>and immediate surgical intervention to control haemorrhage is associated with increased survival and less</p><p>disability.[16] [17]</p><p>Tranexamic acid has been shown to reduce mortality in trauma patients with haemorrhage when given within</p><p>3 hours of injury.[18] [19] A meta-analysis of data from over 40,000 patients with traumatic bleeding or post-</p><p>partum haemorrhage found that delays in administration of tranexamic acid were associated with reduced</p><p>survival (survival benefit decreasing by about 10% for every 15 minutes of treatment delay until 3 hours, after</p><p>which there was no benefit).[20]</p><p>Some patients may require embolisation of bleeding vessels by interventional radiology or exploratory</p><p>surgery to accomplish haemostasis. Coagulopathies may result due to high-volume blood transfusion</p><p>(deficient in clotting factors) or consumption of clotting factors due to continued bleeding. This can be</p><p>corrected with fresh frozen plasma and platelets according to local guidelines.</p><p>Cardiogenic shock</p><p>Immediate management of myocardial infarction includes revascularisation and anticoagulation, either by</p><p>primary angioplasty or, where these modalities are not available, by thrombolysis and immediate transport to</p><p>a facility with revascularisation capability.[21] [22] [23]</p><p>In primary angioplasty, drug-eluting stents reduce target vessel revascularisation compared with bare metal</p><p>stents.[24] A sub-analysis of the SHOCK trial comparing patients treated with coronary artery bypass grafting</p><p>versus primary angioplasty found no difference in survival or disability outcome.[22]</p><p>Acute heart failure may necessitate respiratory support, such as non-invasive or invasive mechanical</p><p>ventilation, and urgent diuresis or nitrate therapy. Inotropic agents and vasodilator strategies may be</p><p>used in the appropriate setting. Pure inotropes are not mandatory in this case, unless significant cardiac</p><p>hypocontractility is demonstrated or suspected.</p><p>6 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Emergencies</p><p>Mechanical measures such as inserting an intra-aortic balloon pump may also be considered in patients</p><p>who are unstable following myocardial infarction or cardiac surgery. The intra-aortic balloon pump augments</p><p>blood pressure and coronary perfusion by inflating during diastole and deflating during systole.</p><p>Extracorporeal membrane oxygenation (ECMO) may be considered for the management of appropriately</p><p>selected patients with cardiogenic shock.[21] [25]</p><p>Obstructive shock</p><p>Tension pneumothorax is a possible diagnosis in patients with chest trauma, young people with a previous</p><p>history of pneumothorax, or patients who exhibit signs of hypotension and hypoxia with unilaterally</p><p>decreased breath sounds. These findings usually mandate immediate needle thoracostomy drainage</p><p>followed by a formal chest drain.</p><p>Patients with haemodynamic compromise and clinical findings suggestive of pericardial tamponade (Beck's</p><p>triad of muffled heart sounds, jugular venous distention, and bradycardia) need urgent evaluation with</p><p>echocardiography and pericardiocentesis.</p><p>Pulmonary embolism is a consideration in patients with recent surgery and immobilisation; treatment usually</p><p>includes anticoagulation, thrombolysis (if there are no absolute contra-indications), or rarely surgical or</p><p>mechanical clot removal.</p><p>Distributive shock</p><p>Results in inadequate tissue perfusion; comprises anaphylaxis, septic shock, and neurogenic shock.</p><p>Anaphylactic shock</p><p>Anaphylaxis may present after exposure to new foods, drugs, blood transfusions, rashes, bites, and stings,</p><p>and is often associated with bronchospasm. All potentially offending agents should be stopped. In patients</p><p>with hypotension and signs of anaphylactic shock, intramuscular adrenaline should be given immediately.[26]</p><p>[27] [28]</p><p>Septic shock</p><p>Sepsis is a spectrum of disease, where there is a systemic and dysregulated host response to an</p><p>infection.[29] Presentation may range from subtle, non-specific symptoms (e.g., feeling unwell with a normal</p><p>temperature), to severe symptoms with evidence of multi-organ dysfunction and septic shock. Patients may</p><p>have signs of tachycardia, tachypnoea, hypotension, fever or hypothermia, poor capillary refill, mottled or</p><p>ashen skin, cyanosis, newly altered mental state, or reduced urine output.[30] Sepsis and septic shock are</p><p>medical emergencies.</p><p>The Third International Consensus Group (Sepsis-3) defines septic shock as a subset of sepsis in which</p><p>profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than</p><p>with sepsis alone. Both of the following should be present (despite adequate volume resuscitation):[29]</p><p>• Persistent hypotension requiring vasopressors to maintain mean arterial pressure (MAP) ≥65 mmHg,</p><p>and</p><p>• Serum lactate >2 mmol/L (>18 mg/dL).</p><p>EM</p><p>ERG</p><p>EN</p><p>C</p><p>IES</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>7</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Emergencies</p><p>EM</p><p>ER</p><p>G</p><p>EN</p><p>C</p><p>IE</p><p>S</p><p>Risk factors for sepsis include: age under 1 year, age over 75 years, frailty, impaired immunity (e.g., due to</p><p>illness or drugs), recent surgery, or other invasive procedures, any breach of skin integrity (e.g., cuts, burns),</p><p>intravenous drug misuse, indwelling lines or catheters, and pregnancy or recent pregnancy.[30]</p><p>Early recognition of sepsis is essential because early treatment (i.e., when sepsis is suspected but is yet</p><p>to be confirmed) is associated with significant short- and long-term benefits in outcome.[30] [Evidence</p><p>C] [Evidence C] However, detection can be challenging because the clinical presentation of sepsis can</p><p>be subtle and non-specific. A low threshold for suspecting sepsis is therefore important. The key to early</p><p>recognition is the systematic identification of any patient who has signs or symptoms suggestive of infection</p><p>and who is at risk of deterioration due to organ dysfunction.</p><p>Screening tools</p><p>Several risk stratification approaches have been proposed. All rely on a structured clinical assessment and</p><p>recording of the patient’s</p><p>vital signs.[30] [31] [32] [33] It is important to check local guidance for information</p><p>on which approach your institution recommends. The timeline of ensuing investigations and treatment should</p><p>be guided by this early assessment.[33]</p><p>Sepsis screening tools are designed to promote the early identification of sepsis and consist of manual</p><p>methods or automated use of the electronic health record (EHR). These include the Sequential (or</p><p>Sepsis-related) Organ Failure Assessment (SOFA) score, the quick SOFA (qSOFA) criteria, National</p><p>Early Warning Score (NEWS), and Modified Early Warning Score (MEWS). There is wide variation in the</p><p>diagnostic accuracy of these tools, but they are an important component of identifying sepsis early for timely</p><p>intervention.[34]</p><p>The Third International Consensus Group (Sepsis-3) recommends using the SOFA score (primarily validated</p><p>in patients in intensive care), with a score ≥2 in a patient with a suspected infection being suggestive of</p><p>sepsis.[29]</p><p>8 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Emergencies</p><p>Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) criteria</p><p>Created by BMJ, adapted from Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ</p><p>Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-</p><p>Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22:707-710.</p><p>SOFA criteria</p><p>Although the presence of a positive qSOFA should alert the clinician to the possibility of sepsis in all resource</p><p>settings, its poor sensitivity has led the Surviving Sepsis Campaign to advise against using the qSOFA,</p><p>compared with NEWS or MEWS, as a single screening tool for sepsis or septic shock.[34]</p><p>The National Institute for Health and Care Excellence (NICE) UK guideline on sepsis emphasises the need</p><p>to ‘think sepsis’ in any patient presenting with possible infection. It recommends structured observations and</p><p>stratification of risk of severe illness and death according to patient age and setting.[30]</p><p>Management of patients with suspected sepsis</p><p>Treatment guidelines have been produced by the Surviving Sepsis campaign and remain the most widely</p><p>accepted treatment standards.[34] [35]</p><p>Recommended treatment of patients with suspected sepsis is:</p><p>• Measure lactate level, and re-measure if initial lactate is elevated >2 mmol/L (>18 mg/dL).</p><p>• Obtain blood cultures before administering antibiotics.</p><p>EM</p><p>ERG</p><p>EN</p><p>C</p><p>IES</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>9</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Emergencies</p><p>EM</p><p>ER</p><p>G</p><p>EN</p><p>C</p><p>IE</p><p>S</p><p>• Administer broad-spectrum antibiotics (with methicillin-resistant Staphylococcus aureus [MRSA]</p><p>coverage if there is high risk of MRSA) for adults with possible septic shock or a high likelihood for</p><p>sepsis.</p><p>• For adults with sepsis or septic shock at high risk of fungal infection, empiric antifungal therapy should</p><p>be administered.</p><p>• Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate level ≥4 mmol/L (≥36 mg/</p><p>dL).</p><p>• Administer vasopressors peripherally if hypotensive during, or after, fluid resuscitation to maintain</p><p>MAP ≥65 mm Hg, rather than delaying initiation until central venous access is secured. Noradrenaline</p><p>(norepinephrine) is the vasopressor of choice.</p><p>• For adults with sepsis-induced hypoxaemic respiratory failure, high-flow nasal oxygen should be given.</p><p>Ideally, these interventions should all begin in the first hour following sepsis recognition.[35]</p><p>For adults with possible sepsis without shock, where concern for infection persists, antibiotics should be</p><p>given within three hours from the time when sepsis was first recognised.[34]</p><p>For adults with a low likelihood of infection and without shock, antibiotics can be deferred while continuing to</p><p>closely monitor the patient.[34]</p><p>Patients with severe septic shock may develop corticosteroid insufficiency, diagnosed by</p><p>adrenocorticotrophic hormone stimulation test, or simply based on high vasopressor requirement. Current</p><p>guidelines recommend that low-dose corticosteroids are given only to adults with septic shock and ongoing</p><p>requirement for vasopressor therapy (defined as a dose of adrenaline or noradrenaline [epinephrine or</p><p>norepinephrine] ≥0.25 mcg/kg/min for at least 4 hours after initiation to maintain the target MAP).[34]</p><p>ECMO may be considered in carefully selected patients with refractory septic shock.[36] [37] [38]</p><p>Neurogenic shock</p><p>Patients with suspected neurogenic shock require immediate imaging and possible intervention to reverse</p><p>potentially reversible deficits, as well as fluid resuscitation to maintain vascular volume and cardiac output.</p><p>10 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>Approach</p><p>All patients who are clinically in a state of shock should be managed in a resuscitation, high-dependency, or</p><p>intensive care setting.</p><p>Transfer out of the resuscitation room should only be considered when the patient's vital signs are stabilised.</p><p>In any evaluation of shock, haemodynamic measurements have to be interpreted in the clinical context of</p><p>some basic principles. The following questions are useful:</p><p>• Is the patient in shock? (Is oxygen delivery or cellular metabolic demand not being met?)</p><p>• Does the patient respond to fluids? (Do they have a decreased preload?)</p><p>• If the patient is fluid responsive, is the arterial tone (afterload) increased or decreased?</p><p>• Is pump function (cardiac contractility) increased or decreased?</p><p>The answer to these questions will help to determine the type of shock.</p><p>Parameters to differentiate between types of shock and examples</p><p>Adapted with permission from 'Rady MY. Bench-to-bedside review:</p><p>Resuscitation in the emergency department. Crit Care. 2005;9:170-176'.</p><p>The usual parameters of blood pressure (BP), heart rate, and urine output, which have been traditionally</p><p>used as indicators of global perfusion since the 1960s, have given way to a new definition of shock based</p><p>on the demand and supply of oxygen at the tissue level; thus, measures of regional perfusion have replaced</p><p>global vital signs. Normal BP does not necessarily mean normal perfusion, as adequate pressure does not</p><p>equate to adequate cardiac output.[39] [40] Indicators of regional perfusion, such as arterial or venous serum</p><p>D</p><p>IAG</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>11</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>D</p><p>IA</p><p>G</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>lactate and base deficit, are important because early haemodynamic assessment based on vital signs and</p><p>central venous pressure (CVP) does not detect early or persistent global hypoxia.[41]</p><p>Parameters to evaluate shock</p><p>Clinical criteria, including vital signs, level of consciousness and assessments of peripheral</p><p>perfusion (core-</p><p>periphery temperature gradient, capillary return time) are mandatory.</p><p>Haemodynamic monitoring</p><p>• Mean arterial pressure (MAP), systolic BP, and diastolic BP can be done continuously with an arterial</p><p>line and confirmed with hourly non-invasive BP monitoring.</p><p>• MAP may be calculated by adding the diastolic pressure to one third of the difference between the</p><p>systolic and diastolic pressures.</p><p>Ultrasonography[42]</p><p>• Decreased inferior vena cava filling and diameter are suggestive of hypovolaemic shock.</p><p>• Abdominal-thoracic ultrasound seeking free fluid (focused assessment with sonography for trauma</p><p>[FAST] scan) or pneumothorax is suggestive of internal haemorrhage.[43]</p><p>• Cardiac sonography to determine ventricular volumes and cardiac output is helpful in assessing</p><p>cardiogenic shock.[44]</p><p>Shock Index[45]</p><p>• Defined by the ratio of heart rate to systolic BP.</p><p>• A ratio of 1, it usually indicates a</p><p>variable response to fluid administration.[46]</p><p>• Use of the shock index is mostly confined to hypovolaemic shock. It may be unreliable in septic and</p><p>cardiogenic shock (when heart rate may increase in response to other factors), and in the setting of</p><p>older age, hypertension, or beta-blocker or calcium-channel blocker therapy.[45] [47]</p><p>Monitoring organ system effects</p><p>• Urine output of 4 mmol/L (>36 mg/dL) have been associated with greater mortality in shock. Early</p><p>lactate clearance is associated with better prognosis.[48]</p><p>• Lactate can be measured from an arterial gas sample 2 or 3 times a day, or more often if required, to</p><p>monitor response to treatment.</p><p>• Base deficit, negative base excess, also correlates with outcome in shock. Initial base deficit does not</p><p>correlate well with initial blood lactate because there are numerous causes of a raised lactate (e.g.,</p><p>metformin, beta-2 agonists) other than hypoperfusion. The base excess is defined as the amount of</p><p>hydrogen ions that would be required to return the pH of the blood to 7.35 if the PaCO₂ levels were</p><p>adjusted to normal.</p><p>12 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>Scoring systems</p><p>Sepsis screening tools are designed to promote the early identification of sepsis, and consist of manual</p><p>methods or the automated use of the electronic health record (EHR). These include the Sequential (or</p><p>Sepsis-related) Organ Failure Assessment (SOFA) score, the quick SOFA (qSOFA) criteria, National Early</p><p>Warning Score (NEWS), and Modified Early Warning Score (MEWS). The accuracy of each tool varies, but</p><p>they are an important component of identifying sepsis early for timely intervention.[34]</p><p>Of these scoring systems, the SOFA scoring system has been subject to greatest study and has been</p><p>adopted for use in emergency and critical care management of potential shock victims, including screening</p><p>for shock and ongoing assessment.[49] [50] [51] A SOFA score of 7 or more on initial evaluation has been</p><p>associated with significant shock, with a score of 13 or greater associated with significant risk for mortality in</p><p>the intensive care setting.</p><p>Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) criteria</p><p>Created by BMJ, adapted from Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ</p><p>Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-</p><p>Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22:707-710.</p><p>SOFA criteria</p><p>The Third International Consensus Group (Sepsis-3) recommends using the SOFA score (primarily validated</p><p>in patients in intensive care) to assess for sepsis, with a score ≥2 in a patient with a suspected infection</p><p>being suggestive of sepsis.[29]</p><p>D</p><p>IAG</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>13</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>D</p><p>IA</p><p>G</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>For patients with suspected sepsis outside the intensive care setting, a modified SOFA score, qSOFA, has</p><p>been found to have better predictability of in-hospital mortality.[52] However, there is evidence that qSOFA</p><p>may have poor sensitivity compared with other bedside early warning scores.[53] Therefore, the Surviving</p><p>Sepsis Campaign advises against using qSOFA, compared with NEWS or MEWS, as a single screening tool</p><p>for sepsis or septic shock.[34]</p><p>Early recognition of sepsis is essential because early treatment (i.e. when sepsis is suspected but is yet to be</p><p>confirmed) is associated with significant short- and long-term benefits in outcome.[30]</p><p>See urgent considerations section for more details on immediate management.</p><p>Measuring the preload</p><p>Preload is measured by dynamic response of the CVP to a fluid challenge (e.g., 250 to 500 mL of balanced</p><p>crystalloid solution). Mini-fluid challenges (e.g., 100 mL) may be used to predict the effects of larger fluid</p><p>challenges in critically ill patients.[54]</p><p>In some centres other methods are used, including echocardiography and various methods of determining</p><p>cardiac output (e.g., pulse-induced continuous cardio-output monitoring). In selected situations, pulmonary</p><p>artery catheters may be helpful in initial and ongoing monitoring of preload.</p><p>Measuring preload responsiveness</p><p>Measures of preload responsiveness can guide fluid administration. There are various methods of doing</p><p>this such as stroke volume variation, systolic pressure variation, pulse pressure variation, plethysmographic</p><p>variation, and passive leg raising.[55] [56] [57] [58] [59] [60] [61] [62] [63] [64] [65] [66]</p><p>Typically an increase in cardiac output of 10% to 12% after a fluid bolus of 300 to 500 mL of crystalloids is</p><p>taken as a positive response. Passive leg raising is frequently used as a simple mechanical manoeuvre to</p><p>optimise the preload.</p><p>Evaluation of haemodynamic status is difficult in some situations, including in mechanically ventilated</p><p>patients. Inappropriate fluid administration can be harmful, and measures of preload (e.g., CVP) are</p><p>unhelpful because, as end-diastolic pressure exceeds a given value, giving further fluids does not increase</p><p>stroke volume (Starling's principle).[57]</p><p>Measuring contractility and afterload</p><p>Cardiac output is the output of the left ventricle/right ventricle per minute. There are various methods of</p><p>calculating cardiac output, but an ideal standard has not been established.</p><p>The most commonly used method is bedside echocardiography.[44] Alternative non-invasive methods</p><p>include Doppler ultrasound and measurements of pulse pressure, although the latter is a function of both</p><p>cardiac output and arterial function. As cardiac output is affected by the phase of respiration, it needs to be</p><p>measured at the same point in the respiratory cycle each time to enable comparison.</p><p>Other methods include dilution and thermodilution using a pulmonary artery catheter. These use Fick's</p><p>principle, and the rate at which an indicator substance is diluted or temperature falls is proportional to the</p><p>cardiac output.</p><p>14 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>The ratio of the cardiac output (stroke volume x heart rate) to the body surface area in metres squared is the</p><p>cardiac index. Normal values of the cardiac index range from 2.2 to 2.5 L/minute/m². In cardiogenic shock the</p><p>cardiac index is typically 600 ml/min/m² has been associated</p><p>with better outcomes.[68]</p><p>• DO₂ = cardiac output x oxygen saturation x haemoglobin level g/L (1.36) x 100.</p><p>Mixed venous oxygen saturations: the saturation of oxygen in the pulmonary artery, and the standard for</p><p>defining global adequacy of tissue perfusion.[69] [70] Normal venous saturations are between 65% and</p><p>75%. Superior vena cava oxygen saturation is usually higher by about 8% compared with inferior vena</p><p>cava oxygen saturation, but they parallel each other in shock.[71] [72] A sustained elevation of >80% in the</p><p>presence of low oxygen delivery carries a poor prognosis, as it indicates tissue inability to utilise oxygen,</p><p>and is usually seen after cardiac arrest resuscitation.[73] During initial stabilisation, even after attaining</p><p>global indices such as BP and urine output, tissue hypoxia can still persist. If uncorrected, it can lead to</p><p>oxygen debt.[41] Oxygen debt is due to an imbalance between supply and demand, which is associated with</p><p>increased organ dysfunction.[74] Early correction of venous saturations to >70% is associated with better</p><p>outcomes.[12] Venous saturations of 4 mmol/L (>36 mg/dL) are associated with greater mortality in shock. Base excess levels are</p><p>used during bedside resuscitation in determining fluid volume replacement for acute trauma victims.</p><p>New technologies</p><p>New methods and devices that aid in the assessment of shock are available, such as the pulse</p><p>contour analysis catheter, lithium dilution contour analysis, sublingual capnograph, and Doppler</p><p>echocardiography.[55][76] [77] [78] [79] [80] [81] [82]</p><p>The pulse contour and lithium dilution contour (Lidco) analysers are less-invasive alternatives to monitor</p><p>continuous cardiac output. The pulse contour analyser requires calibration with the Lidco initially, but results</p><p>seem to be reliable, even immediately after cardiac surgery.[77]</p><p>Sublingual capnography is potentially a good marker for tissue hypoxia and responds quickly to therapeutic</p><p>interventions, and therefore it could play a role in goal-directed therapy.[80] However, there is no consistent</p><p>relationship between improvements in markers of microcirculatory perfusion and clinical outcome.[83]</p><p>Doppler echocardiography is used to assess blood flow through the heart chambers and valves. This is</p><p>particularly useful in detecting valvular abnormalities. It is also useful in detecting other cardiac causes of</p><p>shock (cardiac tamponade, myocardial infarction) and to detect cardiac involvement in distributive shock.</p><p>D</p><p>IAG</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>15</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>D</p><p>IA</p><p>G</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>Differentials overview</p><p>Common</p><p>Myocardial infarction</p><p>Heart failure</p><p>Beta-blocker and other drug-related toxicity</p><p>Haemorrhage, external or internal from any site</p><p>Trauma with external or internal haemorrhage</p><p>Gastrointestinal fluid losses</p><p>Intestinal obstruction with fluid third spacing</p><p>Pancreatitis with fluid third spacing or haemorrhage</p><p>Burns</p><p>Excessive renal loss</p><p>Pulmonary embolism</p><p>Septic shock</p><p>Anaphylaxis</p><p>Poisoning and adverse drug reaction</p><p>Uncommon</p><p>Cardiomyopathy</p><p>Cardiac valve disease</p><p>Heat stroke and/or insensible fluid losses</p><p>Tension pneumothorax</p><p>Cardiac tamponade</p><p>Neurogenic shock</p><p>16 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>Uncommon</p><p>Adrenal crisis</p><p>Thiamine deficiency</p><p>Arteriovenous fistulae</p><p>D</p><p>IAG</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>17</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>D</p><p>IA</p><p>G</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>Differentials</p><p>Common</p><p>Myocardial infarction</p><p>History Exam 1st Test Other tests</p><p>central chest pain,</p><p>radiation to left arm,</p><p>history of exertional</p><p>chest pain; smoking,</p><p>hypercholesterolaemia;</p><p>family history of</p><p>diabetes mellitus; high</p><p>BP</p><p>signs of heart failure;</p><p>jugular venous</p><p>distention, basal</p><p>crackles on lung</p><p>auscultation; heart</p><p>murmur</p><p>»serum troponin:</p><p>elevated</p><p>High sensitivity troponin</p><p>assays are preferred.</p><p>They allow for early</p><p>detection of cardiac</p><p>injury at 1 hour.</p><p>Standard assays are</p><p>elevated maximally at</p><p>10 to 12 hours.[84]</p><p>»serum creatine</p><p>kinase (CK-MB</p><p>isoenzyme fraction):</p><p>elevated</p><p>»ECG: may show ST-</p><p>segment elevation or</p><p>depression</p><p>»coronary</p><p>angiography: may</p><p>show presence</p><p>of thrombus with</p><p>occlusion of the artery</p><p>Diagnostic modality of</p><p>choice to confirm acute</p><p>myocardial infarction in</p><p>patients with STEMI.</p><p>»echocardiography:</p><p>regional wall</p><p>abnormalities and</p><p>valvular abnormalities</p><p>◊ Heart failure</p><p>History Exam 1st Test Other tests</p><p>shortness of breath,</p><p>ankle swelling,</p><p>orthopnoea,</p><p>paroxysmal nocturnal</p><p>dyspnoea, history</p><p>cardiac risk factors,</p><p>previous myocardial</p><p>infarction, valvular heart</p><p>disease</p><p>jugular venous</p><p>distension, orthopnoea,</p><p>lower extremity</p><p>swelling, crackles in the</p><p>chest on auscultation,</p><p>increased respiratory</p><p>rate, S3 gallop rhythm</p><p>on cardiac auscultation</p><p>»echocardiography:</p><p>depressed ejection</p><p>fraction, decreased</p><p>systolic left ventricular</p><p>function</p><p>Only the systolic</p><p>function is preserved;</p><p>diastolic indices are</p><p>altered.</p><p>»B-type natriuretic</p><p>peptide (BNP) or</p><p>N-terminal pro-</p><p>BNP (NT-proBNP):</p><p>elevated</p><p>In acute settings,</p><p>natriuretic peptide</p><p>biomarker levels may</p><p>be more useful for</p><p>18 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>Common</p><p>◊ Heart failure</p><p>History Exam 1st Test Other tests</p><p>ruling out than ruling</p><p>in a diagnosis of heart</p><p>failure. Several other</p><p>cardiac and non-</p><p>cardiac conditions may</p><p>also be associated with</p><p>elevated BNP or NT-</p><p>proBNP levels.[85]</p><p>»chest x-ray:</p><p>pulmonary oedema,</p><p>Kerley's A, B, and C</p><p>lines, cardiomegaly</p><p>Sometimes difficult to</p><p>differentiate from acute</p><p>respiratory distress</p><p>syndrome.</p><p>◊ Beta-blocker and other drug-related toxicity</p><p>History Exam 1st Test Other tests</p><p>prior hypertension or</p><p>heart disease being</p><p>medically treated</p><p>with a beta-blocker,</p><p>a calcium-channel</p><p>blocker, or a class 1c</p><p>anti-arrhythmic such</p><p>as flecainide; syncope</p><p>and lightheadedness;</p><p>weakness; loss of</p><p>appetite</p><p>weak pulse, pulmonary</p><p>rales, slow heart</p><p>rate (beta-blockers),</p><p>peripheral oedema,</p><p>signs of poor skin</p><p>perfusion</p><p>»ECG: bradycardia,</p><p>increased PR interval</p><p>»urine drug screen:</p><p>presence of drug in</p><p>urine</p><p>»serum levels for</p><p>suspected drugs:</p><p>drug level</p><p>◊ Haemorrhage, external or internal from any site</p><p>History Exam 1st Test Other tests</p><p>external injury such</p><p>as laceration; vomiting</p><p>blood or bloody stools;</p><p>melaena; vaginal blood</p><p>loss; or pelvic pain in a</p><p>woman of childbearing</p><p>age</p><p>tachycardia;</p><p>lightheadedness; pale</p><p>fingernail beds and</p><p>signs of poor skin</p><p>perfusion; weak pulse;</p><p>decreased urine output</p><p>»haemoglobin/</p><p>haematocrit: low</p><p>blood count</p><p>»stool guaiac test</p><p>for blood: presence of</p><p>blood in stool</p><p>»serum lactate: >2</p><p>mmol/L (>18 mg/dL)</p><p>abnormal; >4 mmol/L</p><p>(>36 mg/dL) associated</p><p>with higher mortality</p><p>»base deficit: 2</p><p>mmol/L (>18 mg/dL)</p><p>abnormal; >4 mmol/L</p><p>(>36 mg/dL) associated</p><p>with higher mortality</p><p>»base deficit: 3 times</p><p>the upper limit of the</p><p>normal range</p><p>Use serum lipase</p><p>testing (if available)</p><p>in preference to</p><p>serum amylase.[86]</p><p>[87] Serum lipase</p><p>and amylase have</p><p>similar sensitivity</p><p>and specificity but</p><p>lipase levels remain</p><p>elevated for longer</p><p>(up to 14 days after</p><p>symptom onset vs.</p><p>5 days for amylase),</p><p>providing a higher</p><p>likelihood of picking</p><p>up the diagnosis in</p><p>patients with a delayed</p><p>presentation.[88]</p><p>»LFTs: usually elevated</p><p>if gallstones are the</p><p>cause</p><p>»CRP: elevated</p><p>»CT scan: pancreatic</p><p>inflammation,</p><p>complications;</p><p>pseudocyst, abscess</p><p>formation</p><p>»ultrasound</p><p>abdomen: fluid</p><p>around the pancreas;</p><p>may show biliary</p><p>duct dilation or acute</p><p>cholelithiasis</p><p>D</p><p>IAG</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>21</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>D</p><p>IA</p><p>G</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>Common</p><p>Burns</p><p>History Exam 1st Test Other tests</p><p>children and older</p><p>people are at risk</p><p>erythema, cellulitis,</p><p>clouded cornea;</p><p>burns: dry and painful</p><p>(first degree), wet</p><p>and painful (second</p><p>degree), dry and</p><p>insensitive (third</p><p>degree), affecting</p><p>subcutaneous tissue,</p><p>tendon, or bone (fourth</p><p>degree)</p><p>»FBC: low haematocrit,</p><p>hypovolaemia,</p><p>neutropenia,</p><p>thrombocytopenia</p><p>Indicated in patients</p><p>with significant burns.</p><p>Neutropenia and</p><p>thrombocytopenia may</p><p>be indicators of sepsis.</p><p>»metabolic panel:</p><p>high levels of urea,</p><p>creatinine, glucose;</p><p>hyponatraemia,</p><p>hypokalaemia</p><p>Indicated in patients</p><p>with significant burns.</p><p>»carboxyhaemoglobin:</p><p>high levels</p><p>Indicated if inhalation</p><p>injury is suspected.</p><p>»arterial blood gas:</p><p>may show hypoxia</p><p>Indicated if inhalation</p><p>injury or carbon</p><p>monoxide/cyanide</p><p>poisoning is suspected.</p><p>»fluorescein</p><p>staining: damaged</p><p>corneal epithelial cells</p><p>»CT scan of head</p><p>and spine: brain</p><p>injury, fracture</p><p>May be indicated based</p><p>on injury mechanism</p><p>and history.</p><p>»wound histology</p><p>and biopsy culture:</p><p>infection</p><p>Indicated if sepsis is</p><p>suspected.</p><p>22 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>Common</p><p>◊ Excessive renal loss</p><p>History Exam 1st Test Other tests</p><p>use of diuretic</p><p>medications; poorly</p><p>controlled diabetes</p><p>mellitus with polyuria</p><p>weakness,</p><p>lightheadedness,</p><p>tachycardia, dry</p><p>mucous membranes,</p><p>signs of poor skin</p><p>perfusion</p><p>»urine osmolality:</p><p>unconcentrated</p><p>»urine electrolytes:</p><p>sodium loss</p><p>Pulmonary embolism</p><p>History Exam 1st Test Other tests</p><p>chest pain; shortness of</p><p>breath; recent surgery</p><p>or immobilisation;</p><p>active malignancy;</p><p>recent long flight;</p><p>known deep vein</p><p>thrombosis; known</p><p>prothrombotic</p><p>tendency; use of oral</p><p>contraceptive pill</p><p>possible cyanosis,</p><p>respiratory distress</p><p>with use of accessory</p><p>muscles, lung</p><p>auscultation</p><p>normal; jugular</p><p>venous distention</p><p>if large embolism;</p><p>calf tenderness,</p><p>tachycardia, low oxygen</p><p>saturations</p><p>»CT pulmonary</p><p>angiogram (CTPA)</p><p>or multi-detector</p><p>CT scan: clots in the</p><p>pulmonary arteries</p><p>CTPA is the preferred</p><p>investigation for</p><p>definitive confirmation</p><p>of pulmonary</p><p>embolism.</p><p>»ventilation/</p><p>perfusion lung scan:</p><p>may show an area of</p><p>ventilated lung that is</p><p>not being perfused</p><p>»D-dimer: elevated</p><p>»duplex of leg veins:</p><p>positive for deep vein</p><p>thrombosis</p><p>Septic shock</p><p>History Exam 1st Test Other tests</p><p>recent illness, fever,</p><p>rigors, chills, may be</p><p>symptoms suggestive</p><p>of infective focus;</p><p>history of</p><p>splenectomy</p><p>(including sickle cell</p><p>disease); possible</p><p>risk factors include:</p><p>recent surgery,</p><p>immunosuppression</p><p>may be fever >38˚C</p><p>(100.4˚F) or 65 mmHg; warm</p><p>peripheries (early</p><p>shock); cool peripheries</p><p>(as shock progresses);</p><p>altered mental state;</p><p>»FBC: may be WBC</p><p>count >11,000 or</p><p>10% bands</p><p>»serum chemistry:</p><p>may be elevated</p><p>creatinine</p><p>»CRP: elevated</p><p>»serum PT, INR, and</p><p>PTT: may be elevated</p><p>»lactate: >2 mmol/L</p><p>(>18 mg/dL)</p><p>»cultures and</p><p>Gram stain of urine,</p><p>sputum, and body</p><p>fluid: responsible</p><p>organisms identified</p><p>and recovered</p><p>»lumbar puncture:</p><p>elevated WBC count,</p><p>responsible organisms</p><p>identified and recovered</p><p>»chest x-ray: may</p><p>show pleural effusion,</p><p>consolidation, cardiac</p><p>abnormalities</p><p>D</p><p>IAG</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>23</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>D</p><p>IA</p><p>G</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>Common</p><p>Septic shock</p><p>History Exam 1st Test Other tests</p><p>focus for infection</p><p>evident</p><p>»ABG: metabolic</p><p>acidosis with anion gap</p><p>>12</p><p>Anion gap = ([Na+]+[K</p><p>+]) - ([Cl-]+[HCO3-])</p><p>It may be possible to</p><p>measure lactate on</p><p>ABG sample.</p><p>»venous oxygen</p><p>saturations: typically</p><p>100</p><p>nanograms/L may</p><p>indicate heart failure</p><p>◊ Cardiac valve disease</p><p>History Exam 1st Test Other tests</p><p>rheumatic fever,</p><p>spiking fevers or new</p><p>murmur suggestive of</p><p>endocarditis, recent</p><p>myocardial infarction,</p><p>bicuspid aortic valve,</p><p>shortness of breath on</p><p>exertion, syncope</p><p>mitral facies,</p><p>heart murmur on</p><p>auscultation, rales at</p><p>lung bases, spiking</p><p>temperatures if</p><p>endocarditis</p><p>»Doppler</p><p>echocardiography:</p><p>demonstrates stenosis</p><p>or regurgitation of</p><p>valve, mobility of valve</p><p>leaflets, and large</p><p>vegetations if present</p><p>If endocarditis</p><p>suspected but</p><p>transthoracic</p><p>echo-negative,</p><p>transoesophageal study</p><p>is indicated.</p><p>»FBC: elevated WBC</p><p>count with endocarditis</p><p>»blood cultures:</p><p>positive for growth if</p><p>endocarditic cause for</p><p>valvular destruction</p><p>Three sets of cultures</p><p>suggested.</p><p>◊ Heat stroke and/or insensible fluid losses</p><p>History Exam 1st Test Other tests</p><p>prolonged exposure to</p><p>warm temperatures,</p><p>prolonged exertion in</p><p>hot climates, burns</p><p>dry skin and mucosa,</p><p>loss of skin turgor,</p><p>may be lethargic and</p><p>confused, burns</p><p>»trial of fluids (oral</p><p>or intravenous):</p><p>clinical improvement</p><p>with rehydration</p><p>26 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>Uncommon</p><p>◊ Heat stroke and/or insensible fluid losses</p><p>History Exam 1st Test Other tests</p><p>»serum chemistries:</p><p>increased urea/</p><p>creatinine ratio</p><p>Tension pneumothorax</p><p>History Exam 1st Test Other tests</p><p>sudden onset, often</p><p>pleuritic, chest pain;</p><p>shortness of breath;</p><p>rapid deterioration;</p><p>recent placement</p><p>of a central venous</p><p>pressure line; history</p><p>of emphysema; chest</p><p>trauma</p><p>absent unilateral breath</p><p>sounds on the affected</p><p>side; trachea deviated</p><p>to the opposite side;</p><p>hyper-resonance to</p><p>percussion on affected</p><p>side</p><p>»diagnostic and</p><p>therapeutic needle</p><p>thoracostomy: hiss of</p><p>air as cannula/needle</p><p>enters the pleural</p><p>space</p><p>Formal chest drain</p><p>needed.</p><p>»bedside</p><p>ultrasound:</p><p>pneumothorax</p><p>visualised</p><p>»chest x-ray after</p><p>decompression:</p><p>chest drain correctly</p><p>placed; lung inflated</p><p>Cardiac tamponade</p><p>History Exam 1st Test Other tests</p><p>recent cardiac</p><p>surgery or angiogram/</p><p>angioplasty; chest</p><p>trauma; malignancy;</p><p>pericarditis; increasing</p><p>shortness of breath on</p><p>minimal exertion</p><p>muffled hearts sounds,</p><p>low BP; jugular</p><p>venous distention</p><p>(Beck's triad); pulsus</p><p>paradoxus</p><p>»echocardiography:</p><p>pericardial fluid causing</p><p>restriction of cardiac</p><p>filling</p><p>»ECG: electrical</p><p>alternans</p><p>◊ Neurogenic shock</p><p>History Exam 1st Test Other tests</p><p>brain or spinal cord</p><p>injury, epidural or spinal</p><p>procedures</p><p>hypotension,</p><p>bradycardia, and</p><p>hypothermia; warm</p><p>dry peripheries with</p><p>bounding pulses;</p><p>priapism; flaccid</p><p>paralysis</p><p>of limbs</p><p>»MRI of the</p><p>spine: damage or</p><p>compression of spinal</p><p>cord</p><p>D</p><p>IAG</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>27</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Diagnosis</p><p>D</p><p>IA</p><p>G</p><p>N</p><p>O</p><p>S</p><p>IS</p><p>Uncommon</p><p>◊ Adrenal crisis</p><p>History Exam 1st Test Other tests</p><p>can occur in context of</p><p>other illness especially</p><p>sepsis, trauma, and</p><p>surgery, use of steroids</p><p>either oral, inhaled, or</p><p>topical over large areas;</p><p>anticoagulant therapy;</p><p>nausea and vomiting</p><p>lack of signs to indicate</p><p>an alternative cause</p><p>»serum chemistry:</p><p>may be hyponatraemic</p><p>and hyperkalaemic</p><p>»cortisol:</p><p>https://www.aaaai.org/Allergist-Resources/Statements-Practice-Parameters/Practice-Parameters-Guidelines</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Guidelines</p><p>Oceania</p><p>Clinical practice guidelines: trauma/hypovolaemic shock (https://</p><p>ambulance.qld.gov.au/CPGtable.html)</p><p>Published by: Queensland Ambulance Service</p><p>Last published: 2021</p><p>G</p><p>U</p><p>ID</p><p>ELIN</p><p>ES</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>31</p><p>https://ambulance.qld.gov.au/CPGtable.html</p><p>https://ambulance.qld.gov.au/CPGtable.html</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Evidence tables</p><p>EV</p><p>ID</p><p>EN</p><p>C</p><p>E</p><p>TA</p><p>B</p><p>LE</p><p>S</p><p>Evidence tables</p><p>What are the effects of early versus late initiation of empiric antimicrobial</p><p>treatment in adults with or at risk of developing sepsis or severe sepsis?[30]</p><p>This table is a summary of the analysis reported in a guideline (underpinned by a systematic review)</p><p>that focuses on the above important clinical question.</p><p>View the full source guideline (https://www.nice.org.uk/guidance/ng51/evidence)</p><p>Evidence C * Confidence in the evidence is very low or low where GRADE has been performed</p><p>and the intervention may be more effective/beneficial than the comparison for key</p><p>outcomes. However, this is uncertain and new evidence could change this in the</p><p>future.</p><p>Population: Adults with or at risk of developing sepsis or severe sepsis</p><p>Intervention: Early initiation of empiric antimicrobial treatment</p><p>Comparison: Late initiation of empiric antimicrobial treatment</p><p>Outcome Effectiveness (BMJ rating)</p><p>†</p><p>Confidence in evidence (GRADE)</p><p>‡</p><p>1 hour</p><p>Mortality ᵃ Favours intervention Very Low</p><p>Mortality - Intensive Care Unit</p><p>(ICU) setting</p><p>Favours intervention Very Low</p><p>Mortality - Emergency</p><p>Department (ED) setting</p><p>No statistically significant</p><p>difference</p><p>Very Low</p><p>2 hours</p><p>Mortality ᵃ No statistically significant</p><p>difference</p><p>Very Low</p><p>Mortality - ICU setting Favours intervention Very Low</p><p>Mortality - ED setting No statistically significant</p><p>difference</p><p>Very Low</p><p>3 hours</p><p>Mortality ᵃ Favours intervention Very Low</p><p>Mortality - ICU setting No statistically significant</p><p>difference</p><p>Very Low</p><p>32 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://www.nice.org.uk/guidance/ng51/evidence</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Evidence tables</p><p>Outcome Effectiveness (BMJ rating)</p><p>†</p><p>Confidence in evidence (GRADE)</p><p>‡</p><p>Mortality - ED setting Favours intervention Very Low</p><p>4 hours</p><p>Mortality - ED setting No statistically significant</p><p>difference</p><p>Very Low</p><p>5 hours</p><p>Mortality - ED setting No statistically significant</p><p>difference</p><p>Very Low</p><p>6 hours</p><p>Mortality ᵃ Favours intervention Very Low</p><p>Mortality - ICU setting No statistically significant</p><p>difference</p><p>Very Low</p><p>Mortality - ED setting Favours intervention Very Low</p><p>Recommendations as stated in the source guideline</p><p>The guideline committee recommends that adults, children, and young people over the age of 12 who have</p><p>suspected sepsis and one or more high-risk criteria, should be given a broad-spectrum antimicrobial at the</p><p>maximum recommended dose without delay (within 1 hour of establishing they meet high-risk criteria in an</p><p>acute hospital setting).ᵇ See guideline for details on criteria for different levels of risk.</p><p>Note</p><p>Results in this table are based on observational studies only.</p><p>ᵃ Includes overall mortality in intensive care and emergency department settings.</p><p>ᵇ This guideline recommends that all people with suspected sepsis have a face-to-face assessment and a</p><p>risk stratification tool is used to determine risk of severe illness and death from sepsis. Recommendations</p><p>depend on the presence and number of high-, moderate-to-high, and low-risk criteria.</p><p>EVID</p><p>EN</p><p>C</p><p>E TA</p><p>B</p><p>LES</p><p>This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>33</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Evidence tables</p><p>EV</p><p>ID</p><p>EN</p><p>C</p><p>E</p><p>TA</p><p>B</p><p>LE</p><p>S</p><p>What are the effects of early versus late initiation of empiric antimicrobial</p><p>treatment in children with or at risk of developing sepsis or severe sepsis?[30]</p><p>This table is a summary of the analysis reported in a guideline (underpinned by a systematic review)</p><p>that focuses on the above important clinical question.</p><p>View the full source guideline (https://www.nice.org.uk/guidance/ng51/evidence)</p><p>Evidence C * Confidence in the evidence is very low or low where GRADE has been performed</p><p>and the intervention may be more effective/beneficial than the comparison for key</p><p>outcomes. However, this is uncertain and new evidence could change this in the</p><p>future.</p><p>Population: Children with or at risk of developing sepsis or severe sepsis</p><p>Intervention: Early initiation of empiric antimicrobial treatment</p><p>Comparison: Late initiation of empiric antimicrobial treatment</p><p>Outcome Effectiveness (BMJ rating)</p><p>†</p><p>Confidence in evidence (GRADE)</p><p>‡</p><p>1 hour ᵃ</p><p>Paediatric Intensive Care Unit</p><p>(PICU) mortality</p><p>No statistically significant</p><p>difference</p><p>Very Low</p><p>2 hours ᵃ</p><p>PICU mortality No statistically significant</p><p>difference</p><p>Very Low</p><p>3 hours ᵃ</p><p>PICU mortality Favours intervention Very Low</p><p>4 hours ᵃ</p><p>PICU mortality Favours intervention Very Low</p><p>Recommendations as stated in the source guideline</p><p>The National Institute of Health and Care Excellence (NICE) guideline on Sepsis: recognition, diagnosis and</p><p>early management makes the following recommendation:</p><p>For children aged 5–11 years who have suspected sepsis and 1 or more high-risk criteria, give a broad-</p><p>spectrum antimicrobial ᵇ at the maximum recommended dose without delay (within 1 hour of identifying that</p><p>they meet any high-risk criteria in an acute hospital setting).</p><p>Note</p><p>The guideline group noted that the direct evidence in children came from one small (n=130), single-</p><p>centre retrospective study of children in PICU with severe sepsis and septic shock. Therefore, they also</p><p>34 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 14, 2024.</p><p>BMJ Best Practice topics are regularly updated and the most recent version</p><p>of the topics can be found on bestpractice.bmj.com . Use of this content is</p><p>subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.</p><p>https://www.nice.org.uk/guidance/ng51/evidence</p><p>https://bestpractice.bmj.com</p><p>Assessment of shock Evidence tables</p><p>extrapolated from the indirect evidence in adults to make the same recommendation for all age groups</p><p>(including children aged under 5 years and 5-11 years).</p><p>ᵃ Time from sepsis recognition to initial treatment and first appropriate treatment.</p><p>ᵇ See full guideline for more information.</p><p>* Evidence levels</p><p>The Evidence level is an internal rating applied by BMJ Best Practice. See the EBM Toolkit (https://</p><p>bestpractice.bmj.com/info/evidence-tables/) for details.</p><p>Confidence in evidence</p><p>A - High or moderate to high</p><p>B - Moderate or low to moderate</p><p>C - Very low or low</p><p>† Effectiveness (BMJ rating)</p><p>Based on statistical significance, which demonstrates that the results are unlikely to be due to chance, but</p><p>which does not necessarily translate to a clinical significance.</p><p>‡ Grade certainty</p>