Facilitator - WHO Western Pacific Region - World Health Organization

Module 6: Patient assessment & evaluation
SLIDE 11: Haemodynamic changes in hypotensive shock
•Facilitator
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explains the critical signs:
•Worsening hypovolaemic shock manifests as increasing tachycardia and peripheral
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vasoconstriction.
•Not only are the extremities cold and cyanosed, but the limbs become mottled, cold and clammy.
•By this stage, the breathing becomes more rapid and increases in depth, a compensation for
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the metabolic acidosis (Kussmaul’s breathing).
•Finally, there is decompensation and both systolic and diastolic blood pressures disappear
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suddenly and dramatically; the patient becomes hypotensive.
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•At this time, the peripheral pulses disappear while the central pulse (femoral) will be weak.
•Hypotension develops when physiologic attempts to maintain systolic blood pressure and
perfusion are no longer effective.
SLIDE 12: Hemodynamic Assessment – Hypotensive Shock
•Facilitator
•
explains:
•One key clinical sign of this deterioration is a change in mental state as brain perfusion declines.
The patient becomes restless, confused and extremely lethargic. Seizures may occur. Agitation
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may alternate with lethargy.
•Early ominous signs of cortical hypoperfusion in infants and children are failure to recognize,
focus or make eye contact with parents and failure to respond to painful stimuli such as
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venepuncture.
•Parents may be the first to recognize these signs, but they may be unable to describe them
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other than to say something is wrong. Listen to parents!
•On the other hand, children and young adults have been known to have clear mental status
even in profound shock, and adults have been known to be able to work until the stage of
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profound shock.
•Hypotension is a late finding and signals an imminent total cardiorespiratory collapse.
SLIDE 13: Haemodynamic Assessment – Monitoring Urine Output
•Facilitator
•
explains:
•The urine output reflects renal blood flow and perfusion. Close monitoring of urine output is
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thus an important aspect of haemodynamic monitoring.
•In the outpatient setting, the patient should drink enough fluids to pass urine about 4 to 6
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times a day.
•In early shock state, with reduced renal perfusion, kidneys conserve fluids by reducing urine
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volume. In severe shock, no urine is produced.
•An indwelling catheter will give an accurate measurement. The minimal amount of urine for a
dengue shock patient is about 0.5 ml/kg/hr. If the urine output is more than this amount and
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the patient is stable, you should consider reducing the IV fluid therapy.
•Do remember that patients with uncontrolled diabetes or hyperglycaemia may produce
inappropriately large quantities of urine (glycosuria). This should not be considered adequate
at all. In fact, the shock becomes worse because of glycosuria.
SLIDE 14: Haemodynamic Assessment – Hypotensive Shock (cont.)
SLIDE 15: Definition of hypotension
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