1: Acute Circulatory Failure/Shock Flashcards
What is shock
Circulatory failure causing inadequate end-organ perfusion
What blood pressure defines shock
Systolic BP <90 and MAP <65 with evidence of end-organ damage
What are 3 pieces of evidence of tissue hypo perfusion
- Urine output <0.5
- Mottled skin
- Serum lactate >2
How can the causes of shock be divided
Shock caused by:
- Decrease cardiac output
- Drop in systemic vascular resistance
What are the two types of shock due to inadequate cardiac output
Cardiogenic
Hypovolaemic
What are the four types of shock due to decrease in systemic vascular resistance
Anaphylactic
Neurogenic
Distributive
Septic
How can shock be categorised
Class I - Class 4
What are the following for class I shock
a. blood loss
b. HR
c. BP
d. RR
e. Urine output
f. behaviour
a. <750ml. (15%)
b. <100
c. Normal
d. Normal
e. >30
f. Anxious
What are the following for class 2 shock
a. blood loss
b. HR
c. BP
d. RR
e. Urine output
f. behaviour
g. cap refill
a. 750-1000 (15-30%)
b. >100
c. Normal
d. 20-30
e. 20-30
f. anxious
g. >2s
What are the following for class 3 shock
a. blood loss
b. HR
c. BP
d. RR
e. Urine output
f. behaviour
g. cap refill
a. 1500-2000 (30-40%)
b. 120-140
c. Low systolic BP
d. >30
e. 5 - 20
f. Confused
g. >2
What are the following for class 4 shock
a. blood loss
b. HR
c. BP
d. RR
e. Urine output
f. behaviour
g. cap refill
a. >2000 (>40%)
b. >140
c. Unrecordable
d. >35
e. Negligible
f. Unresponsive
g. Absent
How much blood is lost in the following classes of shock
a. Class I
b. Class 2
c. Class 3
d. Class 4
a. <750ml
b. 750-1500
c. 1500-2000
d. >2000
What percentage of blood is lost in the following
a. 15%
b. 15-30%
c. 30-40%
d. >40%
How is mean arterial pressure calculated
MAP = CO x SVR
What is hypovolaemic shock
Shock due to loss of more than 20% of circulating volume
What are the two categories of hypovolaemic shock
- Fluid Loss
- Blood Loss
What blood loss could lead to hypovolaemic shock
Trauma
Ruptured AAA
GI Bleed
What fluid loss could lead to shock
- Steven Johnson
- Vomiting
- Diarrhoea
- Distributive: pancreatitis, burns
Outline NICE resuscitation guidelines for managing shock
- A-E approach to identify individual is in shock
- 500ml resuscitation fluids over 15-minutes
- Re-assess using A-E
- 250-500ml bolus if no improvement
- If given 2L and no improvement, contact ICU
Outline how much of the following individuals should have in maintenance fluids:
a. Water
b. Glucose
c. Sodium
d. Potassium
e. Chloride
a. 20-30ml/Kg/d
b. 50-100g/d
c. 1mmol/Kg/d
d. 1mmol/Kg/d
e. 1mmol/Kg/d
What is cardiogenic shock
Shock due to cardiac dysfunction
How can aetiology of cariogenic shock be divided
- Obstructive
2. Non-obstructive
What are the 5 causes of obstructive cardiogenic shock
- Constrictive pericarditis
- Tension pneumothorax
- Cardiac tamponade
- Restrictive cardiomyopathy
- PE
What are the 2 causes of non-obstructive cardiogenic shock
- MI
2. Arrhythmias
Explain management of cardiogenic shock
- Oxygen (94-98%)
- Diamoprhine
- Identify and treat cause
- Asses fluid status (JVP, BP, HR)
If under-filled: give crystalloid fluid resuscitation until MAP 70
If over-filled: give inotropic support using dobutamine until MAP 70
What mean arterial pressure is aimed for in cariogenic shock
70
Define sepsis
Life-threatening organ dysfunction caused by dysregulated immune response to infection
Define septic shock
Sepsis w/
- Lactate >2 despite fluid resuscitation
- Requiring inotrope support to maintain MAP 65
What causes sepsis
Infection
What are 4 risk factors for sepsis
- <1 or >75
- Immunocompromised
- ICU
- Invasive medical procedure
What is used to assess the risk of patients not in ITU of sepsis
qSOFA score
What qSOFA score indicates a risk of sepsis
> 2
What are the three aspects of the qSOFA score
- Altered mental state
- RR > 22
- Systolic BP < 100
What is used to assess the risk of sepsis in ITU patients
Full SOFA score
What is the difference between septic shock and other forms of shock clinically
in septic shock the skin will be warm and flushed compared to other types where peripheries often cold.
What are the red-flag criteria of sepsis set-out by NICE
- V,P or U of AVPU
- Acute confusional state
- Systolic BP <90
- HR >130
- RR >25
- Oxygen to maintain SpO2 >92
- Non-blanching rash
- Not passed urine in 18h
- Lactate >2
- On chemotherapy
What are the amber-flag criteria set out by NICE for sepsis
- Relative concerned over mental state
- Acute deterioration in function
- Immunosuppressed
- Trauma or surgery in past 6W
- RR: 21-24
6.BP 91-100 - HR 100-130 or new dysarrythmia
8 No urine in 12-18h - T <36
- Skin wound/Infection
What is the sepsis 6 care bundle
Blood cultures
Urine output - measure hourly
Fluid - resuscitation protocol
Antibiotics
Lactate
Oxygen to maintain SpO2: 94-98
What are the 4-criteria to contact ITU for septic shock
- RR > 25
- Systolic BP <100
- Altered consciousness
- Lactate remains high
What is anaphylactic shock
type I IgE mediated hypersensitivity reaction
What is an anaphylactoid reaction
release of mediators from mast cells without use of IgE antibodies
How will anaphylaxis present
- Itching
- Bronchospasm
- Angioedema
- Tachycardia
- Hypotension
What should be measured following suspected anaphylactic reaction
serum tryptase
What is the time-frame to measure serum tryptase
1-6h after anaphylactic reaction
Outline management of anaphylaxis
- Secure airway: give oxygen if required and consider intubation
- IM adrenaline
- IV chlorphenamine
- IV hydrocortisone
- Fluid resuscitation
- If wheeze, manage as for asthma
What dose of adrenaline is given and how
0.5mg IM
After what time-frame is adrenaline repeated
Every 5-minutes
What dose of chlorphenamine is given
10mg
Whose dose of hydrocortisone is given
200mg
If individual with anaphylaxis has a wheeze what is offered
Salbutamol
If after initial management of anaphylaxis individual is still hypotensive what may be done
Admit ot ITU
What could be given in ITU to manage anaphylaxis
IV adrenaline
Aminophylline
Nebulised salbutamol
What dose of adrenaline is in epi-pens
0.3mg
