Initial evaluation of shock in the adult trauma patient and management of NON-hemorrhagic shock
- Christopher Colwell, MD
Christopher Colwell, MD
- Chief of Emergency Medicine
- Zuckerberg San Francisco General Hospital and Trauma Center
- Professor and Vice-Chair, Department of Emergency Medicine
- University of California at San Francisco School of Medicine
- Section Editor
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Shock refers to inadequate tissue perfusion, which manifests clinically as hemodynamic disturbances and organ dysfunction. At the cellular level, shock results from insufficient delivery of required metabolic substrates, principally oxygen, to sustain aerobic metabolism.
In the setting of trauma, loss of circulating blood volume from hemorrhage is the most common cause of shock. Inadequate oxygenation, mechanical obstruction (eg, cardiac tamponade, tension pneumothorax), neurologic dysfunction (eg, high-spinal cord injury), and cardiac dysfunction represent other potential causes or contributing factors . Shock is a common and frequently treatable cause of death in injured patients and is second only to brain injury as the leading cause of death from trauma [2,3].
This topic will review the evaluation of shock in the adult trauma patient, focusing on recognition of shock, basic initial management, and acute interventions needed to treat non-hemorrhagic causes of shock. General management of the adult trauma patient, management of hemorrhagic shock, and other aspects of shock, including the pathophysiology and differential diagnosis, are discussed separately. (See "Initial management of trauma in adults" and "Initial management of moderate to severe hemorrhage in the adult trauma patient" and "Definition, classification, etiology, and pathophysiology of shock in adults".)
The pathophysiology of shock primarily relates to an imbalance in oxygen supply and demand. Patients in shock suffer from a critical reduction in the oxygen available to the mitochondria. Adenosine triphosphate (ATP) can still be synthesized by anaerobic glycolysis but at only 5 to 10 percent of the normal rate . Anaerobic glycolysis results in the accumulation of pyruvate, which is converted to lactate . The pathophysiology of shock is discussed in greater detail separately. (See "Definition, classification, etiology, and pathophysiology of shock in adults".)
The compensatory physiologic responses to acute hemorrhage attempt to maintain adequate oxygen delivery to tissues. Stimulation of the sympathetic nervous system results in an increased heart rate, vasoconstriction, and increased ventricular contractility. As the shock state progresses, vital organ (eg, brain and heart) perfusion can only be maintained at the expense of nonvital organs. If the process is not reversed, progressive lactate production leads to worsening systemic metabolic acidosis, which along with hypoxemia ultimately causes the loss of peripheral vasoconstriction and cardiovascular collapse.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- DIFFERENTIAL DIAGNOSIS
- RECOGNITION OF SHOCK
- PREHOSPITAL MANAGEMENT
- INITIAL HOSPITAL MANAGEMENT
- Basic approach and initial interventions
- Fluid resuscitation and blood transfusion
- Interventions for non-hemorrhagic threats to life
- Reversal of anticoagulation
- Laboratory evaluation
- IMMEDIATE INTERVENTIONS TO MANAGE NON-HEMORRHAGIC SHOCK
- Pericardial tamponade
- Emergency thoracotomy
- Neurogenic shock
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS