Critical Care

Question 1

define shock

Answer 1

inadequate blood flow to the tissues to meet demands

Question 2

MAP equation

Answer 2

MAP = CO x TPR

Question 3

CO equation

Answer 3

CO = HR x SV

Question 4

list signs of shock

Answer 4

neuro - confusion, agitation, LOC
kidney - reduced UO
tissues - raised lactate, poor perfusion

Question 5

list 4 main types of shock & 2 lesser types of shock

Answer 5

hypovolaemic
distributive
cardiogenic
obstructive
(neurogenic)
(high output)

Question 6

what is hypovolaemic shock

Answer 6

reduced pre load and CO leading to intravascular volume depletioj

Question 7

how is intravascular volume depleted in hypovolaemic shock

Answer 7

blood loss
third space loss - interstitial space relocation
GI losses eg D&V

Question 8

what is a good indicator of perfusion in a sick ?shock person

Answer 8

mental status - shows good perfusion to brain

Question 9

at what % of blood loss does BP start to change

Answer 9

30-40% !!

Question 10

do you need to be hypotensive to be shocked

Answer 10

NO - it is common to be shocked but not necessary

Question 11

what is distributive shock

Answer 11

vascular dilation reduces TPR (loss of vascular tone)

Question 12

causes of distributive shock

Answer 12

sepsis
anaphylaxis
acute adrenal insufficiency

Question 13

what is cardiogenic shock

Answer 13

cardiac pump failure reducing CO

Question 14

what can cause cardiogenic shock

Answer 14

MI
arrhythmias
cardiomyopathy
valve disease

Question 15

what is obstructive shock

Answer 15

obstruction (in larger vessels or around heart) preventing complete cardiac filling

Question 16

causes of obstructive shock

Answer 16

PE
tension pneumothorax
pericardial effusion
tamponade

Question 17

what is neurogenic shock

Answer 17

disruption to autonomic pathways following spinal injury

Question 18

what type of shock is neurogenic

Answer 18

distributive

Question 19

signs of neurogenic shock

Answer 19

low BP
vasodilatation so warm peripheries
LOW HR !! (inappropriate as it should be high)
autonomic lability of temperature

Question 20

is neurogenic shock the same as spinal shock

Answer 20

NO - spinal shock involves spinal cord stunning so LMN signs and paralysis, but no autonomic issues

Question 21

list HR, JVP and tissue perfusion for hypovolaemic shock

Answer 21

HR high
JVP down
tissue perfusion - cool

Question 22

Mx of hypovolaemic shock

Answer 22

treat the underlying cause !!
fluid replacement - blood, crystalloids, colloids (rare)

Question 23

when would you give blood replacement vs crystalloids in hypovolaemic shock

Answer 23

give blood if blood was lost (trauma / haemorrhage)
give crystalloids if dehydrated etc

Question 24

list HR, JVP and tissue perfusion for distributive shock

Answer 24

HR high
JVP down
tissue perfusion - warm peripheries

Question 25

Mx of distributive shock

Answer 25

treat the cause !!! - sepsis = ABx - anaphylaxis = remove allergen, adrenaline fluid replacement vasopressors

Question 26

what are vasopressors

Answer 26

vasoconstrictors

Question 27

types of vasopressors

Answer 27

noradrenaline vasopresin dopamine meteraminol

Question 28

list HR, JVP and tissue perfusion for cardiogenic shock

Answer 28

HR can be high/low/normal JVP up tissue perfusion - cool peripheries

Question 29

Mx for cardiogenic shock

Answer 29

treat the cause - PCI - arrhythmia Tx - repair valve inotropes GTN - reduce afterload

Question 30

what do inotropes do

Answer 30

cause increase in cardiac conrtility and CO

Question 31

examples of inotropes

Answer 31

adrenaline dobutamine

Question 32

list HR, JVP and tissue perfusion for obstructive shock

Answer 32

HR up JVP up - great vessels are blocked so blood backs up tissue perfusion - cool

Question 33

Mx of obstructive shock

Answer 33

treat the cause - thrombolysis - needle decompression (T pneumo) in 2nd ICS MCL - drain effusion inotropes / vasopressors

Question 34

list HR, JVP and tissue perfusion for neurogenic shock

Answer 34

HR can be up or down JVP down tissue perfusion - warm

Question 35

Mx of neurogenic shock

Answer 35

vasopressors get them to a neuro centre asap

Question 36

70M cough and SOB. COPD and HF. Smoker. cyanosed, dyspnoea. crackles hr 100, bp 105/78, rr 30, o2 sats 84%. CO2 high. given salbutamol nebs, what is next Mx?

Answer 36

non invasive ventilation

Question 37

70M cough and SOB. COPD and HF. Smoker. cyanosed, dyspnoea. crackles hr 100, bp 105/78, rr 30, o2 sats 84%. CO2 high. why not increase the o2 via non rebreathe?

Answer 37

can reduce the capnic drive to breathe if o2 is too high in COPD pt

Question 38

26M found unconcious in street. gcs 3/15, hr 60, bp 100/60, rr 5. pin point pupils. Dx?

Answer 38

opioid overdose

Question 39

26M found unconscious in street. gcs 3/15, hr 60, bp 100/60, rr 5. pin point pupils. Dx?

Answer 39

opioid overdose

Question 40

44F increasingly hypotensive in ICU. admitted with ?pylonephritis. temp 38, hr 110, bp 91/60, o2 sats 95% on 60% o2. jvp high. normal K/Na, but AKI. UO 400ml total, 10-20ml/hr for 4hrs. given 3L 0.9% NaCl since admission. best immediate Mx?

Answer 40

IV noradrenaline infusion

Question 41

purpose of IV norad

Answer 41

vasopressor so constricts blood vessels peripherally to protect organs

Question 42

71M on ICU after cardiac arrest. intubated and ventillated. high co2, low o2, slightly high bicarb, low ph. what is happening?

Answer 42

respiratory acidosis with partial metabolic acidosis

Question 43

71M on ICU after cardiac arrest. intubated and ventillated. high co2, low o2, slightly high bicarb, low ph. Mx?

Answer 43

increase ventillation

Question 44

69M central chest pain radiating to shoulder. hr 88, bp 138/85, temp 37, o2 sats 95% RA. ecg sinus rhythm with ST depression V2-V6. Dx?

Answer 44

NSTEMI

Question 45

69M central chest pain radiating to shoulder. hr 88, bp 138/85, temp 37, o2 sats 95% RA. ecg sinus rhythm with ST depression V2-V6. what is the best O2 therapy?

Answer 45

no supplemental o2 - his sats are fine for now

Question 46

27F has cardiac arrest with PEA. she had attended with L chest pain, pleuritic, sudden onset. before arrest: hr 126, bp 88/40, rr 32, o2 sats 94% on 15L. ecg sinus tachy, cxr normal. cause of arrest?

Answer 46

PE

Question 47

37M trapped in burning house. facial erythema, beard singed, oral burns inspiratory stridor, hoarse voice, accessory muscle use. what has been damaged to cause resp sx?

Answer 47

larynx

Question 48

50F acute exacerbation of asthma. had salbutamol, ipratropium, IV hydrocortisone. rr 38, hypercapnic resp failure, sats 88 on 15L. mx?

Answer 48

intubate and ventilate

Question 49

is aminophylline used for asthma mx routinely?

Answer 49

not any more - only if controlled monitoring is done in extreme circumstances

Question 50

24M purpuric rash, fever, neck stiffness hr 130, bp 88/50 what mediator causes hypotension?

Answer 50

nitric oxide

Question 51

35M weighs 80kg needs norad infusion at 0.1 micrograms/kg/min infusion is made up of 4mg/50ml dextrose saline. what is the most appropriate rate of administration?

Answer 51

6ml/hour working out: 80 x 0.1 micr/kg/min = 8micr/kg/min = 480mcr/kg/hr 400mcr