acutely unwelll Flashcards
how do you define shock?
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
what leads to distributive shock?
inflammation leads to increased vascular permeability
leads to colloid osmotic pressure decreasing
decreased reabsorption at venous end
fluid loss into interstitial space
what leads to hypovolaemic shock?
loss in fluid volume via damaged dermal barrier
what leads to cardiogenic shock?
cardiac stress
what is circulatory shock?
inadequate blood flow results in damage to body tissues
what is hypovolaemic shock?
loss of plasma or blood volume
what is obstructive shock?
obstruction of system
what is distributive shock?
vasodilatory shock; no resistance
what is cardiogenic shock?
heart issues causing circulatory shock
burns leading to distributive shock (fluid in body retained, just not where it should be)
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»_space; (fluid loss to interstitium)
oncotic pressure «_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
burns causing hypovolaemic shock
fluid evaporation
burns causing cardiogenic shock
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)
fluid resuscitation: history
volume loss: bleeding, dehydration, vomiting and diarrhoea
volume shift: sepsis, anaphylaxis, neurogenic
previous limited intake, thirst, abnormal loss, comorbidities
fluid resuscitation: examination
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
fluid resuscitation: observations
sys BP < 100mmHg
HR>90
RR>20
NEWS>5
giving fluid: 70kg, burnt whole right arm and front of chest
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%
1L of 5% dextrose
intravascular: 83ml
interstititium: 250ml
(glucose transporter)
intracellular: 660ml
IL 0.9% saline
intravascular: 250ml
interstititium: 750ml
(sodium potassium pump)
intracellular: 0ml
1L Hartmann’s
intravascular: 225ml
interstititium: 675ml
(low water entry due to lower osmolality)
intracellular: 100ml
superficial thickness (1st degree) - just dermis
painful
no blister
no scar
partial or intermediate thickness (2nd degree) - dermis and epidermis
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
full thickness (third degree) - towards adipose tissue and muscle
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
fourth degree - down to bone and muscle
leads to loss of tissue
aspects of care after fluids
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
PTSD around burn
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
treating PTSD
support throughout burn pathway, charities, psychological support
psychotherapy, CBT
medical needs and psychosocial impact
