Toxic shock syndrome classic patient is woman of reproductive age who leaves tampons

in place too long. Look for skin, desquamation. Caused by Staphylococcus aureus toxin.

Note: ABCs (airway, breathing, circulation) come first. Patients in shock often need heroic measures to survive. Intubate at the drop of a hat, and keep NPO, avoid narcotics if possible (mental status changes are often an important clue to impending doom). Monitor EKG, vital signs, Swan-Ganz parameters, urine output, arterial blood gases (ABGs), hemoglobin, and hematocrit.

Note; Most patients in shock need fluid. The standard bolus is 10-20 ml/kg of normal saline (roughly 1—2 L infused as fast as it will go). After the bolus, reassess the patient to determine whether the bolus helped. Do not be afraid to bolus twice if the first bolus has no effect. Of course, you must watch for fluid overload, which may cause congestive heart failure (especially in cardiogenic shock when the patient is already in failure).

IV medications and their use to support blood pressure should be understood:

1. Dobutamine: betat agonist used to increase cardiac output by increasing contractility (ICU equivalent of digoxin).

2. Dopamine: low doses hit dopamine receptors in renal vasculature and keep kidney perfused. Higher doses have beta, agonist effects to increase contractility. Highest doses have alpha] agonist effects and cause vasoconstriction.

3. Norepinephrine: used for its alpha, agonist effects; given in hypotension to increase peripheral resistance so that perfusion to vital organs can be maintained. Also has beta agonist effects.

4. Phenylephrine: used for its alpha, agonist effects.

5. Epinephrine: used for cardiac arrest and anaphylaxis,

6. Milrinone/amrinone: phosphodiesterase inhibitors used in refractory heart failure (not first-line agents) because they have a positive inotropic effect.

Note: Remember Addison's disease as a cause of shock, especially in a postoperative patient who has taken steroids in the past year and recei ved no extra steroids perioperatively. Give patient steroids!

For shock in the setting of trauma, see trauma section (Surgery).

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