acutely unwelll

Question 1

how do you define shock?

Answer 1

inadequate perfusion; inadequate blood pressure (no oxygen)

cardiac output does not match demand

life threatening generalised form of acute circulatory failure with inadequate oxygen delivery to (and consequently oxygen utilisation) by cells

state of cellular and tissue hypoxia due to either reduced oxygen delivery, increased oxygen consumption, inadequate oxygen utilization, or a combination of these processes

Question 2

what leads to distributive shock?

Answer 2

inflammation leads to increased vascular permeability

leads to colloid osmotic pressure decreasing

decreased reabsorption at venous end

fluid loss into interstitial space

Question 3

what leads to hypovolaemic shock?

Answer 3

loss in fluid volume via damaged dermal barrier

Question 4

what leads to cardiogenic shock?

Answer 4

cardiac stress

Question 5

what is circulatory shock?

Answer 5

inadequate blood flow results in damage to body tissues

Question 6

what is hypovolaemic shock?

Answer 6

loss of plasma or blood volume

Question 7

what is obstructive shock?

Answer 7

obstruction of system

Question 8

what is distributive shock?

Answer 8

vasodilatory shock; no resistance

Question 9

what is cardiogenic shock?

Answer 9

heart issues causing circulatory shock

Question 10

burns leading to distributive shock (fluid in body retained, just not where it should be)

Answer 10

inflammation leads to increased vascular permeability

• damaged tissue releases permeability factors, allows WBCs in, neutrophils release more permeability factors (cytokines etc.)
• formation of fibrin clot
• if burns 15-20% SA - systemic issue (mediators e.g. TNF

hydrostatic pressure&raquo_space; (fluid loss to interstitium)
oncotic pressure &laquo_space;(no ability to draw fluid back from interstitium)

BP falls

leads to colloid osmotic pressure decreasing

decreased reabsorption at venous end

fluid loss into interstitial space

Question 11

burns causing hypovolaemic shock

Answer 11

fluid evaporation

Question 12

burns causing cardiogenic shock

Answer 12

venous return «

lower end diastolic volume (less cardiac contractility)

less cardiac output

• if burns 15-20% SA - systemic issue. Mediators leak into bloodstream etc. (mediators e.g. TNF alpha worsen cardiac contractility)

Question 13

fluid resuscitation: history

Answer 13

volume loss: bleeding, dehydration, vomiting and diarrhoea

volume shift: sepsis, anaphylaxis, neurogenic

previous limited intake, thirst, abnormal loss, comorbidities

Question 14

fluid resuscitation: examination

Answer 14

signs of fluid loss, cool peripheries, prolonged cap refill, positive 45 degree leg raise

cap refill, pulse, BP, oedema, postural hypotn

cool peripheries, cyanosis, weak peripheral pulses

dry mucous membranes, reduced skin turgor

Question 15

fluid resuscitation: observations

Answer 15

sys BP < 100mmHg

HR>90

RR>20

NEWS>5

Question 16

giving fluid: 70kg, burnt whole right arm and front of chest

Answer 16

Parkland’s formula for Ringer’s solution:

4 x BSA% x weight = x ml
4x18x70 = 5040ml

give half the solution for 1st 8 hours
other half over next 16 hours

rule of 9s - one arm and upper chest = 18%

Question 17

1L of 5% dextrose

Answer 17

intravascular: 83ml
interstititium: 250ml
(glucose transporter)
intracellular: 660ml

Question 18

IL 0.9% saline

Answer 18

intravascular: 250ml
interstititium: 750ml
(sodium potassium pump)
intracellular: 0ml

Question 19

1L Hartmann’s

Answer 19

intravascular: 225ml
interstititium: 675ml
(low water entry due to lower osmolality)
intracellular: 100ml

Question 20

superficial thickness (1st degree) - just dermis

Answer 20

painful
no blister
no scar

Question 21

partial or intermediate thickness (2nd degree) - dermis and epidermis

Answer 21

superficial partial
- may scar, more painful, do not require surgery

deep partial
- more scars, less painful, require surgery

blisters and weeps. increased depth = increased risk of infection and scarring

Question 22

full thickness (third degree) - towards adipose tissue and muscle

Answer 22

dry

insensate to light touch and pin prick

small areas will heal with substantial scar or contracture

large areas require skin grafting

high risk of infection

Question 23

fourth degree - down to bone and muscle

Answer 23

leads to loss of tissue

Question 24

aspects of care after fluids

Answer 24

admission to specialist burns centre - hands, face, genitals (requires MDT involvement and intervention not at local hospital)

ongoing fluid resus - bear in mind infection and fluid overload/hypoperfusion

supportive care - nutritional support (e.g. if burns involve face and neck think about able to take food orally)

tetanus immunisation - antimicrobial prophylaxis

surgery - 3rd/4th degree may cut off venous supply causing compartment syndrome (SGARotomy). Also grafts, other wound support

VTE prophylaxis - dehydration, risk of clot

pain and anxiety - analgesia, address concerns about cosmetic outcome and ADLs

Question 25

PTSD around burn

Answer 25

flashbacks - vivid experience reliving a traumatic event

dissociation - disruptions in consciousness and perception, disconnect mind from feelings

avoidance - attempt to avoid distressing memories, thoughts, or feelings as well as external reminders such as conversations about the traumatic event or people or places that bring the event to mind

insomnia - difficulty with getting to sleep or staying asleep

hyperarousal - fight-or-flight response is perpetually turned on, and you are living in a state of constant tension. This can lead to a constant sense of suspicion and panic

hypoarousal - low physiological function as a response to traumatic memory/event

Question 26

treating PTSD

Answer 26

support throughout burn pathway, charities, psychological support

psychotherapy, CBT

medical needs and psychosocial impact