How the resuscitation changes the cardiogenic shock, hypovolemic shock, septic shock, and... Cardiac resuscitation. According to Sri Lankan guidelines. And an epileptic shock
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Do you mean anaphylactic shock rather than “epileptic shock”? Also, should I cover adult resuscitation (Sri Lankan practice) or paediatric care?
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Which condition did you mean by “epileptic shock”? · Which resuscitation guidance do you need?
Do you mean anaphylactic shock rather than “epileptic shock”? Also, should I cover adult resuscitation (Sri Lankan practice) or paediatric care?
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Sri Lanka adult resuscitation guidelines cardiogenic hypovolemic septic anaphylactic shock cardiac arrest
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shock resuscitation
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site:health.gov.lk "Accident & Emergency Care Manual" Sri Lanka PDF shock resuscitation
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Sri Lanka College Emergency Physicians anaphylaxis septic shock resuscitation guideline
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https://www.slcep.lk/index.php/els-resources
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“Epileptic shock” is not a standard type of shock. You may mean anaphylactic shock. I have included both anaphylaxis and the immediate approach to an ongoing seizure/status epilepticus.
For Sri Lankan adult emergency care, start with the same ABCDE resuscitation for every critically ill patient, then change the treatment according to the shock mechanism. The Sri Lankan Ministry of Health A&E guideline classifies cardiac arrest, ongoing seizures, respiratory arrest, and profound hypotension with hypoperfusion as immediate, life-threatening emergencies requiring resuscitation and senior help. The Sri Lanka College of Emergency Physicians also provides local emergency-learning resources on allergy, sepsis, shock-related presentations, and seizures. See the Sri Lankan MoH A&E guidance and SLCEP emergency resources.
1. First actions in all shock states
- Call for help, move to resuscitation area, monitor ECG, SpO₂, non-invasive BP, temperature.
- Airway: protect airway, suction if needed.
- Breathing: give oxygen if hypoxaemic or in respiratory distress. Assist ventilation if inadequate.
- Circulation:
- Two large-bore IV lines, or intraosseous access if IV access fails.
- Blood tests: FBC, crossmatch, electrolytes, renal function, glucose, lactate, blood gas as available.
- Check capillary refill, skin temperature, mental status, urine output, lactate, and BP.
- Reassess after every intervention. The aim is restoration of perfusion, not simply raising BP.
- Look for and treat the cause immediately.
2. How resuscitation differs by type of shock
| Type | Main problem | Fluids | Main specific treatment | What to avoid |
|---|---|---|---|---|
| Hypovolaemic shock | Too little circulating volume, often haemorrhage | Rapid warmed crystalloid initially if appropriate; in major bleeding, prioritise blood products | Stop bleeding: pressure, tourniquet where appropriate, surgery/interventional radiology, obstetric or GI cause control | Delaying haemorrhage control; excessive crystalloids in major bleeding |
| Septic shock | Vasodilatation, capillary leak, infection | Balanced crystalloid, given in boluses with frequent reassessment | Early antibiotics, cultures if they do not delay treatment, source control; norepinephrine if hypotension persists | Delay in antibiotics/source control; continuing fluids despite overload |
| Cardiogenic shock | Pump failure, usually acute MI or severe cardiac dysfunction | Only small, cautious test boluses if fluid responsive and no pulmonary oedema | ECG, urgent reperfusion for MI, norepinephrine for hypotension, consider dobutamine for low output, specialist cardiac/ICU care | Large fluid boluses, especially with pulmonary oedema |
| Anaphylactic shock | Allergy-mediated vasodilatation, capillary leak and airway oedema/bronchospasm | Rapid IV crystalloid if hypotensive | Immediate IM adrenaline, remove trigger, airway support | Waiting for rash or giving antihistamine/steroid instead of adrenaline |
A. Hypovolaemic or haemorrhagic shock
Typical signs: tachycardia, cold clammy skin, delayed capillary refill, low urine output, hypotension late.
Resuscitation
- Control external haemorrhage immediately.
- Use pelvic binder when indicated in suspected unstable pelvic trauma.
- Give warmed crystalloid while blood is being obtained, but for major haemorrhage move early to blood-component resuscitation according to local massive transfusion availability.
- Keep the patient warm and correct hypocalcaemia/coagulopathy during massive transfusion.
- Definitive treatment is stopping the loss: operating theatre, endoscopy, obstetric intervention, etc.
For non-haemorrhagic fluid losses, such as severe diarrhoea or vomiting, crystalloid fluid replacement is the core treatment. Textbook guidance describes hypovolaemic shock as low preload and low cardiac output, with crystalloid resuscitation for dehydration or fluid loss. Sabiston Textbook of Surgery, hypovolaemic shock section.
B. Septic shock
Typical signs: suspected infection plus hypotension or hypoperfusion, raised lactate, altered mentation, oliguria. Early sepsis can be warm with bounding pulses; later it may become cold.
Resuscitation
- Give IV crystalloid in repeated boluses and reassess lung signs, BP/MAP, capillary refill, urine output and lactate.
- Take blood cultures and other samples if this does not delay antibiotics.
- Start broad-spectrum IV antibiotics early, selected for the likely source and local Sri Lankan hospital antimicrobial policy.
- Find and control the source: drain abscess, remove infected device, relieve obstruction, debride infected tissue, etc.
- If hypotension persists after adequate fluid assessment, start norepinephrine, usually targeting MAP about 65 mmHg in an adult.
- Consider ICU referral, invasive monitoring and additional inotrope if there is persistent low cardiac output.
Key difference: septic shock needs fluids plus vasopressor support and infection treatment. Fluid needs must be reassessed often, especially in elderly patients or those with heart/renal failure. Recent systematic reviews on sepsis fluid strategies include PMID 40540789 and PMID 39956601.
C. Cardiogenic shock
Typical signs: hypotension with hypoperfusion plus pulmonary oedema, raised JVP, chest pain or MI, cold peripheries, oliguria, altered consciousness.
Resuscitation
- Obtain 12-lead ECG early and use bedside ultrasound/echo if available.
- Give oxygen only if hypoxaemic or severely distressed. Consider non-invasive ventilation or intubation if pulmonary oedema causes respiratory failure.
- Give very cautious fluids only if there is evidence of low filling pressure or right ventricular infarction. Stop if crackles, worsening oxygenation, raised JVP or pulmonary oedema.
- Norepinephrine is generally preferred for profound hypotension. Add an inotrope such as dobutamine when low cardiac output persists after BP is supported.
- If acute coronary syndrome is suspected, activate urgent cardiology care for reperfusion, usually PCI where available.
- Treat arrhythmias, mechanical complications, tamponade, pulmonary embolism, or acute valvular pathology as applicable.
Key difference: unlike septic or hypovolaemic shock, indiscriminate fluid can worsen pulmonary oedema. Emergency medicine references prefer norepinephrine or inotropes and specifically caution against crystalloid in cardiogenic shock with pulmonary oedema. Rosen’s Emergency Medicine, cardiogenic shock section.
D. Anaphylactic shock
Suspect it after an allergen exposure with sudden airway swelling, wheeze, stridor, hypotension, collapse, or skin/mucosal features. Skin signs may be absent.
Resuscitation
- Stop the likely trigger if possible.
- Lay the patient flat with legs elevated. Do not allow a hypotensive patient to stand or walk.
- Give IM adrenaline into the anterolateral mid-thigh immediately. Adult dose commonly used: 0.5 mg IM using 1 mg/mL adrenaline, repeat after 5 minutes if ABC problems continue.
- Give high-flow oxygen, establish IV access, and give rapid crystalloid boluses for hypotension.
- Prepare early airway intervention if voice change, stridor, tongue swelling or deteriorating consciousness.
- For refractory shock, a carefully monitored IV adrenaline infusion is required in a resuscitation/ICU setting.
- Nebulised salbutamol helps bronchospasm but does not replace adrenaline.
- Antihistamines and corticosteroids are adjuncts only, not first-line resuscitation treatment.
Adrenaline is the first-line treatment, with no absolute contraindication in true anaphylaxis. Rosen’s Emergency Medicine, anaphylaxis section. The anaphylaxis first-aid guidance also stresses supine positioning, IM adrenaline, oxygen, and CPR if the patient becomes unresponsive and is not breathing normally.
3. Cardiac resuscitation: cardiac arrest
If the patient is unresponsive and not breathing normally:
- Call emergency help and bring defibrillator.
- Start high-quality CPR immediately:
- Adult compression rate: 100-120/min
- Depth: 5-6 cm
- Allow full recoil
- Minimise interruptions
- 30 compressions to 2 breaths until advanced airway placement.
- Attach defibrillator/monitor as soon as possible.
Shockable rhythm: VF or pulseless VT
- Defibrillate as soon as possible.
- Resume compressions immediately after the shock.
- Continue 2-minute CPR cycles, rhythm checks, adrenaline and antiarrhythmic treatment according to the ALS algorithm and local hospital availability.
Non-shockable rhythm: asystole or PEA
- CPR continuously in 2-minute cycles.
- Give adrenaline as soon as IV/IO access is obtained.
- Search for reversible causes: hypoxia, hypovolaemia, hypo/hyperkalaemia or metabolic disorders, hypothermia, tension pneumothorax, cardiac tamponade, toxins, pulmonary thrombosis, coronary thrombosis.
The clinical priority is uninterrupted effective compressions and rapid defibrillation for VF/pulseless VT. Harrison’s Principles of Internal Medicine, postcardiac-arrest acute management section. The Sri Lankan national A&E document places cardiac arrest in the highest triage category requiring immediate resuscitation.
4. If you meant seizure/status epilepticus
A seizure is not “shock,” but prolonged or repeated seizures can cause hypoxia, acidosis, aspiration and eventually cardiac arrest.
- ABCDE first, protect from injury, place in lateral recovery position when feasible.
- Check bedside blood glucose and correct hypoglycaemia immediately.
- Give oxygen, establish IV access, monitor ECG and SpO₂.
- If seizure lasts 5 minutes or more, or recurs without recovery, treat as status epilepticus with a benzodiazepine according to the hospital protocol, then load a longer-acting antiseizure medicine if seizure persists.
- Investigate cause: glucose, sodium, calcium, infection, stroke, toxic exposure, alcohol withdrawal, malaria/dengue-related complications where relevant, etc.
- Escalate early for airway control and ICU/anaesthetic support if refractory.
One-line memory aid
- Hypovolaemic: replace volume and stop the loss.
- Septic: fluids + antibiotics/source control + norepinephrine if needed.
- Cardiogenic: support the pump, reperfuse if MI, avoid fluid overload.
- Anaphylactic: IM adrenaline first, then oxygen, fluids and airway care.
- Cardiac arrest: CPR, defibrillate shockable rhythms, treat reversible causes.
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