Chapter 1- Resuscitation

Question 1

What is shock?

Answer 1

State of impaired perfusion leading to inadequate O2 delivery and nutrients and clearance of metabolites with consequent reversible and eventual irreversible cellular injury

Question 2

How is Hypotension and shock related?

Answer 2

state of low BP but hypotension can happen without the presence of shock and vici versa.

Question 3

What is the pathophysio in shock?

Answer 3

Reduced delivery of O2, proportionally increased O2 extraction ratio to a point where there is supply-dependent O2 consumption and a oxygen deficit.

Question 4

What are the mechanisms of shocks?

Answer 4

1) Preload decreased-Cardiogenic, hypovolemic and hemorrhagic
2) Pump failure- Obstructive
3) Reduced afterload- Septic, neurogenic and anaphylactic

Question 5

what is the aim of rx in shock

Answer 5

Restore oxygen delivery to tissues and the end point of resus is complete repayment of oxygen debt

Question 6

what are the classical signs of a hypoperfused state?

Answer 6

pallor, cool skin, tachycardia, diaphoresis, AMS, tachypnoea, reduced urine output

Question 7

Which group of patients do not exhibit tachycardia in shock?

Answer 7

pts on B Blockers, athletes, neurogenic shock

Question 8

What initial mgmnt caveats are there in shock?

Answer 8

1) Begin fluid resus only when cardiogenic shock is ruled out
2) Be prepared to intubate the patient on grounds of clinical deterioration

Question 9

Basic investigations to order in Shock?

Answer 9

1) FBC-Hb and HCt to look for hemoconcentration and anemia. Neutrophil count not very suggestive
2) U/E/Cr- look for AKI and elevated urea suggestive of GI bleeding
3) ABG- get from both arterial and venous blood gas to look for widening gap
4) Lactate-for anaerobic resp
5) Trop T and cardiac enzymes and ECG-secondary MI
6) CXR-if indicated
7) GXM
8) CBG-in DM patients and peds patients
9) Blood cultures and septic work up(Urine culture,CRP) if indicated
10) UPT-if female and unexplained shock

Question 10

What is the rx of hypovolemic shock?

Answer 10

• Aggressive fluid resus with 1 to 2L crystalloids

- once there is adequate fluid resus, can start inotropic support with Dopamine and Noradrenaline

Question 11

What is the Rx of hemorrhagic shock?

Answer 11

Problem is inadequate vol and O2 carrying capacity
Hence, Rx is:
1) Control all external hemorrhage and involve the relevant surgical disciplines
2) -Prior to definitive surgical hemorrhagic control, low fluid resus strategy to prevent dislodgement of clot
-If severely hypotensive, GXM and transfuse 6 units of blood early

Question 12

What is the rx of Obstructive shock?

Answer 12

Depends on the suspected etiology:

1) if tension pneumothorax is suspected then immediate relief with needle thoracotomy and definitive tube thoracostomy should be performed
2) If cardiac tamponade then FAST U/S exam followed by CTVS consult and prepare for pericardiocentesis.
3) If PE suspected, consider noradrenaline, adrenaline or dopamine

Question 13

What is the rx of Cardiogenic shock?

Answer 13

1) Systolic BP

Question 14

What is the rx of neurogenic shock?

Answer 14

1) IV fluids
2) Inotropic support
3) Atropine
4) Vasopressors
5) Urgent neuro or ortho consult

Question 15

What is SIRS?

Answer 15

Systemic Inflammatory Response Syndrome(SIRS) is 2 out of the 4 of:

1) Fever>38 or 90bpm
3) WBC count>12 000
4) RR> 20 breaths/min or PaCO2

Question 16

What is septic shock?

Answer 16

Hypotension (systolic40mmHg from baseline) due to sepsis despite adequate fluid resus along with presence of perfusion abnormalities(lactate>=4.0, oliguria)

Question 17

Which groups exhibit an atypical response in sepsis?

Answer 17

Elderly-may present as tachycardia, tachypnoea, AMS
Young
Immunocompromised

Question 18

What are RFs of Gram-negative Bacteremia?

Answer 18

1) DM
2) Lymphoproliferative disease
3) Chemotherapy
4) Burns
5) Cirrhosis

Question 19

What is the mgmnt of septic shock?

Answer 19

1) Blood investigations as per routine shock
2) Maintain airway and consider intubation if needed
3) Aggressive fluid resus
4) Inotropic support with noradrenaline 1ug/kg/min
5) Antibiotic therapy:
- For meningitis, UTI, Biliary tract infection, immunocompetent with no obvious source: IV ceftriaxone
- For Intra-abdo infections: IV Metronidazole and IV ceftriaxone
- For CAP: IV augmentin, IV ceftazidime and IV Azithromycin

Question 20

What is resp failure and the different types?

Answer 20

It is the failure of the lungs to oxygenate and/or remove CO2
Type I: Arterial Pa02

Question 21

What are some hypercapnia?

Answer 21

1) Decreased central resp drive-Head injury, Drugs, CNS lesions, loss of hypoxic drive in chronic type 2 treated with O2
2) Airway obstruction-Asthma and COPD
3) Thoracic cage abnormalities-Rib fractures, kyphoscoliosis and morbid obesity
4) Neuromuscular abnormalities-MG, GBS, cervical/high thoracic injury

Question 22

What are some mgmnt caveats in resp failure?

Answer 22

• Do not give bicarbonate to reduce the resp acidosis and correct the pH as it will exacerbate it instead
• Always give as much O2 as necessary to correct hypoxia in COPD patients as hypoxia kills before hypercapnia

Question 23

How do you manage resp failure?

Answer 23

1) ECG, Vitals and Pulse Oximetry
2) Secure Airway via either invasive or non-invasive ventilation
3) Give Supp O2(devices dependant on the situation)
4) Perform early ABG to detect the type of resp failure and find cause asap

Question 24

What is Non-Invasive Ventilation?(NIV)

Answer 24

NIV is the application of positive pressure vent to a patient in the absence of definitive airway such as ETT/tracheostomy. 2 types: Continuous postive airway pressure (CPAP) and Bi-level Positive airway pressure(BiPAP)

Question 25

What are the indications of NIV?

Answer 25

1)Clinical Inclusion Criteria:
Signs and symp of acute resp distress
Moderate-sev hypoxia
Abdominal paradox and accessory muscle use
RR>24
2) Blood Gas findings
-Resp Acidosis pH7.10
-PaCO2>45
3) Dx
pneumonia
COPD
APO

Question 26

What are some CI of NIV?

Answer 26

• Cardiac/resp arrest
• Trauma causing inability to use mask
• Excessive secretions
• Risk of aspirations
• Hemodynamic instability
• AMS/ agitation

Question 27

Cx of NIV?

Answer 27

• Pneumothorax
• Patient-Ventilator dysynchrony
• Hypotension to PEEP causing reduced preload