Clinical Guidelines for Diagnosis and Treatment of Common Conditions in Kenya: 1. ACUTE INJURIES AND TRAUMA & SELECTED EMERGENCIES: 1.9. Shock

1.9. Shock

Hypovolaemic shock

This is due to loss of intravascular volume.

Causes:

• Haemorrhage

• Severe burns:

- (rapid plasma loss from damaged tissues) when over 25% BSA is burnt.
- Endotoxaemia makes matters worse

• Dehydration

• Vomiting and Diarrhoea (cholera and enterocolitis)

• Intestinal obstruction (mechanical or paralytic ileus) until 10-15% of blood volume is lost the cardiac output is maintained by tachycardia and vasoconstriction.

Clinical Features

The patient becomes cold, clammy, drowsy and tachypnoeic. There is cold sweat. restlessness and blood pressure may even become unrecordable. The skin is pale and cold with collapsed peripheral veins, with a tachycardia. The urinary output is an indicator of renal blood flow, and will significantly fall. Temperature is subnormal (less than 35°C).

Investigations

• Hb and PCV
• Urea and Electrolytes
• Blood sugar
• Group and Xmatch Blood
• Blood gas analysis if possible.

Management

• Once shock is suspected, the medical staff on the patient should swing into co-ordinated action and treatment to the patient intensified

• Treat the primary problem e.g control haemorrhage, endotoxaemia etc.

• Secure a large intravenous line, if there is no accessible peripheral line do a cutdown

• Central venous pressure line is preferable if available

• Start infusion of isotonic saline, or Run 2 litres fast in adult

• In children calculate against Body weight 200 mls/Kg/24 hr, give first half in 4 hours

• Group and Xmatch Blood before you give Plasma expanders (Dextran 70, etc.):

- Transfuse in cases of blood loss, burns shock
- If shock is due to vomiting or diarrhoea replace continuing loss
Adults: 1 litre 6 hourly Hartmann's solution; children 30 mls/Kg 6 hrly - half strength Darrows. Continue with IV fluids till shock reversed and cause treated

• Maintenance continues till shock is reversed and the cause is reversed

• Surgical intervention is undertaken as soon as patient is stable i.e. Laparotomy for intestinal obstruction etc., Broad spectrum antibiotics for sepsis and burns.

Clinical Features and Treatment of Common Poisonings

SUBSTANCE	CLINICAL FEATURES	TREATMENT
Mineral acids e.g. HCl, H₂SO₄	Excruciating pain orally, pharyngeally, substantially, epigastric, dysphagia, vomiting, haematemesis Later Laryngeal oedema; obstruction, oesophageal perforation Long term: Stenosis of oesophagus	Lethal dose if concentrated- 20 mls • Liberal water or milk orally • Analgesic injection to relieve pain • DO NOT GIVE ALKALIS OR INDUCE VOMITING/LAVAGE
Alkalis e.g. Sodium hydroxide	As above	As above. DO NOT GIVE ACIDS
Organochlorine e.g. DDT, Aldrin, Dieldrin	Excitement, tremors, convulsions with respiratory failure due to convulsions	• IV diazepam for convulsions • Gastric lavage • Survivors beyond 48 hours almost invariably recover
Organophosphates e.g. Diazinon	Headaches, weakness, vomiting, colicky abdominal pain, profuse cold sweating, hypersalivation, muscular twitching, fasciculations, diarrhoea, tenesmus, convulsions, dyspnoea with bronchoconstriction, meiosis, bilateral crepitations	• Decontaminate (see above) • Gastric lavage • IV atropine 2 mg STAT, repeat after 10-20 min. until full atropinization (pulse 100-120, dilated pupils) and maintain on SC atropine 4-6 hours x 24-48 hours • Pralidoxime (PAM) 1 gm (children 30 mg/kg) STAT, repeat 4 hourly, 12-24 hours depending on response
Bipyridilium herbicides e.g. (paraquat, grammoxine)	Oral/pharyngeal inflammation, later multi-organ failure within hours or days depending on dose. Later interstitial pulmonary oedema and fibrosis Multi-organ failure or pulmonary oedema invariably leads to death!	• Lethal dose as low as 10 mls • Gastric lavage with 50-100 gm activated charcoal 4 hourly until patient improves.
Rodenticide (majority are oral anticoagulant based)	Generalised bleeding, with intracranial haemorrhage being most serious	• Vit. K 10 mg IV STAT • Fresh blood if anaemic
Chloroquine (mistaken for abortifacient)	Convulsions, cardiac arrhythmia, cardiac arrest	• Gastric lavage • IV diazepam for convulsions • Refer if in coma
Methyl Alcohol (methanol)	Intoxication, drowsiness, muscle weakness, blurred vision, photophobia, papilloedema blindness, coma, cerebral oedema, cardio-respiratory depression, seizures, DEATH	• IV sodium bicarbonate • 10% Ethanol/50% Dextrose/5% Dextrose • loading dose 0 7 g/kg over 1 hr. Maintain at 0 1-0.2 g/kg/hr up to ethanol level of 100 mg/d L • Haemodialysis
Carbon Monoxide Automobile exhaust/charcoal jiko Acetylene gas	Vary with percentage of carboxyhaemoglobin • Headache, vertigo, confusion, dilated pupils, convulsions, coma	• 100% oxygen • Hyperbaric oxygen • Respiratory support
Digoxin	Arrhythmias, ventricular fibrillation, anorexia, nausea, vomiting, confusion, ambylopia	• Discontinue drug, potassium administration • Treat arrthymias with lidocaine OR phenytoin • Antidigoxin FAB fragments
Heparin	Bleeding tendencies, gums, petechial haemorrhages, GIT bleeding	Protamine sulphate
Iron ferric salts, FeSO4, Vitamins with iron	Vomiting, abdominal pain, pallor, cyanosis, diarrhoea, shock	• Emesis • Gastric lavage • Deferoxamine 1 gm IV • Exchange transfusion
Isoniazid	CNS stimulation, seizures, coma	• Emesis, gastric lavage • Diazepam • Pyridoxine (1 mg for 1 mg ingested up to 200 mg) • Sodium bicarbonate for acidosis
Lead: lead salts, solder, paints and painted surfaces	Acute ingestion: thirst, abdominal pain, vomiting, diarrhoea, lead encephalopathy	Chelation (after source of Lead elimination) Dimercapol (BAL) • Calcium sodium editate
Mercury: All mercury compounds, diuretics, mercuric chloride	Acute: gastroenteritis, vomiting, nephritis, anuria Chronic: gingivitis, mental disturbances, neuro deficits, pneumonitis	• Gastric lavage • Activated charcaol • Penicillamine • Haemodialysis for renal failure • Look out for GIT perforation. Lungs: supportive care
Opiates/narcotics	Drowsiness, pin-point pupils, shallow respiration, spasticity, respiratory failure	• Do not give emetics • Gastric lavage, • Activated charcoal • Naloxone 5 μg/kg IV to awaken and improve respiration • IV fluids to support circulation
Warfarin sodium	Bleeding tendencies	Vitamin K 10 mg IV STAT + OD for 5 days

Clinical Monitoring

• Blood pressure measurement

• Urine output (1-2 mls/kg/hr) catheterise

• Nasogastric suction in abdominal conditions

• Blood glucose levels

• Hb or PCV daily and correct appropriately

Treat renal complications appropriately, and more importantly treat the cause of the hypovolaemia to pre empt these complications. Remember to consult in this very dire emergency.

SEPTIC SHOCK

Clinical Features

Due to systemic sepsis. Initially "warm shock": increased heart rate; diaphoresis; warm skin. Later "cold shock": decreased cardiac output; cool vasoconstricted skin.

Complications

• Pulmonary oedema

• Renal Failure

• Disseminated Intravascular Coagulation (DIC), bleeding.

Investigations

• Hb, Wbc, Platelets

• Urea & electrolytes, creatinine

• Blood sugar

• C&S (blood and body fluids).

Management - General

• Resuscitate with normal saline or dextran 70 - large volumes may be required but watch for heart failure. A CVP line is useful

• Hourly pulse and BP

• Catheterise and monitor urine output hourly - if less than 20 ml/hr after adequate fluid replacement then give frusemide 80 mg IV STAT

• Oxygen via face mask

• Definitive treatment of cause.

Management - Pharmacologic

• Start empirically on:

Crystalline penicillin 4 mega units IV QDS
+ gentamicin 80 mg IV 8 hrly
+ metronidazole 500 mg IV 8 hrly or 1 gm suppositories or tablets rectally 8 hrly. Oral metronidazole can be started as soon as patient is able to swallow

• Specific antibiotics depend on source of infection and C&S results.

Resuscitation measures should be commenced immediately the patient is seen.

Refer If

• Complicated.