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SU2.1-3 | Shock and Resuscitation — PBL Case

CLINICAL SETTING

It is a busy evening in the surgical emergency unit. Mr R, a 58-year-old man with known diverticular disease, is brought in by his wife and adult daughter. For two days he has had worsening lower abdominal pain and fever; today he became confused and 'not himself'. On arrival he is flushed and warm peripherally, drowsy, with a heart rate of 126/min, a blood pressure of 86/40 mmHg, a temperature of 38.9 C and a respiratory rate of 28/min. His abdomen is rigid. The working diagnosis is perforated diverticulitis with septic shock. His family are frightened and keep asking the team what is happening and whether he will survive. The team must resuscitate Mr R while keeping his family informed and supported.

Trigger 1: Recognition and classification in the resuscitation bay

Mr R is warm peripherally yet profoundly hypotensive, tachycardic, febrile and confused. The intern comments that he 'can't be in serious shock because his hands are warm'. The registrar disagrees and calls for immediate resuscitation while a cause is sought.

DISCUSSION POINTS

  • Why is Mr R warm despite being in shock, and which type of shock does this point to? Relate your answer to BP = CO x SVR.
  • What bedside features confirm that he is in shock, and why is the 'warm hands' reasoning dangerous?
  • How would the early picture of septic (distributive) shock differ from that of haemorrhagic shock in the same department?
Click to reveal Trigger 2: Resuscitation and monitoring (discuss previous trigger first!)

Trigger 2: Resuscitation and monitoring

The team begins resuscitation using an ABCDE approach. Mr R is given oxygen, intravenous fluids and early broad-spectrum antibiotics, blood cultures and a lactate are sent, and a urinary catheter is placed. Over the next two hours his lactate begins to fall and his urine output rises, but he still needs vasopressor support to maintain his perfusion pressure.

DISCUSSION POINTS

  • What are the two simultaneous principles of resuscitation, and how do they apply to Mr R's septic shock (restore perfusion AND treat the source)?
  • Which perfusion endpoints would you monitor to judge whether resuscitation is working, and why are trends more useful than a single blood-pressure reading?
  • Why does source control (here, surgical management of the perforation) matter as much as fluids and antibiotics?
Click to reveal Trigger 3: The conversation with the family (discuss previous trigger first!)

Trigger 3: The conversation with the family

While Mr R is being stabilised, his wife stops you in the corridor. Through tears she asks, 'Please, just tell me — is he going to die?' His prognosis is genuinely guarded. You need to answer her honestly and compassionately, in a setting that is far from ideal, using a structured approach.

DISCUSSION POINTS

  • Using the SPIKES framework, how would you structure this conversation from setting it up to summarising and planning next steps?
  • Using the NURSE skills for responding to emotion, how would you reply to her direct question without either false reassurance or brutal bluntness?
  • What does 'honesty with compassion' look like in practice here, and how would you review afterwards whether the conversation was conducted well?

Group Task Assignments

  • Group A: Construct a side-by-side comparison of distributive (septic) and hypovolaemic (haemorrhagic) shock for Mr R's unit — mechanism, typical bedside picture, and first resuscitation moves.
  • Group B: Draft an ABCDE resuscitation and monitoring plan for Mr R, listing the perfusion endpoints the team will track over the first six hours and what each would tell them.
  • Group C: Write and role-play a SPIKES/NURSE-structured script for answering Mrs R's question 'Is he going to die?', then critique it against a 'what good looks like' standard.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [SU2.1] What is the pathophysiology of shock, what are the four mechanistic types and how do the principles of resuscitation (fluids, blood products, monitoring) differ between them?
  2. [SU2.2] What are the clinical features of the different types of shock and the appropriate immediate treatment for each, including septic and anaphylactic distributive shock?
  3. [SU2.3] How do you communicate and counsel patients and families about the treatment and prognosis of shock with empathy, using structured frameworks such as SPIKES and NURSE?