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ACEM EM Certificate > 1.2i Resuscitation (Shock and Sepsis) > Flashcards

1.2i Resuscitation (Shock and Sepsis) Flashcards

1
Q

What is the formula for cardiac output?

A

CO = SV x HR

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2
Q

Briefly explain how hypovolaemic shock and distributive shock affect blood volume.

A
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3
Q

What is the formula for blood pressure?

Explain how this is affected in cardiogenic shock or sepsis.

A

BP = CO x SVR

  • In sepsis, BP (low) = CO (increased) x SVR (decreased), due to widespread vasoconstriction
  • In MI, BP (low) = CO (decreased) x SVR (increased
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4
Q

Describe the physiology of shock from hypovolaemic, cardiogenic and obstructive causes.

A

There is a widespread sympathetic response, causing vasoconstriction (pale, clammy), which increases SVR.

CO is decreased because of reduced blood volume, cardiac failure or mechanical or physiological obstruction.

The decreased CO and increased SVR causes decreased BP, leading to a narrow pulse pressure, reduced MAP.

The heart may be tachycardiac as a compensatory measure.

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5
Q

Describe the physiology of shock from distributive mechanisms.

A

Peripheral resistance (SVR) is low due to widespread vasodilation, e.g. anaphylaxis.

CO is high, MAP is low, there is a wide pulse pressure.

If vasoconstriction then occurs, as a result of decreased CO, this is called ‘cold shock’ and is ominous.

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6
Q

Question:

In paediatrics, the satisfactory urine output (mL/kg) increases the younger the patient is.

True or False?

A

True.

  • Adults: 0.5mL/kg
  • Children: 1mL/kg
  • Very young children: 2mL/kg
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7
Q

Describe the bolus size.

A

20mL/kg is a rough rule of thumb, but exercise caution in the elderly, those with poor LV failure.

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8
Q

When should you consider pressors?

A

After 2L of fluid and if it is still not responding, start thinking about pressors.

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9
Q
A
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10
Q

Question: The pitfalls of shock…

A
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11
Q

What are the 2 types of hypovolaemic shock?

A

Haemorrhagic and non-haemorrhagic.

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12
Q

How much fluid is lost in shock?

A

7% in adults, 9% in children.

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13
Q

What are the causes of non-haemorrhagic hypovolaemic shock?

A
  • GI losses, e.g. gastroenteritis
  • Renal losses, e.g. osmotic diuresis
  • Skin losses, e.g. burns
  • Third space losses, e.g. pancreatitis
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14
Q

What is the target MAP for those with shock?

A

65mmHg, helps to perfuse vital organs.

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15
Q

What are the trends you might expect to see in vitals, cognition, urine output in worsening stages of shock?

What types of fluid should you consider?

A
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16
Q

What are the features of Class I haemorrhagic shock?

A
17
Q

What are the features of Class II haemorrhagic shock?

A
18
Q

What are the features of Class III haemorrhagic shock?

A
19
Q

What are the features of Class IV haemorrhagic shock?

A
20
Q

How to evaluate response to fluid?

A
  • Rapid responder: <20% blood loss, responds to initial fluid bolus.
  • Transient responder: 20-40% blood loss, responds to initial bolus, then worsens. Give crystalloids and blood.
  • Minimal to no response: >40% blood loss, initiate massive transfusion protocol and seek urgent OT.
21
Q

What are common complications of hyper-resuscitation?

A
  • Fluid overload, pulmonary oedema
  • Acidosis, coagulopathy, hypothermia
22
Q

When should you consider arterial/central line monitoring?

A
  • Fluid resuscitation with vasopressors/inotropes
  • Multi-organ failure
23
Q

The most common cause of hypovolaemic shock is?

A
24
Q

What are the principles of treatment for cardiogenic shock?

A
  • Treat cause, e.g. MI, toxins, arrhythmia
  • Inotropes
  • ECMO
  • Theatre - intra-aortic balloon pump, stent, urgent angiography…
25
Q

Explain what the SOFA score is.

A

SOFA score >2 means increased risk of bad outcomes.

  1. O2
  2. Coagulation
  3. Bilirubin
  4. Blood pressure
  5. GCS
  6. Renal creatinine/output
26
Q

Question: The pitfalls of sepsis management…

A
  • Severe sepsis may have normal observations, especially in the young and sick, as they may compensate and crash suddenly
  • Elderly patients may have ‘blunted’ responses
27
Q

Describe the basic principles of managing resuscitation and sepsis.

A
  • A is for Airway/Adrenaline*
  • B is for Breathing*
  • Assisted breathing may decrease venous return, so always keep well hydrated
  • Consider treating arrhythmias to help with circulation

Circulation

  1. Bolus
    • Healthy adults - 1L stat, followed by 2-3L
    • Children - 20mL/kg bolus
  2. After 2L, consider vasopressors
    • Adrenaline in anaphylaxis
    • Noradrenaline 6mg in 100mL normal saline, then 5mL/hour and titrate
  3. Steroids
    • Consider if patient is normally on steroids, as adrenal suppression may be an issue
    • 100mg hydrocortisone or 10mg dexamethasone IV
    • For relative adrenal insufficiency consult your senior colleagues
  4. Antibiotic therapy
    • Blood cultures
    • Empirical antibiotics
    • Treat source, e.g. drain collection
28
Q

Question: An 80 y.o. with urosepsis…

A
29
Q

Question: All the selections below…

A

PE is an obstructive form of shock.

30
Q

What is obstructive shock?

What causes obstructive shock?

A

Obstructive shock causes impairment of:

  1. Cardiac filling
  2. Cardiac output
  3. Both

Common causes include tension pneumothorax, pericardial tamponade and massive pulmonary embolism

31
Q

What is the management of tension pneumothorax?

A

Clinical diagnosis, do not wait for XR. Rapid needle decompression, followed by re-XR.

32
Q

What are the causes of pericardial tamponade?

A

>200mL fluid in pericardial sac, usually acute.

Acute Causes

  1. Penetrating trauma, e.g. iatrogenic (PPM leads)
  2. Ruptured myocardium, e.g. MI
  3. Type A aortic dissection

Chronic Causes

  1. Pericarditis
  2. Malignancy
  3. Connective tissue disease
  4. Infection, TB, HIV
33
Q

What are the clinical signs of percardial tamponade?

A

Sinus tachycardia, dyspnoea.

Pulsus paradoxus.

Electrical alternans on ECG.

Beck’s Triad (Late, but highly specific.)

  • Hypotension
  • JVP engorgement
  • Muffled heart sounds
34
Q

What is pulses paradoxus?

A

Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus.

Measure BP manually, note the mmHg when the Koratkoff sounds are first heard on expiration.

Repeat, and note the mmHg when the Koratkoff sounds are first heard on inspiration.

35
Q

What is ECG electrical alternans?

What does it indicate?

A

Electrical alternans is an electrocardiographic phenomenon of alternation of QRS complex amplitude or axis between beats and a possible wandering base-line.

It indicates pericardial tamponade.

36
Q

What is the treatment for pericardial tamponade?

A

Diagnose with echocardiography.

Small fluid boluses to maintain blood pressure.

Needle pericardiocentesis +/- placement of catheter.

Patient should be sitting at 45 degrees, to move the heart to the anterior chest wall.

37
Q

Explain the basic approach for a needle pericardiocentesis.

A

2 basic approaches, ACEM recommends the subcostal (classical) approach, but apical and parasternal approaches are also possible.

Parasternal approach not recommended due to high risk of lacerating the left anterior descending artery…

Tutorial:https://www.youtube.com/watch?v=M4vHEr25yFk

38
Q

Question: Tension pneumothorax causes obstructive shock. True or false?

A

Obstructive shock, which leads to haemodynamic compromise.

ACEM EM Certificate (18 decks)

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