Deck 8 Flashcards
Shock definition
Life threatening failure of oxygen delivery to tissues (leads to anaerobic respiration)
Shock manifestations
Skin (
Brain IC autoregulation
MAP 50-150
Kidney pressure autoregulation
MAP 70-170
Hypovolaemic shock
Reduced preload, reduced EDV (low SV and CP impacted, so hypotension)
Compensation by tachycardia, vasoconstriction.
See cold peripheries, tachycardia, hypotension, hypovolaemia.
Haemorhagic is special type that needs RBCs an clotting factors as Tx
How much blood lost until BP drops
Stage 3, 1500-2000mL loss
Distributive shock tpyes
Sepsis, anaphylaxis, neurogenic
Anaphylactic shock
Distributive, but also hypovolaemic. T1HS. Histamine mediated vasodilation and pooling into interstiium. Give adrenaline (0.5mg (0.5mL 1:1000), 10mh chlorphenamine and 200mg steroid) plus fluids as adrenaline wont reverse fluid movement
Septic shock
distributive and hypovolaemic.
If refractory to fluids then send to ITU for vasopressor
Neurogenic shock
Spinal injury above T6, leaving vagus unopposed.
Paradoxical bradycardia.
Needs fluid therapy (even though euvolaemic) and vasopressor + ionotropes and chronotopes (Adrenaline)
Distributive shock signs
hypotension, shock signs, flushed complexion and warm peripheries. May have tachycardia, but bradycardia in neurogenic shock
Cardiogenic shock
Can be post MI, arrythmias, bradycardia or CHF
Compensatory tachycardia and increased heart contraction. Hypotension, reduced urine, altered GCS and peripheral shutdown. May have fluid overload.
Tx with morphine (2.5mg-5mg for pain, anxiety, dyspnoea), assess fluid balance and give furosemide if pulmonary oedema
Obstructive shock
Can be tension pneumothorax with mediastinal shift, PE, aortic dissection or cardiac tampoade.
SV impaired, hypotension occurs. Tachycardia and vasoconstriction. Fluid status may be normal.
All shock types have
hypotension, oliguria/anuria (AKI risk) and altered mental state)
peripheral temp cool in shock with
All types, except distributive
Skin pale in shock?
Hypovolaemic and obstructive
Skin pale and clammy in ? shock
cardiogenic
Skin flushed in ? shock
distributive
Thready pulse in ? shock
hypovolaemia and cardiogenic (due to vasoconstriction)
Rapid bounding pulse in ? shock
Septic shock (wide due to vasodilation)
Urine monitoring in shock
hourly
mast cell tryptase?
may test for this in anaphylactic shock
sepsis
Life threatening response to injury which damages body
NEWS2 for sepsis
5 or more triggers sepsis screen in presence of RF or concern from HCP
Sepsis RF
Age extremes, impaired immunity, recent invasive procedure, broken skin
Common causes of sepsis
pneumonia, UTIs, abdominal source, MSK endocarditis, meningitis
Red flag sepsis criteria
Evidence of altered mental state Sys BP<90 (or 40 below normal) HR >130 RR>25 Needs oxygen for min sats Skin stigmata (rash, cyanosis, mottling) Lactate >2 Recent chemo Anuria for 8h/<0.5mL/kg/hr
If any ONE of these then sepsis 6
Amber sepsis criteria
Concern over mental status "off legs" Immunosuppressed Recent surgery/trauma RR 21-24 BP 91-100 Temp <36 Clinical signs of wound infection
Any ONE of these triggers further review
Septic shock diagnosis
Technically sepsis AND persistent hypotension, vasopressor to maintain MAP >65 and lactate >2
But vasopressor not available outside CC, so sepsis AND <90 despite fluid AND lactate >2
Escalation criteria for sepsis
Lactate >4, or SBP<90 or lactate/SBP abnormal despite 20mL/kg bolus after 1 h
Management of septic shock
Broad spec Abx
500mL fluid bolus (up to 20mL/kg)
Take lactate, urine, blood culture
Neutropoenic sepsis
Diagnosis is <0.5 10x9
Consider atypical infection sites (including perianal area, but do not perform PR )
Adrenaline dose for anaphylaxis
0.5mL of 1:1000 adrenaline (IM) - 0.3mL if <10.
10mg chlorphenamine by low IV infusion/IM
200mg hydrocortisone slow IV
Also give 15L oxygen, raise legs and give fluid
Causes of airway obstruction
CNS depression, physical obstruction, infection, inflammation, bronchospasm, laryngospasm
Space for needle decompression in pneumothorax
4/5th IC space above rib with orange/greay cannula
Immediate acute asthma management
OSHIT Oxygen (15L) Salbutamol Hydrocortisol (IV, or oral pred) Ipratropium (SAMA if salbutamol not working) Theophylline (or aminophylline IV)
Can also give magnesium sulphate
Escalate
Medium concentration oxygen mask
35-80% at 5-8L/min
Nasal cannulae
24,28,32,36,40,44 at 1.5L/min
Venturi mask
Gives most accurate delivery
24,28,31,35,40,60% - valve dependent
Higher oxygen venturi
Green
Medium oxygen venturi
Yellow
Low oxygen venturi
Blue
Circulation A_>E
BP, HR, fluid, clotting, ECG, blood test, cap reful
Management of ACS
MONA Morphine (5-10mg IV) Oxygen Aspirin (300mg, chewable) Nitrate spray
Can also give beta blocker, reassurance,/clopidogrel, enoxaparin, statin
Hypoglycaemia symptoms
Pallor, headache, tachycardia
If BM <4 and patient swallow ok
15-20g quick carb
60mL glucagon
2x tube of 40% glucose gel
Glucose tablets
Repeat BM after 15 mins, if <4 then repeat up to 3 cycles then escalate
If >4 BM following hypo and able to swallow
20g long acting (2 biscuits or 1 slice bread, or carb meal)
Look for cause
Continue insulin
If <4BM and not able to swallow
100mL 20% glucose IV over 15 mins
1mg IM glucagon
Repeat BM after 15 mins, if >4 then long acting carb. If not then 100mL 20% glucose 3x
DKA diagnosis and management
Glucose >11, ketones (blood >3, urine ++), acidotic or low bicarb
get dehydration, hypovolaemia, hyponatraemia, hyper/hypokalaemia
Give fluid (1L at initial, 1L/2h x2, 1L/4hx2, 1L/8h.
If K 3.5-5.5 then 40mmol/L/L
If <3.5 then senior review.
Give insulin infusion based on weight.
Give glucose once <14mmol/L (10%@125mL/h)
Severe DKA
Ketone>6 pH <7.1 HCO3 <6 Anion gap >16 K<2.5 GCS<12 SPO2 <98
DKA complications
hypokalaemia, hypomagnesaemia, hypophosphataemia, cerebral oedema, cardiac arrythmias, aspiration pneumonia thromboembolism
Main ketones in DKA
acetone and 2 hydroxybutyric acid
HSS
BM>30, lack of Ketones, osmolarity 320+ (2Na+ glucose+ urea)
Gives fluid, generally more slowly
Give insulin once glucose reduction <5mmol/L/hour and then give 1/2 strength
Primary Pneumothorax
No underlying lung disease, due to pleural blep rupture (often apical, CT defect at alveolar wall)
Think marfans and young males
RF for primary pneumothorax recurrance
60+, smoking
Symptoms and signs of primary pneumothorax
Symptoms: minimal/absent, but sudden onset pleuritic pain and dyspnoea. If larger the pallor and tachycardia.
Signs are reduced chest expansion, hyperresonance on percussion, dimished breath sounds on auscultation.
Secondary pneumothorax
Underlying lung disease (COPD, asthma, abscess, pumonary fibrosis)
More common 40+ and smoking
RF for secondary pneumothorax reoccurance
age, emphysema , fibrosis
Symptoms of secondary pneumothorax
Symptoms: more severe than primary, pleuritic, unilateral chest pain, dyspnoea. Pallor and tachycardia
Tension pneumothorax symptoms
Tacheal deviation, hypomobility on affected side, cyanosis, severe tachyponoea, tachycardia, hypotension
Clinical diagnosis, decompress immediately
RF for tension pneumothorax
Ventilated patient, truama patient, post CPR, acute asthma/COPD, blocked chest drain, hyperbaric oxygen Tx
Pneumothorax size
50% volume lung takes 40 days to reabsorb.
2cm interpleural distance at hilum is 50% volume
Pneumothorax management
If primary and young/fit, <2cm then consider disacharge with outpatient FU
IF >2cm and dyspnoea then aspirate
If secondary, over 50, smoking Gx or lung disease then admit all
If <1cm then oxygen and obs
1-2: aspirate and admit
>2cm and dyspnoea then chest drain
Further Tx with chemical pleurodesis/thoractomoy
Safety net for pneumothorax discharge
smoking cessation, no air travel for 6 weeks, no scuba ever
Upper GI bleed definition
Proximal to ligament of treitz (duodenal/jejunal flexure)
Upper GI bleed Ddx
peptic ulcer, varicoel bleed, oesophagitis (GERD or candida), Mallory Weiss tear (epithelial tear), Boerhaave’s syndrome (transmural), upper GI malignancy, aortoenteric fistula, AV malformation, Dieulafoy’s lesions (abnormally large blood vessel)
Key questions in upper GI bleed
blood colour, bolume, clots, retching syncope, pain, bowel symptoms, B lymphomts, surgical Hx, ulcer risk, liver damage drugs, smoking, alcohol, tattoos, liver disease
Melaena
Black tarry stools. acute upper GI bleed or sometimes small bowel/right colon
Coffee groundvomit
Digested, so ceased or mild bleed
Imaging for ulcers
CXR if ? perforation
FBC, u&E, LFT, clotting screen, G&S, VBG
OGD within 24h of acute haematemesis +CT abdo with contrast if active beel in unstable patient
Glasgow Blachtford bleeding score
Hb, urea, systolic BP, clinical features (HR, melaena, syncope), clinical features (HF, liver disease)
6+ needs intervention
1+ needs encoscopy
Rockall score
rebleed risk post endoscopy
Looks at age, shock, comorbidities,, endoscopic findings and predicts risk
Most common peptic ulcer
Duodenum
Peptic ulcer that bleeds more
gastric
Which ulcer worse after earing
gastric, duodenal tend to be less painful after eating, moreso 2-4 h later
Oesophageal varices management
Endoscopy
If unstable then theatre
Give prophylactic Abx due to sepsis risk
Give terlipressin to reduce poortal HTN
Lower GI bleed definition
distal to ligament of treitz
Types of bleed
Occult (FIT screen, IDA)
Mod rectal bleed (PR bleed/melaena in haemodynamically stable)
Severe bleed (hypotension and hct drop)
Common lower GI bleed in <30
haemorrhoids, anal fissure, IBD
> 50 lower GI bleed common causes
? colorectal cancer, divetircular disease
> 65 lower GI bleed
Angiodyplasia, diverticular disease
Angiodysplasia
Acquired
Submucosal AV malformations
Aortic stenosis association (and other valve disease
Commonly presents as IDA (occult loss). Often painless, bried, brisk loss
Blood mixed with stool
suggests proximal to sigmoid to allow mixing time
Blood on stool surface
Suggests sigmoid or rectal source
Blood after stool
Suggests anal cause
Blood only on paper
suggests fissure
Blood lone, no stool
Large bleed that’s stimulated bowel
paracetamol OD presentation
N&V, RUQ pain, jaundice
Benzo OD presentation
CNS depression, ataxia, slurred speech, resp depression
opioid OD presentation
resp depression, pin point pupil, coma
Alcohol intoxication presentation
slurred speech, ataxia, vomiting
Investigations in OD/tox
physical obs and exam (esp neuro), ABG/VBG, ECG, baseline bloods (renal and hepatic), serum level
Alcohol effects due to
GABA and 5HT actions
Alcohol withdrawal
Seen in people >20 units/ day
Chlordiazepoxide plus vit D and thiamine
Wernicke’s
B1 (thiamine) deficiency. Ataxia, ophthalmoplegia, new onset confusion
Korsakoff’s
Irreversible brain damage on background of Wernicke’s. Anterograde amnesia, confabulation, personality change
paracetamol toxicity mechanism
saturated glucuraonide conjugation (N acetyl p benziquinoneimine builds up)
N&V initially.
Then loin pain, vomiting, jaundice, abod pain, hypotension, hypoglycaemia, pancreatitis arrythmias
Tx with acetylcysteine (or activated charcoal if recent ingestion)
Use paracetamol level (post 4h - Note LFT wont show damage until 18h) for dose.
Psychiatric assessment once stable
acetycysteine side effects
rash, oedema, hypotension, bronchospasm - manage with IV chlorphenamine
OD assess,emt
current state, events prior to OD, planning, concealment, substance abuse at time, access to means for repeat
Self harm RF
Men at 25-34, women at 15-24, personality disorder, drug/alcohol abuse
Suicide RF
psychiatric illness, statement of intent, access to means, Hx of self harm/violence, FHx self harm/suicide, significant life events, painful physical illness, impulsive personality, male, older age, post partum psychosis
High risk/low risk suicide
low risk is first attempt, impulsive, non violent, relieved at rescue, unsure of outcome
High risk is concealment, notes, violent means, previous attempts
% of body weight that’s water
60 (55 in women)
Proportion of body water intra/extracellular
2/3s intracellular, 1/3 extracellular
% of extracellular water that’s intravascular/interstitial
25% intravascular, 75% interstitial
Hydrostatic pressure gradient causes
circulatory pressure, oedema, mechanical restrictions (plaster cast, infection, bandaging)
Neonate/children water %
70-80%
Metabolic fluid
400mL/day (often not counter for fluid balance)
Average adult fluid needs
2-2.5L
Adult daily insensible loss
500-800mL
Guideline for IV fluid (NICE)
25-30mL/kg/day (around 2L)
Electrolyte need/day (NICE)
1mmol/kg/day Na/Cl/K (~70mmol)
Glucose need per day in fluid (NICE)
50-100g/day glucose (limits ketosis)
GI losses /day
100mL/day (more in GI upset)
Minimum obligatory urine production
0.5mL/kg/hr (~840mL/day)
Typical ward fluid regime
1L saline with 20mmol KCl/8h
1L 5% dextrose with 20mmolKCl/8h x 2
Sweating electrolyte
sodium
Diarrhoea electrolyte loss
sodium, potassium, bicarb
vomiting electrolyte loss
potassium, chloride, hydrogen
Urine output suggestive of dehydration
<1mL/kg/hour
Hypervolaemia symptoms
cough, frothy sputum, fluid in serous cavities, HTN, peripheral oedema, pulmonary oedema, dyspnoea, raised JVP, S3/S4 , tachycardia
Hypovolaemia symptoms
headache, absent/low JVP, decreased skin turgor, dry mucous membrane, low BP, oliguria/anuria, orthostatic hypotension, peripheral shutdown, prolonged cap refil, shock.
Urine output below 1mL/kg/hour suggests dehydration.
Isotonic fluid (crystalloid) properties
0.9%NaCl stays in EC space
Hypertonic fluid
e.g. 3% NaCl/mannitol draws fliud out
Hypotonic fluid
e.g. 0.45% NaCl lowers serum osmolarity
Properties of 0.9%NaCl
154mmol Na and 154 mmol Cl
25% ditributes intravascular, 75% interstitial. so in 1L, 250mL intravascular
Glucose solution properties
Generally 5% (50g/L). ISomolar with plasma. 2/3s intracellular, 1/3 extracellular. Only 8% stays IV
Colloids
Blood, dextrans, gelatin, human albumin HES.
Draws fluid into IV compartment. Higher cost, anaphylaxis risk
NICE colloid recommendation
4-5% human albumin only in severe sepsis. 20% should not be used as too rapid.
4Ds of fluid therapy
drug, dose, duration, de-escalation
Fluid therapy initiating
Sys<100 HR>90 CAP>2s/cold peripheries RR>20 NEWs5+ Passive leg raise suggests fluid responsiveness
Giv e 500mL 0.9%NaCl in 15 mins.
Tx in fluid overload
Stop fluids
furosemide
sublingual nitrate (reduce preload)
IV nitrates (reduces pre and afterload but needs BP monitoring)
CPAP (improves gas exchange and recruits collapsed alveoli - needs critical care)
Blood transfusion
ID checks crucial
Verbal consent
Administer 1.5-2h/unit
FFP at 30mins/unit
Hypertensive emergency
Signs
Papilloedema on fundoscopy
May show enlarged blind spot in visual field test
May see retinal haemorrhage
Hypertensive emergency investigation
FBC U&E (renal function) Glucose level Cholesterol profile LFT Calcium (?PTH) cortisol +/- dex suppression Renin/aldosterone urine protein:creatinine ratio Urine metanpehrrines (?phaeochromocytoma) imaging (ecg, echo, USS, CT, MRI, MRA)
Malignant HTN pathology
- Cerebral infarction, IC haemorrhage, subarachnoid haemorrhage
- MI, HF, AAA
- Acute renal failure
Retinopathy
Cardiac arrest protocol:: shockable
VF/VT
1 shock, CPR for 2 mins
After 3 shocks, 10mL 1:10000 IV adrenaline, 300mg amiodarone
Repeat adrenaline 3-5 mins
Non shockable Cardiac arrest
10mL 1:10000IV adrenaline
30:2 CPR
Reversible causes of cardiac arrest
Toxins
Tamponade
Tension pneumothorax
Thombosis (coronary or pulmonary)
Hypoxia
Hypovolaemia
Hypothermia (note that hypothermia inhibits clotting factors)
Hyperkalaemia/hypokalaemia
