Leading Indicators of Shock

[Steve Whitehead]

I came up with this idea while reading some of the feedback in the "Shock Index" thread I posted last week.

The previous thread brought forward a lot of good discussion about recognition of shock and what indicators were thought to be reliable and unreliable. Another theme was early vs late indicators of shock states. It reminded me of years back when I learned about analyzing stocks and predicting their movements. Some signs were considered reliable and others were considered unreliable. Some indicators were considered "leading indicators" meaning they appeared early and others were considered "trailing indicators" meaning that they appeared late in the stocks movement. (These are sometimes referred to as confirming indicators.) As you might guess, leading indicators were less reliable that trailing indicators. (Had less predictive value.)

I imagine that, between the folks who frequent this forum, we've collectively assessed and treated shock presentations in the six figure patient range. I'd like to know, what do you all feel are the most reliable early indicators of shock? What are the most unreliable indicators? If you had to make a list of the best assessment findings or symptom constellations to identify shock early in the compensated phase, what would they be?

Two disclaimers:

1) I understand that they type of shock will change the constellations of symptoms, especially when we're considering skin signs.

2) If I get a bunch of good feedback, I may make this into a blog post. If you'd like your input excluded from the blog post, please say so.

[Bieber]

In my limited experience, the two most common things I've seen in patients in shock are pallor, diaphoresis and tachycardia. I'm not sure what I would say is the least reliable indicator of shock though, honestly. Maybe tachycardia, but that's mostly because the heart rate seems to vary so much from person to person and there are so many extrinsic and intrinsic factors that can alter it. No clue if my experience is at all representative of shock patients as a whole, but from my limited window of experience, that's what I've seen.

[mobey]

I like to use the shock index.

OK, being a smartass. I have a few things that will be productive to your thread, but I want to find some studies to support them. I'll post them later tonight.

[chbare]

With the caveat already discussed, my top two indicators would include both a quantitative and qualitative assessment modality:

Quantitative:

Elevated serum lactate level.

Qualitative:

Changes in mental status.

[Asysin2leads]

Well, most shock that we deal with is either hypovolemic or cardiogenic. The early warning signs of hypovolemic shock are subtle, but I think fairly regular. Almost everybody has probably been mildly to moderately hypovolemic at some point, be it after a long flu, or out exercising with inadequate fluid intake. What do you usually feel like? Like crap, to put it bluntly. A pounding headache, weakness, maybe a little dizziness, irritability, dry mouth, a racing heart, in a person who is sick or mildly dehydrated, these signs are not particularly troublesome, they can usually be alleviated with some fluids. But in a person who you've ruled out vomiting, nausea, or dehydration, particularly someone who is at risk for internal bleeding, these signs are extremely relevant.

[Steve Whitehead]

Mobey, your initial response gave me a huge smile. i probably would have openly laughed if I hadn't been in a room full of people. Thanks for that. I'd love to hear what people who are using serum lactate as an early indicator. I'm using it in my rig (in the context of septic shock) and I'm finding it very relevant and useful.

I was wondering how quick mentation changes would come up. I don't personally feel that true confusion is an early sign of shock but I certainly agree with Asys on the weakness, malaise and generalized dizziness / instability. I've seen some folks in fairly profound shock who were still able to speak in context and oriented. (Slow, sluggish and weak...but oriented.) I'd like more input here.

Pallor... good one. How many times have you seen compensated shock that wasn't pale? (With the exception of anaphylactic shock.) Come to think of it, I've seen some pretty pale anaphylactics too.

Mobey, last thing. Research is great, but I don't mind hearing subjective opinion here as well. The science of what we do is critically important. If you find relevant research, please pass it on to us all. But our personal experiences touch in the art of what we do. I know a lot of people dismiss the art. I don't.

Now I should be quiet for a while and let this develop without my intrusive nonsense.

[HERBIE1]

We could go on all day about the clinical signs and symptoms as well as the textbook definition, so I'll stay fairly subjective and anecdotal here. Pallor is good, weakness, general malaise, simply looking like crap. Depending on the type of shock, I think we can all pretty much say that if we have a GI bleeder for example, it's pretty obvious if they are in trouble. Quiet patients of these types scare me- soft spoken, appear apprehensive, weak, fearful- they generally are the ones who are severely compromised. I had one GI bleeder lying in bed- looking like crap, and before we could even get vitals he sat up to greet us, had a syncopal episode, and arrested. As we were leaving his house, only then I noticed the massive amount of blood on his bathroom floor and toilet.

It drives me crazy that I still need to remind some folks I work with that just because someone is normotensive, it does NOT mean they are not in shock. Hypotension is such a late sign that by that time, the person is in real trouble.

Good topic.

[BushyFromOz]

Pallor and + or - sweating but with tachypnoea in the low 20's without a reasonable cause always gets me thinking. Skin and resp rate is evident so much earlier than tachycardia and hypotension. It really irks me to see patients who clearly have a perfusion problem but dont get managed Because they are GCS 15, normotensive with pulse rate in the high end of normal. Hyovoleamia and anaphylactic shock are generally well recognised, cardiogenic not too bad but i think we generally do a poor job of identifying sepsis and septic shock

[Kiwiology]

i think we generally do a poor job of identifying sepsis and septic shock

This.

I think septic shock is fairly easily recognised but that sepsis (in particular meningococcaemia) is an absolute atrocious bastard of a thing to recognise as it can present very subtly especially in early stages and you know how it goes leave patient at home with some panadol next minute dead whoops

Now technically sixty hundred billion of the people that present to ambo have "sepsis" because they meet SIRS physiologic signs and symptoms of an infection (which are also symptoms of sixty hundred billion other things). The trick is to differentiate between the fit young man who is a bit tachycardic and has been febrile for two days and just needs some antibiotics and panadol and can stay at home vs. nana with a morphine pump in the rest home who has been febrile and tachycardic for two days who is probably the latest victim of community acquired sepsis and needs to go to the hospital.

I've updated my living will to include limited resuscitation (no adrenaline and no intubation or ventilation until ROSC) and no long term care facility

[Bieber]

With the caveat already discussed, my top two indicators would include both a quantitative and qualitative assessment modality:

Quantitative:

Elevated serum lactate level.

Qualitative:

Changes in mental status.

Oh, to have lactate meters here. I know there's a service up north that's started carrying them, primarily for sepsis patients.