Level 1 of 6Core
Principles of resuscitation and the ABCDE approach
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- The three windows of shock: new confusion, urine output below 0.5 mL/kg/hr, and cold mottled skin with delayed capillary refill — any one with a plausible precipitant is shock until proved otherwise, whatever the blood pressure.
- Hypotension is SBP below 90 mmHg or MAP below 65 mmHg — but a value above these does not exclude shock; a chronic hypertensive may be profoundly hypoperfused at SBP 120 mmHg. Judge against the patient's own baseline and trend.
- Classify the type in three bedside observations: peripheral temperature with pulse pressure (output), jugular venous pressure (filling — low below 8 cm in hypovolaemia, raised in cardiogenic and obstructive), and chest auscultation (left-sided failure) — distributive, cardiogenic, hypovolaemic or obstructive.
- Airway sounds name the obstruction and the breathing rate warns first: snoring = tongue, gurgling = secretions/blood/vomit, stridor = upper airway obstruction, silence with effort = complete obstruction; a rate above 40/min is distress, and a falling rate in a patient who still looks distressed is pre-terminal, not improvement.
- Numbers that mark severity: lactate above 2 mmol/L is hypoperfusion and above 8 mmol/L carries extremely high mortality; shock index (HR ÷ SBP) above 0.9 flags critical bleeding; qSOFA ≥ 2 of (SBP ≤ 100, RR ≥ 22, GCS < 15) with suspected infection predicts substantially greater risk of death.Not available at your setup — Arterial blood gas.
- In children hypotension is very late and pre-terminal (lower limit of SBP for ages 1–10 ≈ 70 + 2 × age in years): act on tachycardia, tachypnoea, capillary refill over 2 seconds, cool peripheries and reduced alertness — grunting, silent chest, bradycardia and a child too tired to cry are pre-arrest signs.
Manage now— do this, in order
- Treat and diagnose at the same time — initiate therapy simultaneously with the evaluation of cause, and give every intervention a stated physiological endpoint that is checked afterwards.
- Airway in escalating order: suction under direct vision; head tilt–chin lift (jaw thrust if the cervical spine is not cleared); oropharyngeal airway sized incisors-to-angle-of-jaw; two-person bag-valve-mask with reservoir; supraglottic airway; then intubation — recovery position for the unconscious patient who is breathing adequately.
- Oxygen immediately: reservoir mask at 15 L/min in any shocked or hypoxic patient, then titrate to SpO₂ 92–95% — both hypoxaemia and hyperoxia are harmful.
- Access: two peripheral cannulae of 16 or 18 gauge (intraosseous in extremis) — draw every blood sample from the first cannula before connecting fluid, and catheterise for hourly urine measurement.Doctor / Nurse
- Fluid is a drug — bolus with a predefined endpoint: 10 mL/kg or 250–500 mL in an adult, then stop and reassess; in suspected septic shock a minimum of 30 mL/kg as repeated challenges; warm the fluid — cold fluid causes hypothermia and hypothermia causes coagulopathy. In haemorrhage give red cells rather than more crystalloid, targeting haemoglobin 70–90 g/L.Doctor / Nurse
- Noradrenaline is the first-line vasopressor in distributive shock: IV infusion from 0.05 micrograms/kg/min titrated to MAP ≥ 65 mmHg — it may be started peripherally, and in severe hypotension it need not wait for the full 30 mL/kg.Doctor / NurseNot available at your setup — Infusion pump.
- In possible septic shock give broad-spectrum IV antibiotics as early as possible (after cultures only where they cause no delay) — every hour of delay adds 5–10% to mortality; deliver the whole Sepsis Six within one hour.Doctor / NurseNot available at your setup — Blood culture. Inability to obtain cultures must never delay the first antibiotic dose.
- 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.Doctor / Nurse
- Act at once on the causes needing a specific intervention: needle decompression then chest drain for tension pneumothorax — a clinical diagnosis, imaging must not precede treatment; adrenaline 0.5 mg IM (0.5 mL of 1:1000) into the anterolateral thigh for anaphylaxis, repeated at 5 minutes; hydrocortisone 100 mg IV with fluid in suspected adrenal crisis without waiting for testing.
- Return to A every few minutes and after every intervention. The four signs it is working: falling lactate, rising urine output, warming peripheries with faster capillary refill, improving conscious level — blood pressure alone is the least reliable.
Classify the shock at the bedside
| Distributive | Cardiogenic | Hypovolaemic | Obstructive | |
|---|---|---|---|---|
| Peripheries | Warm, bounding | Cold, clammy | Cold, clammy | Cold, clammy |
| Pulse pressure | Wide | Narrow | Narrow | Narrow |
| JVP | Low | Raised | Low (< 8 cm) | Raised |
| Response to fluid | Improves then plateaus | May worsen | Improves markedly | Little or none |
Refer / escalate
Escalate immediately for critical care or transfer when hypotension persists after adequate volume or any vasopressor is required, when lactate rises despite adequate fluid, when GCS is 8 or less, when a needed intervention (PCI, thrombolysis, surgery, pericardial drainage, dialysis) is unavailable, and in any child with pre-arrest signs.
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