In almost all medical and surgical emergencies, consider hypovolaemia to be the primary cause of shock,
until proven otherwise. Unless there are obvious signs of a cardiac cause, give intravenous fluid
to any patient with cool peripheries and a fast heart rate. In surgical patients, rapidly exclude haemorrhage
(overt or hidden). Remember that respiratory pathology, such as a tension pneumothorax,
can also compromise a patient’s circulatory state. This should have been treated earlier on in the assessment.
- Look at the colour of the hands and digits: are they blue, pink, pale or mottled?
- Assess the limb temperature by feeling the patient’s hands: are they cool or warm?
- Measure the capillary refill time (CRT). It is assessed by applying cutaneous pressure
for five seconds on a fingertip held at heart level (or just above) and counting the time it takes
for capillary refill after the pressure has been released. The normal value for CRT is usually less than two seconds.
- Assess the state of the veins: they may be under-filled or collapsed when hypovolaemia is present.
- Count the patient’s pulse rate.
- Palpate all the peripheral and central pulses, assessing for presence, rate, quality,
regularity and equality. Barely palpable pulses suggest a poor cardiac output, whilst a bounding pulse
may indicate sepsis.
- Measure the patient’s blood pressure. Even in shock, the blood pressure may be entirely normal,
as compensatory mechanisms increase peripheral resistance in response to reduced cardiac output.
Where possible, the diastolic and systolic values should be noted.
A low diastolic BP suggests arterial vasodilatation (as in anaphylaxis or sepsis).
A narrowed pulse pressure (difference between systolic and diastolic pressures; normally ~ 35-45 mmHg)
suggests arterial vasoconstriction (cardiogenic shock or hypovolaemia).
- Auscultate the heart.
- Look for other signs of a poor cardiac output, such as reduced level of consciousness and,
if the patient has a urinary catheter, oliguria
(urine volume < 0.5 ml kg-1 hour-1).
- Examine the patient thoroughly for external haemorrhage from wounds or drains
or evidence of concealed haemorrhage (e.g., thoracic, intraperitoneal or into gut).
Remember that intrathoracic, intrabdominal or pelvis blood loss may be significant,
even if drains are empty.
- The specific treatment of cardiovascular collapse will be determined by the cause,
but should be directed at fluid replacement, haemorrhage control and restoration of tissue perfusion.
Seek out the signs of conditions that are immediately life threatening, e.g., cardiac tamponade,
massive or continuing haemorrhage, septicaemic shock, and treat them urgently.
- Insert one or more large (14 or 16 G) intravenous cannulae. Use short, wide-bore cannulae,
as they have the highest flow rate.
- Take blood from the cannula for routine haematological, biochemical, coagulation
and microbiological investigations, and cross-matching, before infusing intravenous fluid.
- Give a rapid fluid challenge (over 5-10 minutes) of 500 ml of warmed crystalloid solution
if the patient is normotensive. Give 1 litre, if the patient is hypotensive.
Use smaller volumes (e.g., 250 ml) for patients with known cardiac failure and use closer monitoring
(listen to the chest for crepitations after each bolus, consider a CVP line).
- Reassess the pulse rate and BP regularly (every 5 minutes), aiming for the patient's normal BP
or, if this is unknown, a target > 100 mmHg systolic.
- If the patient shows no signs of improvement, the fluid challenge can be repeated.
- If symptoms and signs of cardiac failure (dyspnoea, increased heart rate, raised JVP,
a third heart sound and pulmonary crepitations on auscultation) occur, decrease the fluid infusion rate
or stop the fluids altogether. Seek alternative means of improving tissue perfusion
(e.g., inotropes or vasopressors).
Common causes of unconsciousness include profound hypoxaemia, hypercapnia, cerebral hypoperfusion,
or the recent administration of sedatives or analgesic drugs.
- Review the ABCs: exclude hypoxaemia and hypotension.
- Check the patient’s drug chart for reversible drug-induced causes of depressed consciousness.
Give the appropriate antagonist, where available.
- Examine the pupils (size, equality and reaction to light).
- Assess the patient’s conscious level using either the AVPU or Glasgow Coma Scales.
- Measure the blood glucose using a rapid glucose meter or stick method to exclude hypoglycaemia.
If below 3 mmol l-1, give 25-50 ml of 50% glucose solution intravenously.
- Nurse unconscious patients in the recovery position, where possible.
Exposure / Examination (E)
In order that patients are examined properly, and detail is not missed, full exposure of the body may be necessary.
Do this in a way that respects the dignity of the patient and prevents heat loss.
- Take a full clinical history from the patient, his relatives or friends, and other staff.
- Review the patient notes and charts
a. Study both absolute and trended values of vital signs.
b. Check that important routine medications are prescribed
and being administered.
- Review the results of laboratory or radiological investigations.
- Consider which level of care is required by the patient (e.g., ward, HDU, ICU).
- Make complete entries in the patient’s notes of your finding, assessment and treatment.
Record the patient’s response to therapy.
- Consider definitive treatment of the patient’s underlying condition.
© Resuscitation Council (UK) 2005
This page last updated: 24 June 2005