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SURGERY - 3+ conditions > 3+ conditions > Flashcards

3+ conditions Flashcards

Aetiology, pathophys, epidemiology, risks, clinical features, Hx, exam, DDx, investigations, management

1
Q

Define shock

A

State of cellular and tissue hypoxia due to reduced oxygen delivery and/or increased O2 consumption or inadequate O2 utilisation.
- Circulatory failure

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2
Q

What is undifferentiated shock?

A

Shock with an unknown cause

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3
Q

4 types of shock

A
  1. Distributive
  2. Cardiogenic
  3. Hypovolaemic
  4. Obstructive
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4
Q

Shock with more than one cause/category

A

Multifactorial shock

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5
Q

What happens if shock is not recognised and treated early?

A
  • Irreversible organ dysfunction
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6
Q

What type of shock is septic shock?

A

Distributive

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7
Q

Define septic shock

A
  • Distributive shock
  • Most common shock seen in ICU (62%)
  • Dysregulated response to infection - leads to life threatening organ dysfunction
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8
Q

Mortality of septic shock

A

40-50%

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9
Q

What happens to lactate in septic shock

A
  • Elevated - >2mmol/L
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10
Q

Describe distributive shock

A

Severe peripheral vasodilation

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11
Q

Name 6 types of distributive shock

A
  1. Septic shock
  2. SIRS
  3. Neurogenic shock
  4. Anaphylactic shock
  5. Drug and toxin induced shock
  6. Endocrine shock
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12
Q

What is SIRS?

A

Systemic inflammatory response syndrome

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13
Q

Causes of septic shock (4 groups)

A
  1. GPB = pneumonoccus, enterococcus (most common)
  2. MRSA
  3. GNB = pseudomonas, klebsiella, enterobacter
  4. Fungi - candida
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14
Q

SIRS - 2 broad groups

A

Infectious and non-infectious

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15
Q

Non-infectious causes of SIRS

A
  • Burns
  • Pancreatitis
  • Amniotic fluid/air/fat embolism
  • Post-MI
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16
Q

Define neurogenic shock

A
  • Disruption to autonomic pathways - decreases vascular resistance
  • Severe traumatic brain injury, spinal cord injury
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17
Q

Define anaphylactic shock

A
  • IgE allergic reaction

- Many other symptoms

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18
Q

Examples of drug and toxin induced shock

A
  • Overdoses
  • Bites
  • Transfusion reactions
  • Poisoning (eg. heavy metal)
  • ** Also includes infections - toxic shock syndrome (Streptococcus, Escherichia)
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19
Q

Two types of endocrine shock

A
  • Addisonian crisis

- Myxedema

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20
Q

Define Addisonian crisis in terms of endocrine shock

A
  • Altered vascular tone

- Hypovolaemia

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21
Q

Define Myxedema in terms of endocrine shock

A
  • Myocardial depression

- Pericardial effusion

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22
Q

Define cardiogenic shock

A
  • Intracardiac cause

- Cardiac pump failure leads to reduced cardiac output

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23
Q

3 groups of cardiac failure causing cardiogenic shock

A
  1. Cardiomyopathic
  2. Arrythmic
  3. Mechanical
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24
Q

Define cariomyopathic cardiogenic shock

A
  • MI - involves >40% of LV myocardium
  • Ischaemia
  • Severe RV infarction
  • Myocarditis
  • Myocardial depression
  • Dilated cardiomyopathy
  • Hypertrophic cardiomyopathy and diastolic heart failure rarely cause cardiogenic shock (lead to decreased BP and other types of shock)
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25
Q

Define arrythmic cardiogenic shock

A
  • Atrial and ventricular tachy/bradyarrythmias - induce a decrease in BP
  • CO compromised due to rhythm disturbances
  • No ACO = cardiac arrest
26
Q

Define mechanical cardiogenic shock

A
  • Severe aortic/mitral valve insufficiency
  • Acute valvular defects (rupture)
  • Retrograde dissection - ascending aorta
  • Ventricular septal defects
  • Atrial myxoma
  • Ruptured ventricular aneurysm - decrease CO (also features of obstructive shock as bleeding into sack, and haemorrhagic shocok as bleeding out)
27
Q

Define hypovolemic shock

A

Reduced intravascular volume - reduced pre-load - reduced CO

28
Q

2 subgroups of hypovolemic shock

A

Haemorrhagic and non-haemorrhagic

29
Q

Causes of haemorrhagic hypovolemic shock

A
  • Trauma
  • Upper/lower GI blood loss
  • Intra/post operative bleeding
  • Ruptured AAA
  • Iatrogenic
30
Q

Causes of non-haemorrhagic hypovolemic shock

A
  • Fluid loss other than blood
  • GI losses –> diarrhoea, vomiting
  • Skin losses –> heat stroke, burns, SJS
  • Renal losses –> drug-induced, diuresis, nephropathy
  • 3rd space losses –> into extravascular space and body cavities - trauma, intestinal obstruction, crush injury, pancreatitis, cirrhosis)
31
Q

Define obstructive shock

A
  • Usually extracardiac causes of pump failure

- Often associated with poor right ventricle output (pulmonary vascular and mechanical)

32
Q

2 types of obstructive shock

A
  • Pulmonary vascular

- Mechanical

33
Q

Define pulmonary vascular obstructive shock

A
  • RVF due to haemodynamically significant pulmonary embolism or severe pulmonary hypertension
  • RV fails –> unable to generate enough pressure to overcome resistance
  • Pulmonary vasoconstrictors –> serotonin and thromboxane
34
Q

Define mechanical obstructive shock

A
  • Presents clinically as hypovolemic - decreased preload
  • Tension pneumothorax
  • Pericardial tamponade
  • Constrictive pericarditis
  • Constrictive cardiomyopathy
35
Q

Define ACS (abdominal compartment syndrome)

A
  • Sustained intra-abdominal HTN
  • Organ dysfunction
  • Can exacerbate shock
  • Primary cause = intra-abdominal injury
  • Secondary cause = massive volumes given in resus
  • Impairs cardiac function
36
Q

Define the mechanism of shock

A
  • Cellular hypoxia - due to reduced perfusion and delivery
  • Leads to cell ion pump dysfunction, intracellular oedema, leakage of intracellular contents and inadequate regulation of cellular pH
  • Acidosis (decreased pH)
  • Endothelial dysfunction
  • Stimulates inflammatory and anti-inflammatory cascades
37
Q

Stages of shock

A
  • Pre-shock (compensated shock/cryptic shock)
  • Shock
  • End-organ dysfunction
38
Q

Define pre-shock

A
  • Compensatory responses to decreased tissue perfusion

- Tachycardia, peripheral vasoconstriction, mild hyperlactatemia

39
Q

Symptoms of shock

A
  • Tachycardia
  • Dyspnoea
  • Restlessness
  • Diaphoresis
  • Metabolic acidosis
  • Decreased BP
  • Oliguria
  • Cool, clamy skin

–> Clinically evident when blood volume decreases 20-25%

40
Q

Symptoms of end-organ dysfunctin

A
  • Organ damage
  • Multiorgan failure
  • Death
  • Anuria
  • ARF
  • Acidemia
41
Q

Shock spidemiology

A
  • Annual incidence of SEPTIC shock - 03.-0.7 per 1000
  • Complicates MI in 7-9% of patients (cardiogenic)
  • Hypovolaemic shock most common in children
42
Q

Main goals/simple approach to shock

A
  • Restore tissue perfusion
  • Improve O2 delivery
  • Reverse hypertension
  • Prevent organ damage
43
Q

First line treatment of shock

A
  • Volume resuscitation (except anaphylaxis - IM adrenaline)

- Further treatment guided by reponse to IV fluids and aetiology

44
Q

Drugs to give people in shock

A

Vasopressors

  • Alpha agonists
  • Increase MAP
  • Only give after adequate volume resuscitation
45
Q

What type of shock needs special treatment?

A

Cardiogenic

46
Q

Treating shock in all patients

A
  • Assess ABC
  • Treat underlying cause
  • Vasopressor
47
Q

Treating suspected cardiogenic shock

A
  • MAYBE IV fluids
  • Glyceryl trinitrate
  • Inotropic support (force)
  • Intra-aortic balloon pump
48
Q

Treating shock that is NOT cardiogenic

A
  • IV fluids
  • Blood products
  • Tranexamic acid (prevents blood lose)
49
Q

Risk factors for shock

A
  • Older age
  • MI
  • Cardiomyopathy
  • Ruptured AAA
  • Burns
  • Heat stroke
  • Anaphylaxis
  • Spinal/brain injury
  • Heart valve disease
  • Arryhtmias
  • Trauma
  • GIT bleed
  • GIT losses
  • Pancreatitis
  • Sepsis
  • Poinsoning
  • Endocrine disease
  • PE
50
Q

% of males who get gallstones

A

6%

51
Q

% of females who get gallstones

A

9%

52
Q

Define cholecystolithiasis

A

Stones in the gallbladder (not a disease until they cause symptoms)

53
Q

Define gallstone disease

A

Gallstones that cause symptoms

54
Q

Two subtypes of gallstones disease

A

Complicated and non-complicated

55
Q

Name some gallstones related complications

A
  • Cholcystitis
  • Cholangitis
  • Gallstone pancreatitis
  • Gallstone ileus
  • Mirizzi syndrome
56
Q

Define Mirizzi syndrome

A

Common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct or Hartmann’s pouch

57
Q

Gallstone symptoms

A

Biliary colic

  • intense, dull discomfort, RUQ and epigastric
  • may radiate to the back or right shoulder blade
  • often associated with diaphoresis and N/V

Post prandial pain
Nocturnal pain
Pain exacerbated on movement
Visceral pain

58
Q

Atypical symptoms of gallstone disease

A
  • Belching
  • Early satiety
  • Regurgitation
  • Abdominal distension/bloating
  • Epigastric or retrosternal burning
  • Nausea and vomiting
  • Chest pain
  • Non-specific abdominal pain
59
Q

Define cholecystitis

A

ACUTE

  • Most common complication of gallstones
  • RUQ pain
  • Fever
  • Leukocytosis/inflammation

CHRONIC

  • Chronic inflammatory cell infiltration
  • Minimal symptoms
60
Q

Define choledocholithiasis

A
  • Presence of stones in the CBD

- Fever, jaundice, abdo pain –> due to biliary obstruction

61
Q

Define acute gallstone pancreatitis

A
  • Obstruction of flow from the pancreatic duct or obstruction of the ampulla - causes bile to reflux back into the pancreatic duct
  • Presents with elevated bilirubin/APT/ALT

SURGERY - 3+ conditions (1 decks)

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