History:

 

• Blood loss
  • Vaginal/gastrointestinal bleeding
  • AAA
  • Ectopic
• Fluid loss
  • Vomiting
  • Diarrhea
  • Fever
  • Infection
• Cardiac ischemia (MI/CHF)
• Medications
• Allergic reaction
• Pregnancy
• History of poor oral intake

 

Significant Findings:

 

• Restlessness
• Confusion
• Weakness
• Dizziness
• Weak, rapid pulse
• Pale, cool, clammy skin
• Delayed capillary refill
• Coffee-ground emesis
• Tarry stools

 

Differential:

 

• Shock
  • Hypovolemic
  • Cardiogenic
  • Septic
  • Neurogenic
  • Anaphylactic
• Ectopic pregnancy
• Dysrhythmias
• Pulmonary embolus
• Trauma
• Tension pneumothorax
• Medication effect/overdose
• Vasovagal
• Physiologic (pregnancy)
• Pulmonary edema (CHF)

 

Rule out pulmonary edema (CHF)

 

Treatment:

 

• Oxygen

• Initiate IV/IO

• 12-Lead EKG

 

Hypotension due to cardiogenic shock (tachycardia) ?

 

• Yes

 

• • Normal Saline 500 mL Bolus

 

• • Levophed (Norephinephrine) 2-30 mcg/min IO/IV; titrate to maintain a MAP >65

 

Non-trauma Non-cardiac (Possible Sepsis/Neurogenic)?

 

• Yes

 

• • Normal Saline up to 1,000 mL IV/IO

 

• • Push Dose EPI 10-20 mcg (1-2 ml) every 3-5 mins

 

                                          OR

 

• • Levophed (Norephinephrine) 2-30 mcg/min IO/IV; titrate to maintain a MAP >65

 

 

 

Improvement ?

 

• No

 

• • OLMC: Request Additional Fluid

 

• Yes

 

• • Notify receiving facility or contact
  • Medical Control

 

Hypotension due to bradycardia ?

 

• Yes

 

• • See Bradycardia Protocol

 

PEARLS:

 

• Consider all possible causes of shock and treat per appropriate protocol.
• For non-cardiac/non-trauma shock, Push Dose Epi can be given prior to Levophed (Norephinephrine) infusion.
• In the presence of cardiogenic shock and pulmonary edema/respiratory distress, fluid should be withheld in favor of giving pressers.
• Hypotension can be defined as a systolic blood pressure of less than 90, however, shock is often present with a normal blood pressure and tachycardia may be the only manifestation.
• Assess lung sounds frequently.
• Push Dose Epi: Mix 1 ml of Epi 1:10,000 with 9 ml NS=Epi 1:100,000. Admin 1-2 ml (10-20 mcg) every 3-5 minutes for hypotension.