Look at the trend in the vital signs in the hours preceding the development of shock. Examine the heart and lungs and check for capillary refill. A diagnosis of shock is based on the interpretation of clinical signs. Important parameters are the pulse rate, blood pressure, respiratory rate, urine output, and mental status. Changes in these parameters give an idea about the degree of hypoperfusion of vital organs (brain, kidneys) and therefore of the degree of bleeding.
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Bleeding may be observed through a wound or drain, but the absence of blood in drains should not be taken as a sign of absent bleeding (drains can be blocked by clots). If the patient has undergone abdominal surgery, then intraabdominal bleeding may cause abdominal distention.
■ Remember ABC (airway, breathing, and circulation). Give the patient 100% oxygen to improve tissue oxygenation.
■ Perform an electrocardiogram (ECG) and put the patient on a cardiac monitor.
■ Insert two short and wide intravenous cannulae in the ante-cubital fossa, e.g., 16 gauge. If you cannot establish peripheral venous access due to vascular shutdown, either insert a central venous line or perform a short saphenous vein cutdown.
■ Infuse 1 L of warm Hartmann's solution or if severe haemorrhage then start a colloid instead, e.g., gelofusin. Aim for a urinary output of 0.5mL/kg/h and try to maintain the blood pressure.
■ Take blood samples for full blood count (FBC), coagulation screen, urea and electrolytes, and cardiac enzymes.
■ Cross-match six units of blood. There may already be blood in the bank, depending on the operation the patient had. Patients undergoing intermediate or major urological operations will at least have a group and save sample. If there is a delay in the arrival of the blood products, transfuse with O-negative blood. You should be familiar with the location of the blood bank. It takes about 1 hour to provide cross-matched blood and 10 minutes for type-specific blood.