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СКАЧАТЬ with early signs of hypovolaemia is suggestive of severe loss.

6.5 Principles of treatment

      Hypovolaemic shock

      Primary survey and resuscitation should be carried out according to the ABC principles. See Chapter 10 for the management of A and B.

       C: Circulation

      A diagnosis of hypovolaemic shock must be promptly followed by:

       Restoration of adequate oxygen delivery to the tissues by restoration of adequate circulating volume and adequate oxygen carrying capacity (see Chapter 8 for intravenous fluids)

       Stopping the bleeding (see Chapter 28 for major obstetric haemorrhage)

      Consider haemorrhage to be of two types:

       Compressible

       Non‐compressible

      Compressible haemorrhage is controllable by direct pressure, limb elevation, packing, by reduction and immobilisation of fractures or, in obstetric situations, compression of the uterus.

      Non‐compressible haemorrhage occurs in a body cavity (chest, abdomen, pelvis or retroperitoneum). See Chapters 17, 18 and 21 for haemorrhage in trauma.

      Septic shock

      Septic shock complicating delivery may be caused by infection from the genital tract, but can occur with any source of infection, for example a urinary tract or chest infection.

      The development of shock is due to a dysregulated systemic inflammatory and immune response to microbial invasion that results in vasodilatation, hypotension and organ dysfunction. Septic patients have a metabolic acidosis with a raised lactate, detectable on sampling of arterial or venous blood.

      In trauma patients, sepsis is unlikely to cause shock at presentation. It is most likely to develop later in patients with penetrating abdominal injuries and in whom the peritoneal cavity has been contaminated by intestinal contents.

      The key to management is a high degree of suspicion, rapid diagnosis and urgent treatment, as perinatal sepsis is a rapidly progressive disease. Pregnant women with septic shock will require early referral to critical care. See Chapter 7 for further information on maternal septic shock.

      Cardiogenic shock

      Cardiogenic shock in pregnancy is a life‐threatening condition due to failure of the ventricles to produce an adequate cardiac output. Ischaemic heart disease, valvular heart disease, arrhythmia, cardiomyopathy and pulmonary and amniotic fluid embolism are the main causes of cardiogenic shock in pregnancy.

      In trauma, patients can develop cardiogenic shock due to penetrating injury, cardiac tamponade, tension pneumothorax and myocardial contusion.

      There is a significant overlap in the signs and symptoms between these forms of shock and hypovolaemic shock. One distinguishing feature is the extreme air hunger and orthopnoea seen in patients suffering cardiogenic shock. Listening to the chest may give clues of congestion due to increased pressure in the pulmonary circulation causing pulmonary oedema.

Cardiogenic shock has a high mortality and mandates multidisciplinary consultant management with involvement from cardiology, cardiac surgery and critical care. Transfer to a centre able to offer complex invasive cardiac support may be required.

      Anaphylactic shock

      The diagnosis is made on clinical grounds and should be considered if the patient develops:

       Unexplained hypotension or bronchospasm

       Unexplained tachycardia or bradycardia

       Angioedema (often absent in severe cases)

       Unexplained cardiac arrest where other causes are excluded

       Cutaneous flushing in association with one or more of the above signs (often absent in severe cases)

Box 6.1 Management of anaphylactic shock

       Stop administration of drug(s)/blood product likely to have caused anaphylaxis

       Resuscitation as for any collapse following ABC principles with reassessment

       The key treatment therapies are oxygen, adrenaline and fluids. Adrenaline is very effective and should be given as early as possible

       Cardiopulmonary resuscitation (CPR) should be considered when systolic blood pressure is <50 mmHg or the patient is in cardiac arrest

      Source: Adapted from AAGBI (Association of Anaesthetists of Great Britain and Ireland). Quick Reference Handbook 3‐1 Anaphylaxis, 2019

Treatment of anaphylactic shock (Box 6.1) is as follows:

      1 Call for help and note the time.

      2 Call for cardiac arrest trolley, anaphylaxis treatment and investigation pack (should be in theatre recovery – familiarise where it is kept in your unit).

      3 Remove all potential causative agents.

      4 Manual uterine displacement.

      5 Open and maintain airway. Give high‐flow/100% oxygen and ensure adequate ventilation. Intubation may be required for severe stridor or cardiorespiratory collapse.

      6 Elevate the legs if there is hypotension.

      7 If systolic blood pressure is <50 mmHg or there is cardiac arrest start CPR.

      8 Give drugs to treat hypotension:Adrenaline 0.5 mg (0.5 ml of 1:1000) intramuscularly every 5 minutes until there is improvement in the pulse and blood pressure. Intravenous adrenaline may be used by experienced (anaesthetic) staff in a monitored patient in 50 microgram boluses (0.5 ml of 1:10 000) titrated against response.If intravenous access proves difficult obtain intraosseous access. Hypotension may be resistant and require prolonged treatment.Consider starting an adrenaline infusion after three boluses: 5 mg in 500 ml dextrose (1:100 000) titrated to effect, or 3 mg in 50 ml 0.9% saline started at 3 ml/h (= 3 micrograms/min) titrated to maximum of 40 ml/h (40 micrograms/min).Glucagon 1 mg repeated as necessary in beta‐blocked patient unresponsive to adrenaline.If hypotension resistant give alternate vasopressor: metaraminol, noradrenaline СКАЧАТЬ