Survivalist Pro
Survivalist Pro
Photo: Elizaveta Dushechkina
Use the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to assess and treat the patient.
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Read More »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 breathing problems, 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). Apply cutaneous pressure for 5 s on a fingertip held at heart level (or just above) with enough pressure to cause blanching. Time how long it takes for the skin to return to the colour of the surrounding skin after releasing the pressure. The normal value for CRT is usually < 2 s. A prolonged CRT suggests poor peripheral perfusion. Other factors (e.g. cold surroundings, poor lighting, old age) can prolong CRT. Assess the state of the veins: they may be underfilled or collapsed when hypovolaemia is present. Count the patient’s pulse rate (or preferably heart rate by listening to the heart with a stethoscope). Palpate peripheral and central pulses, assessing for presence, rate, quality, regularity and equality. Barely palpable central 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 normal, because compensatory mechanisms increase peripheral resistance in response to reduced cardiac output. A low diastolic blood pressure suggests arterial vasodilation (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) and may occur with rapid tachyarrhythmia. Auscultate the heart. Is there a murmur or pericardial rub? Are the heart sounds difficult to hear? Does the audible heart rate correspond to the pulse rate? Look for other signs of a poor cardiac output, such as reduced conscious level and, if the patient has a urinary catheter, oliguria (urine volume < 0.5 mL kg-1 h-1). Look thoroughly for external haemorrhage from wounds or drains or evidence of concealed haemorrhage (e.g. thoracic, intra-peritoneal, retroperitoneal or into gut). Intra-thoracic, intra-abdominal or pelvic blood loss may be significant, even if drains are empty. The specific treatment of cardiovascular collapse depends on the cause, but should be directed at fluid replacement, haemorrhage control and restoration of tissue perfusion. Seek 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, because they enable the highest flow. Take blood from the cannula for routine haematological, biochemical, coagulation and microbiological investigations, and cross-matching, before infusing intravenous fluid. Give a bolus of 500 mL of warmed crystalloid solution (e.g. Hartmann’s solution or 0.9% sodium chloride) over less than 15 min if the patient is hypotensive. Use smaller volumes (e.g. 250 mL) for patients with known cardiac failure or trauma and use closer monitoring (listen to the chest for crackles after each bolus). Reassess the heart rate and BP regularly (every 5 min), aiming for the patient’s normal BP or, if this is unknown, a target > 100 mmHg systolic. If the patient does not improve, repeat the fluid challenge. Seek expert help if there is a lack of response to repeated fluid boluses. If symptoms and signs of cardiac failure (dyspnoea, increased heart rate, raised JVP, a third heart sound and pulmonary crackles 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). If the patient has primary chest pain and a suspected ACS, record a 12-lead ECG early. Immediate general treatment for ACS includes: Aspirin 300 mg, orally, crushed or chewed, as soon as possible.
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