You walk into a low acuity room in your emergency department, the patient has a vague or trivial problem. You start your history, and the patient is all over the place, not answering the questions, sitting up, laying down, grabbing a K-basin, trying to vomit, putting the K-basin away. Ask yourself the following multiple choice question: The patient above is: a) Being difficult, or b) About to die?
In the emergency room we often see patients in overt shock states and we are good at recognizing this. Sometimes they are septic patients, sometimes trauma patients, and occasionally the cause of shock is something more exotic. Most of these patients either arrive in shock or give us some reason to think shock might develop. Occasionally you walk into a room and are totally surprised to see a patient far more ill than their triage assessment would have lead you to believe.
Shock is a dynamic process and very occasionally you get to witness a patient move across their own physiological tipping point and decompensate in front of your eyes. It sounds like something that should be easy to recognize, but it’s not. The first signs of shock state are subtle. Anxiety is probably the first mental status change to occur, followed closely thereafter by a mild agitation. From there onwards things are unpredictable, some patients follow a predictable path of decompensation, while others simply arrest with little warning.
Geography is destiny in the emergency department. Once a patient gets placed in a minor treatment area, or a low acuity area of the emergency department we all have a tendency to commit a form of anchoring error (the patient is in the minor illness area of the emergency department and therefore must have a minor illness). The agitated and anxious patient must always raise our level of suspicion.Certainly these patients may have underlying mental health problem, but sometimes what we are witnessing is the beginning of cerebral hypoperfusion, and if we are sensitive to this can save lives. There is nothing better than seeing a low acuity patient, recognizing the earliest signs of shock and moving them to your resus room to figure out what they are in shock!