Emergency management
Metabolic and Poison
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Shock Management

  1. If BP unrecordable call the cardiac arrest team
  2. ABC (inc high flow Oxygen )
  3. Raise foot of bed
  4. Wide bore IV access both arms
  5. Identify and treat underlying cause
  6. Infuse crystalloid fast to raise BP (beware not to overload in cardiogenic shock)
  7. Seek expert help early
  8. Ix: FBC, U+E (pre-renal failure?), ABG (lactic acidosis?), glucose, CRP
    ECG: ischaemia
    Cross-match, clotting
    Blood cultures, urine culture, ECG, CXR
    Others: lactate, echo abdo CT, USS
  9. Consider arterial line, CV line, bladder catheter (urine flow> 30ml/h)
  10. If persistently hypotensive consider inotropes
  11. Management:
    1. Anaphylaxis: below
    2. Cardiogenic: below
    3. Septic: IV cefuroxime
    4. Hypovolaemic: Fluid replacement. Saline/colloid, if bleeding use blood. Titrate against BP, CVP, urine output.
    5. Heat exposure: tepid sponging and fanning


BP sys <90mmHg. Pallor, tachycardia, ↓Capill refill, air hunger, oliguria


Pump failure
Cardiogenic shock, secondary (eg pulmonary emoblism)
Peripheral circulation failure
Hypovolaemia, anaphylaxis, sepsis, neurogenic, endocrine failure (Addisons or hypovolaemia), iatrogenic

Anaphylactic shock

  1. Secure airway. 100% oxygen. Intubate if obstruction imminent
  2. Remove the cause. Raise the feet.
  3. Adrenaline: IM 0.5mg (ie 0.5ml of 1:1000) .
  4. IV access
  5. Chorphenamine 10mg IV and hydrocortisone 200mg IV
  6. IVI 0.9% saline. Titrate against BP
  7. If wheeze treat for asthma
  8. If still hypotensive asmit to ITU.

NB: Adrenaline is only given IV if patient severely unwell or has no pulse. 1ml of 1:10,000 solution per minute. Stop when response noted.


Type I IgE mediated hypersensitivity reaction. Release of histamine causes: capillary leak, wheeze, cyanosis, oedema, urticaria

Common preciptants

Drugs (eg penicillin, contrast media), latex, stings


Itching, erythema, urticaria, oedema.
Wheeze, laryngeal obstruction, cyanosis.
Tachycardia, hypotension.

Cardiogenic Shock

  1. Oxygen
  2. Diamorphine 2.5mg-5mg for pain and anxiety
  3. Ix concurrently: ECG, U+E, CK, ABG, CXR, echo. CT thorax (dissection), VQ scan (PE)
  4. Monitor: CVP, BP, ABG, U+E, urine output, consider Swan-Ganz catheter
  5. Correct arrhythmias, U+E abnormalities, acid-base disturbances
  6. Consider plasma expander or inotropic support (eg dobutamine)
  7. Look for and treat reversible cause


MI, arrhythmia, pulmonary embolus, tension pneumo, cardiac tamponade, valvular, dissection
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