Level 2 of 6Must-remember

Principles of resuscitation and the ABCDE approach

Assess, manage and stay safe — enough on its own

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The card — assess, manage, caution

Assessment— look, ask, measure

Ask what has changed: the two most useful historical markers of new organ dysfunction are newly altered mental status and a fall in urine output, so ask the patient, the family or the ward staff about both before anything else.
Airway sounds tell you the obstruction: snoring means the tongue, gurgling means secretions, blood or vomit, stridor means upper airway obstruction, and silence with visible respiratory effort means complete obstruction — while a patient who answers in a full sentence has a patent airway, ventilation adequate for phonation and cerebral perfusion sufficient for comprehension.
Breathing — count the rate: tachypnoea is among the earliest abnormalities and compensates for developing metabolic acidosis; distress is signalled by inability to speak in full sentences, accessory muscle use, paradoxical abdominal movement and a rate above 40 breaths/min, and a falling rate in a patient who still appears distressed is pre-terminal, not improvement.
Circulation — put a hand on the patient: warm peripheries with bounding pulses, rapid capillary refill and a wide pulse pressure mean high output and therefore a distributive process, while cool, clammy, mottled peripheries with delayed refill and a narrow pulse pressure mean low output; palpate the thigh rather than the fingers, because patients with peripheral vascular disease always have cool distal extremities.
Jugular venous pressure separates the low-output states: low (below 8 cm) in hypovolaemia, raised in cardiogenic and obstructive shock, with pulsus paradoxus and a raised JVP suggesting tamponade.
Disability: record AVPU, then a Glasgow Coma Scale broken into its three components E, V and M (a total score conveys much less), check pupils, tone, posture and seizure activity, and measure a capillary glucose in every patient with impaired consciousness.
Exposure: undress fully, examine front and back, then re-cover — looking for a purpuric non-blanching rash, urticaria and angio-oedema, cellulitis, abscess, necrotic tissue, an infected line site, injection or bite marks, large ecchymoses suggesting occult retroperitoneal bleeding, and transdermal opioid or nitrate patches.
Measure a true core temperature with a device reading well below 35°C, because an ordinary clinical thermometer cannot diagnose hypothermia.
The three windows onto organ perfusion are the brain, the kidney and the skin: new confusion, urine output below 0.5 mL/kg/hr, and cold mottled skin with delayed capillary refill — any of these with a plausible precipitant is shock until proved otherwise, whatever the blood pressure.
Hypotension is conventionally SBP below 90 mmHg or MAP below 65 mmHg, but a value above these does not exclude shock — a chronically hypertensive patient may be profoundly hypoperfused at an SBP of 120 mmHg, so judge the pressure against that patient's own baseline and its trend.
Shock index (heart rate divided by systolic pressure) is normally 0.5–0.7; a value above 0.9 is a more sensitive marker of critical bleeding and transfusion need than heart rate or pressure alone and predicts post-intubation hypotension.
qSOFA: systolic pressure 100 mmHg or less, respiratory rate 22/min or more, altered mental status with GCS below 15 — two or more of three with suspected infection predicts substantially greater risk of death.
Lactate: above 2 mmol/L indicates hypoperfusion, above 2.4 mmol/L (22 mg/dL) marks severity, and above 8 mmol/L (72 mg/dL) carries extremely high mortality and demands immediate intensification of treatment.Not available at your setup — Arterial blood gas.
Classify the type at the bedside in three observations — peripheral temperature with pulse pressure (output), jugular venous pressure (filling) and chest auscultation (left-sided failure) — into distributive, cardiogenic, hypovolaemic or obstructive, because the type dictates treatment before any diagnosis is confirmed.
In children hypotension is very late and pre-terminal: the lower limit of acceptable systolic pressure for ages 1–10 years is approximately 70 + (2 × age in years) mmHg, so look instead for tachycardia, tachypnoea, capillary refill longer than 2 seconds, cool peripheries, reduced urine output and a change in alertness noticed by the parent.
Recognise the pre-arrest child: grunting, head bobbing, nasal flaring, a silent chest, a non-blanching rash, a bulging fontanelle, capillary refill beyond 4 seconds and bradycardia in a sick infant are pre-arrest signs, and a child too tired to cry is peri-arrest, not settling.

Management— do this, in order

Treat and diagnose at the same time: initiate therapy simultaneously with, not after, the evaluation of cause; initial assessment should take only a few minutes and every intervention must carry a stated physiological endpoint that is checked afterwards.
Airway in escalating order: suction under direct vision; head tilt with chin lift (or jaw thrust alone where the cervical spine is not cleared); an oropharyngeal airway sized from the incisors to the angle of the jaw; two-person bag-valve-mask ventilation with a reservoir; a supraglottic airway; then tracheal intubation — and put an unconscious but adequately breathing patient in the recovery position meanwhile.Not available at your setup — Endotracheal intubation kit. If intubation is unavailable, continue two-person bag-valve-mask ventilation with an oropharyngeal or supraglottic airway and keep the patient in the recovery position.
Oxygen immediately: reservoir mask at 15 L/min in any shocked or hypoxic patient, then titrate to SpO₂ 92–95%, because both hypoxaemia and hyperoxia are harmful.
Before any induction drug is given, fluid must be running and a vasopressor drawn up — peri-intubation collapse kills; once ventilated, use lung-protective settings with low tidal volumes and optimised PEEP.Doctor / NurseNot available at your setup — Endotracheal intubation kit, Mechanical ventilator.
Access: two peripheral cannulae of 16 or 18 gauge fill a patient faster than a central line, and in extremis intraosseous access is quickest; draw every blood sample from the first cannula before connecting fluid, and catheterise for hourly urine measurement.Doctor / Nurse
Fluid is a drug — give a bolus with a predefined endpoint: typically 10 mL/kg, or 250–500 mL in an adult, then stop and reassess before the next.Doctor / Nurse
In suspected septic shock give a minimum of 30 mL/kg as initial resuscitation, delivered as repeated challenges with reassessment between each; in most other inpatients with a normal MAP there is no role for volumes exceeding 30 mL/kg.Doctor / Nurse
In haemorrhagic shock give red cells rather than more crystalloid, targeting a haemoglobin of 70–90 g/L (also the accepted target in sepsis); transfusion may be justified without haemorrhage below 70 g/L, and in massive transfusion platelets and fresh frozen plasma must accompany red cells.Doctor / NurseNot available at your setup — Blood & blood products.
Noradrenaline is the first-line vasopressor in distributive shock: IV infusion commonly from 0.05 micrograms/kg/min, titrated to MAP 65 mmHg or more; it may be started peripherally while central access is obtained, and where hypotension is severe it need not wait for the full 30 mL/kg.Doctor / NurseNot available at your setup — Infusion pump.
Add vasopressin 0.01–0.04 units/min as the second agent in refractory vasoplegia, and dobutamine 2.5–10 micrograms/kg/min where cardiac output is low in cardiogenic shock or septic cardiomyopathy.Doctor / NurseNot available at your setup — Infusion pump.
Adrenaline: 1 mg IV every 3–5 minutes in cardiac arrest; in anaphylaxis 0.5 mg IM (0.5 mL of 1:1000) into the anterolateral thigh repeated at 5 minutes — in children 0.15 mg under 6 years, 0.3 mg at 6–12 years, 0.5 mg over 12 years; paediatric arrest dose is 10 micrograms/kg IV/IO (0.1 mL/kg of 1:10 000) every 3–5 minutes.Doctor / Nurse
Hydrocortisone 100 mg IV then 200 mg per 24 hours (paediatric 1–2 mg/kg IV) for refractory hypotension, and in suspected adrenal crisis it is not optional — give it with fluid without waiting for confirmatory testing.Doctor / Nurse
Atropine 500 micrograms IV to a maximum of 3 mg for symptomatic bradycardia causing shock (paediatric 20 micrograms/kg IV, minimum 100 micrograms).Doctor / Nurse
Where septic shock is possible give broad-spectrum intravenous antibiotics as early as possible, after cultures only where those can be taken without delay, because every hour of delayed treatment is associated with a 5–10% increase in mortality; deliver the whole Sepsis Six — high-flow oxygen, blood cultures, intravenous antibiotics, serum lactate and full blood count, intravenous fluid and accurate urine output measurement — within one hour of suspecting the diagnosis.Doctor / NurseNot available at your setup — Blood culture. If cultures cannot be taken without delay, give the first antibiotic dose immediately — cultures must never delay treatment.
Hypoglycaemia (glucose below 4.0 mmol/L): 50 mL of 50% dextrose IV through a large free-flowing vein, or 100 mL of 20%, then recheck; in children 2 mL/kg of 10% dextrose IV, recheck at 15 minutes, then start a maintenance glucose infusion.Doctor / Nurse
Act at once on the causes that need a specific intervention: needle decompression then chest drain for tension pneumothorax (a clinical diagnosis — imaging must not precede treatment); pericardial drainage for tamponade; immediate PCI or thrombolysis where PCI is unavailable for STEMI with cardiogenic shock, with aspirin 300 mg chewed unless contraindicated; thrombolysis or clot removal for massive pulmonary embolism; naloxone titrated IV for opioid toxicity; and antibiotics plus antivirals immediately in suspected meningitis or encephalitis without waiting for lumbar puncture or imaging.Doctor / NurseNot available at your setup — Chest drain / tube thoracostomy.
In children estimate the weight first — for ages 1–10 years weight (kg) is approximately (age in years + 4) × 2 — then give fluid as 10 mL/kg of 0.9% sodium chloride over 10–20 minutes, stopping to reassess heart rate, capillary refill, conscious level, liver edge and lung fields before each further bolus; check capillary glucose in every sick child, and target urine output of 1 mL/kg/hr or more in children and 2 mL/kg/hr or more in infants.Doctor / Nurse
Return to A every few minutes and after every intervention: the four signs resuscitation is working are a falling lactate, rising urine output, warming peripheries with faster capillary refill and improving conscious level — blood pressure alone is the least reliable of them.

Caution— what harms

Shock is not a blood pressure: an isolated reading below 90 mmHg systolic or 65 mmHg MAP does not establish shock and a reading above them does not exclude it, and patients with peripheral vascular disease, autonomic dysfunction or antihypertensive medication may live at pressures that would signify catastrophe in another person.
Never be reassured by a normal pressure in a young adult: they compensate vigorously and hold a normal blood pressure for a long period before decompensating abruptly, so a normal pressure with marked tachycardia is an alarm.
The beta-blocked or conduction-diseased older patient may be profoundly shocked without tachycardia, and may be afebrile or hypothermic in severe sepsis, presenting only with delirium or a fall.
Do not keep giving fluid: in an inpatient with a normal MAP there is no role for volumes exceeding 30 mL/kg, over-resuscitation causes harm, and the correct strategy may reverse — a patient who develops ARDS or renal failure after initial resuscitation may need volume removal.
Warm the fluid: large volumes of cold fluid cause hypothermia and hypothermia causes coagulopathy.
Dopamine (5–20 micrograms/kg/min) is not first line: a randomised trial in all-cause shock showed no survival benefit, more arrhythmia, and increased mortality in the cardiogenic subgroup.
A fluid bolus with no named target is a habit, not a treatment, and in cardiogenic shock fluid may worsen the patient — give volume there only after careful assessment of filling.
A falling respiratory rate in a patient who still looks distressed is failure, not recovery, and is one of the four signs that resuscitation is failing along with a rising lactate despite adequate fluid, an escalating vasopressor requirement and falling urine output.
A normal haemoglobin is expected in a patient who has just started bleeding and excludes nothing; likewise a normal chest radiograph is neither sensitive nor specific for pulmonary embolism.
Peripheral oximetry is unreliable in the vasoconstricted, hypoperfused patient — when perfusion is poor, believe the blood gas rather than the probe.Not available at your setup — Arterial blood gas.
Fine, low-amplitude VF mimics asystole: if asystole cannot be confidently diagnosed, treat as VF and defibrillate; and never delay chest decompression in tension pneumothorax for a radiograph.Doctor / NurseNot available at your setup — Defibrillator.
Do not miss the two easily corrected causes of irreversible brain injury in the unconscious patient — hypoglycaemia and acute hyponatraemia.
Do not skip the monitoring: hourly urine measurement, serial lactate and lactate clearance, repeated ABCDE reassessment, and continuous MAP where an arterial line is available — a rising lactate despite adequate fluid means the treatment or the diagnosis is wrong.
Reconsider the diagnosis at around 60 minutes if first-line treatment fails: up to 20% of patients initially treated for sepsis have a non-infectious cause, and there may be an undrained source, an unrecognised obstructive cause or a second shock type superimposed on the first.

Refer / escalate

Escalate immediately for critical care or transfer when hypotension persists after adequate volume or any vasopressor is required, when the lactate rises despite adequate fluid, when GCS is 8 or less (loss of reliable airway protection), when there is a cause needing an intervention you cannot provide (PCI, thrombolysis, surgery, pericardial drainage, dialysis), and in any child with pre-arrest signs.

The card — assess, manage, caution

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