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MODULE 14 - Patient Support > EMERGENCY - Management of Shock > Flashcards

EMERGENCY - Management of Shock Flashcards

1
Q

What is shock?

A

Shock describes a severe imbalance between oxygen supply and demand within the cells that leads to inadequate cellular energy production which can result in cell death and eventually multisystem organ failure

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2
Q

What are the three phases of shock?

A

Compensated shock
Decompensated shock
Terminal shock

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3
Q

What is compensated shock?

A

Compensated shock is the stage where compensatory mechanisms are activated to counteract the decrease in tissue perfusion

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4
Q

What are the two main compensatory mechanisms triggered by the body to counteract shock?

A

Activation of the sympathetic nervous system
Activation of the renin-angiotensin-aldosterone system (RAAS)

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5
Q

How does the activation of the sympathetic nervous system act as a compensatory mechanism for shock?

A

Activation of the sympathetic nervous system triggers the release of catecholamines which triggers peripheral vasoconstriction which decreases the intravascular space to optimise volaemia, and directs blood to the critical organs, tachycardia and increased cardiac contractility to increase tissue perfusion and oxygen delivery to the cells

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6
Q

How does the activation of the renin-angiotensin-aldosterone system act as a compensatory mechanism for shock?

A

Activation of the renin-angiotensin-aldosterone system triggers sodium and water retention increasing fluid retention and thus blood volume. Through a series of mechanisms the renin-angiotensin-aldosterone system also releases angiotensin II which is a potent vasoconstrictor which decreases the intravascular space to optimise volaemia and redirect blood to core organs, which also contributes to increased tissue perfusion and oxygen delivery to the cells

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7
Q

What is decompensated shock?

A

Decompensated shock is the stage where the body’s compensatory mechanisms are actively failing and are unable maintain adequate tissue perfusion and oxygen delivery to the cells due a decrease in cardiac output resulting in hypotension and overall decreased cardiac function. This also results in hyperlacteraemia as the cells have shifted from aerobic to anaerobic metabolism. The body will continue to release catecholamines however this will be ineffective

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8
Q

What is terminal shock?

A

Terminal shock is a critical state in which the body has exhausted all compensatory mechansisms and the body’s organs begin to fail due to prolonged inadequate tissue perfusion and oxygen delivery. This results in vasodilation, hypotension, bradycardia, cardiovascular collapse and death

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9
Q

What are the six types of shock?

A

Hypovolaemic shock
Distributive shock
Cardiogenic shock
Hypoxic shock
Obstructive shock
Metabolic shock

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10
Q

What is hypovolaemic shock?

A

Hypovolaemic shock is a form of shock caused by a deficit in intravascular volume resulting in tissue hypoperfusion and insufficient oxygen delivery to the cells

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11
Q

What is haemorrhagic shock?

A

Haemorrhagic shock is a subset of hypovolaemic shock, however, is specifically a deficit in intravascular volume caused by active bleeding and thus a loss of whole blood

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12
Q

What is distributive shock?

A

Distributive shock is a form of shock caused by a pathological maldistribution of blood flow throughout the body resulting in tissue hypoperfusion and insufficient oxygen delivery to the cells

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13
Q

List three examples of forms of distributive shock

A

Septic shock
Anaphylactic shock
Neurogenic shock

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14
Q

How does septic shock act as a form of distributive shock?

A

Septic shock acts as a form of distributive shock by causing sytemic inflammation and vasodilation, causing a pooling of blood in the peripheral tissues

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15
Q

How does anaphylactic shock act as a form of distributive shock?

A

Anaphylactic shock acts as a form of distributive shock by causing sytemic inflammation and vasodilation, causing a pooling of blood in the peripheral tissues

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16
Q

How does neurogenic shock act as a form of distributive shock?

A

Neurogenic shock acts as a form of distributive shock due to a sudden loss in sympathetic tone, resulting in vasodilation and pooling of blood in the peripheral tissues

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17
Q

What is cardiogenic shock?

A

Cardiogenic shock is a type of shock where there is systolic or diastolic dysfunction resulting in decreased cardiac output resulting in tissue hypoperfusion and insufficient oxygen delivery to the cells

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18
Q

What is hypoxic shock?

A

Hypoxic shock is a type of shock caused by decreased oxygen content within the arterial blood resulting in insufficient oxygen delivery to the cells

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19
Q

List three examples of diseases which can cause hypoxic shock

A

Anaemia
Severe pulmonary disease
Methaemaglobinaemia

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20
Q

What is obstructive shock?

A

Obstructive shock is a type of shock caused by an anatomical obstruction of the great vessels or the heart itself resulting in decreased cardiac output and thus tissue hypoperfusion and insufficient oxygen delivery to the tissues

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21
Q

List three examples of diseases which can cause obstructive shock

A

Cardiac tamponade
Tension pneumothorax
Gastric dilatation volvulus (GDV) resulting in compression of the great vessels

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22
Q

What is metabolic shock?

A

Metabolic shock is a type of shock causes by the inappropriate use of oxygen by the cells

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23
Q

What is a common cause of metabolic shock in puppies?

A

Hypoglycaemia - glucose is essential for cells to utilise oxygen and create energy so hypoglycaemia can result in shock

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24
Q

Which five things can be helpful for the diagnosis and monitoring of shock?

A

Assess clinical signs/pulse parameters
Shock index
Measuring blood lactate levels
Point of care ultrasound
Blood pressure

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25
Q

What is the most important tool for diagnosing shock?

A

Assessing clinical signs/perfusion parameters

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26
Q

What are the seven key clinical signs/perfusion parameters you need to evaluate while diagnosing and monitoring shock?

A

Heart rate
Respiratory rate
Mucous membrane colour
Capillary refill time (CRT)
Mentation
Pulses
Extremities

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27
Q

How do the clinical signs/perfusion parameters manifest in patients with compensated shock?

A

Tachycardia
Normal to tachypnoea
Pink to pale pink mucous membranes
CRT 2 seconds
Mildly obtunded mentation
Fair to good pulse strength
Normal temperature of extremeties

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28
Q

How do the clinical signs/perfusion parameters manifest in patients with decompensated shock?

A

Tachycardia (bradycardia in cats)
Tachypnoea
Pale pink mucous membranes
Capillary refill time (CRT) - 2-3 seconds
Obtunded mentation
Poor pulse strength
Cool extremities

29
Q

How do the clinical signs/perfusion parameters manifest in patients with terminal shock?

A

Tachcardia or bradycardia (bradycardia most likely)
Increased or decreased respiratory rate
White to grey mucous membranes
Capillary refill time (CRT) - over 3 seconds
Stuporous/comatose
Non-palpable pulses
Cold extremities

30
Q

How do you calculate the shock index?

A

Shock index = Heart rate ÷ Systolic blood pressure
If the value is more than 1 then the patient is likely in shock

31
Q

What is an important consideration when using blood lactate levels to help diagnose shock?

A

Blood lactate levels are a non-specific marker of shock. While lactate levels will typically increase during shock, not all increases in lactate are solely due to shock, which can make this measure unreliable. Therefore, it is essential to also assess the clinical signs alongside measuring blood lactate levels before diagnosing shock

32
Q

How can blood lactate levels be used to monitor a patient while treating them for shock?

A

Measuring shock using serial blood lactate measurements throughout treatment can track the patient’s progress and prognosis with an increased lactate clearance indicating a better prognosis

33
Q

How can point of care ultrasound be used to assist in diagnosing and monitoring shock?

A

Point of care ultrasound can be useful for estimating a patient’s volaemia (the volume of blood within their circulatory system)

34
Q

What should you be aware of when using blood pressure to assist in diagnosis and monitoring of shock?

A

Blood pressure readings can be inaccurate. Therefore, it is essential to also assess the clinical signs alongside measuring the blood pressure

35
Q

What is the first line treatment method for shock?

A

Goal directed fluid therapy (also known as fluid challenge)

36
Q

Which four methods can be used to establish vascular access for goal directed fluid therapy?

A

Peripheral venous catheterisation
Central venous catheterisation
Venous cut down procedure
Intraosseous catheterisation

37
Q

What is a venous cut down procedure?

A

A venous cut down procedure is when an incision is made to expose the vein to allow for direct venous catheterisation

Venous cut down procedure
38
Q

Why is goal directed fluid therapy used as the first line treatment for shock?

A

Goal directed fluid therapy is used as first line treatment for shock because it helps to restore circulating blood volume and improve tissue perfusion and thus oxygen delivery to the cells

39
Q

Which route of fluid administration would you want to use to treat a patient in shock and why?

A

The intravenous route would be the most suitable in patients presenting with shock as the patient requires rapid vascular volume restoration

40
Q

How do you carry out goal directed fluid therapy when treating shock?

A

Administer a bolus of intravenous fluid into the patient over 10 to 20 minutes. After the bolus has been administered, reassess the cardiovascular parameters. Repeat the boluses until the patient has reached cardiovascular stability. If you have administered three fluid boluses and the patient’s clinical signs have not improved, then you need to stop and look at an alternative treatment method

41
Q

How much fluid per bolus should you administer to a dog undergoing goal directed fluid therapy to treat shock?

A

10 - 20ml/kg IV fluid per bolus over 10 to 20 mins in a dog

42
Q

How much fluid per bolus should you administer to a cat undergoing goal directed fluid therapy to treat shock?

A

5 - 10ml/kg IV fluid per bolus over 10 to 20 mins in a cat

43
Q

Why are isotonic crystalloid solutions often used as the inital resuscitative fluid for treatment of shock?

A

Isotonic crystalloids are effective replacement fluids as they have a similar osmolarity as plasma and thus when administered these fluids will rapidly redistribute into the intersititial and intracellular compartments leaving about 25% of the delivered volume in the intravascular space to allow for restoration of circulating blood volume. The redistribution of the fluid prevents fluid overload and increase the workload on the cardiovascular system which could potentially exacerbate the shock

44
Q

How do hypertonic crystalloids treat shock?

A

Hypertonic crystalloids have a greater osmolarity than plasma and thus after rapid infusion, an osmotic gradient is created that draws water from the intracellular and interstitial space into the intravascular space resulting in a rapid expansion of intravascular volume

45
Q

What are the indicators for using hypertonic crystalloids to treat shock?

A

Hypertonic crystalloids present as a good option for patients with traumatic brain injury as hypertonic crystalloids can reduce intracranial pressure (ICP), when rapid intravascular volume expansion is required and they are also anti-inflammatory

46
Q

What is the dose rate for hypertonic crystalloids for shock treatment in small animals?

A

2 - 4ml/kg every 10 minutes

47
Q

What are two of the adverse affects of hypertonic crystalloids?

A

Hypernatraemia (due to the high sodium concentration of hypertonic crystalloids)
Dehydration (due to the high volume of water drawn from the intracellular and interstitial space into the intravascular space)

48
Q

Why are hypotonic crystalloids contraindicated in treating patients with shock?

A

Hypotonic crystalloids have a lower osmolarity than plasma and thus adminstration of hypotonic crystalloids would result in the formation of a osmotic gradient that would draw fluid out of the intravascular space, decreasing the blood volume and exacerbating the state of shock

49
Q

Why should you be careful to avoid overzealous IV fluid therapy when treating haemorrhagic shock?

A

Intravenous fluid administration in patients in haemorrhagic shock can increase the risk of fluid overload and exacerbate active bleeding

50
Q

Why should you be careful to avoid overzealous IV fluid therapy when treating cardiogenic shock?

A

Overzealous IV fluids administration in patients in cardiogenic shock can cause fluid overload which can worsen congestion and increase the workload on the heart which is already unable to pump effectively

51
Q

Why would intravenous fluid therapy be contraindicated for hypoxic shock?

A

Intravenous fluid administration in patients in hypoxic shock could worsen the condition by diluting the concentration of oxygen-carrying erythrocytes in the circulation, leading to further tissue hypoxia

52
Q

List three other methods that can be used to treat shock

A

Hypotensive resuscitation
Blood product administration
Drug administration

53
Q

What is hypotensive resuscutation?

A

Hypotensive resuscitation is a resuscitation strategy that uses limited fluids and blood products during the early stages of treatment to deliberately allow the patient’s mean arterial pressure (MAP) to remain lower than normal physiological levels.

54
Q

What mean arterial pressure (MAP) value are you aiming for when carrying out hypotensive resuscitation?

A

60 - 65mmHg

55
Q

How can hypotensive resuscitation be useful as a temporary measure while treating haemorrhagic shock?

A

Hypotensive resuscitation uses limited fluids and blood products during the early stages of treatment which can be beneficial for treating haemorrhagic shock as excessive fluids can exacerbate bleeding

56
Q

How can hypotensive resuscitation be useful as a temporary measure while treating obstructive shock secondary to gastric dilaltation volvulus (GDV)?

A

Hypotensive resuscitation uses limited fluids and blood products during the early stages of treatment which can be beneficial for treating obstructive shock secondary to gastric dilaltation volvulus (GDV) as after the GDV is corrected in surgery, the compressed vessels will return to normal and redistribute the blood around the body and potentially cause hypervolaemia

57
Q

Which blood products can be beneficial to administer to patients in haemorrhagic shock?

A

Whole blood

58
Q

Which blood products can be beneficial to administer to patients in hypoxic shock?

A

Packed red blood cells to replenish oxygen carriers

59
Q

Which two drug classifications can be beneficial for the treatment of shock?

A

Vasopressors
Inotropes

60
Q

How can the administration of vasopressors be beneficial when treating shock?

A

Vasopressors trigger vasoconstriction which decreases the intravascular space to optimise volaemia and redirects blood flow to core organs

61
Q

Give an example of a vasopressor

A

Noradrenaline

62
Q

How can the administration of inotropes be beneficial when treating shock?

A

Inotropes increase cardiac contractility which increases cardiac output to increase tissue perfusion and oxygen delivery to the cells

63
Q

Give two examples of inotropes

A

Dobutamine
Pimobendan

64
Q

What are the four possible consequences of shock?

A

Reperfusion injury
Systemic inflammatory respose syndrome (SIRS)
Multiorgan dysfunction syndrome (MODS)
Dilutional coagulopathy

65
Q

How can shock cause reperfusion injury?

A

Shock can result in reperfusion injury as after a period of hypoperfusion the restoration of blood flow to the tissues can trigger an inflammatory response and the production of reactive oxygen species which can cause damage to the tissues

66
Q

How can shock cause systemic inflammatory respose syndrome (SIRS)?

A

When there is insufficient oxygen delivery to the cells, the cells will shift from aerobic to anaerobic metabolism resulting in increased lactate and H+ in the blood causing metabolic acidosis. In response to this metabolic acidosis, the body will trigger a systemic inflammatory response as it perceives this acidosis as a threat - resulting in systemic inflammatory respose syndrome (SIRS)

67
Q

How can shock cause multiorgan dysfunction syndrome (MODS)?

A

Shock can result in multiorgan dysfunction syndrome (MODS) by causing widespread tissue hypoperfusion leading to cellular damage and dysfunction. This can trigger a cascade of inflammatory responses and oxidative stress causing cell death resulting in multisystem organ dysfunction

68
Q

What is dilutional coagulopathy?

A

Dilutional coagulopathy is the dilution of coagulation factors

MODULE 14 - Patient Support (24 decks)

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