GEN SURG part 3 Flashcards
What are the 2 main causes of hypovolaemic shock?
Haemorrhage
Dehydration
E.g.s of distributive shock (3)
Sepsis
Anaphylaxis
Neurogenic shock
Causes of cardiogenic shock (4)
MI
Arryhthmias
Valve dysfunction
Metabolic disturbance
Causes of obstructive shock (3)
Massive PE
Cardiac tamponade
Tension pneumothorax
CO =
SV x HR
BP =
CO x SVR
MAP =
Diastolic BP + (systolic-diastolic) /3
What are the 3 essential features of any kind of shock?
Fall in BP by at least 40mmHg
TachyC
Tachypnoea
Other features of hypovolaemic/cardiogenic shock
Cold pale clammy pt
Rapid thready pulse
Pulse P = narrow b/c vasoconstriction
Other features of septic shock
Patient = flushed
Hot + sweaty w/ rapid ‘bounding’ pulse
Pulse P = wide b/c vasodilation
Effect of shock - cerebral
Autoregulation over MAP 50-100
Below this pt becomes agitated, confused, drowsy, then unresponsive
Effect of shock - respiratory
Incr RR due to metabolic acidosis
Effect of shock - renal
Autoreg 70-170 MAP
Below this - oliguria –> toxic build up
Effect of shock - GI
Decr gut motility + nutrient absorption
Decreased ability to sustain norm flora –> infections
MEWS score >3 =
Urgent med review
MEWS score >5 =
Critical care teams involved
What is SIRS?
Systemic inflammation response syndrome
SIRS criteria
2+ new from: T >38.3 or <36 RR >20 HR >90 WCC <4 or >12
What is septic shock a result of?
Over activation of the immune system b/c infective causes
Acute Mx of sepsis
Sepsis 6 within 1 hr O2 IV fl (500ml crystalloid stat) IV Abx Serum lactate - urgent Sr review if >4 Cultures Catheterise
When to Tx - ‘suspected sepsis)
New alteration in mental state RR >25 HR >130 SBP <90 or >40 Not passed urine for 18 prevhrs Mottled, ashen, cyanosed skin, or non-blanching rash
Acute Mx of anaphylactic shock
A-E Remove cause Adrenaline 0.5mg IM + repeat ev 5 mins Chlorphenamine 10mg IV Hydrocortisone 200mg IV Raise feet off bed to help restore circulation Serum trypase to confirm ddiag
mx class 1 hypovolaemic shock
Crystalloids
mx class 2 hypovolaemic shock
Consider giving blood
Mx class 3 hypovolaemic shock
give blood, consider surgical mx
Mx class 4 hypovolaemic shock
Will need sugrical mx
initial Mx cardiogenic shock
A-E IV diamorphine 2.5-5mg Assess for pulm oedema Consider Swan-Ganz catheter + art line If pulm cap wedge pressue = low - give 100mg plasma ev 15mins If ok - give inotropic support
Mx neurogenic shock
Fluid resus + vasopressors
What is the difference between neurogenic shock and spinal shock
Neurogenic = inhibition of sympathic outflow from spinal cord –> VD
Spinal shock = concussion of spinal cord –> flaccid arreflexia which resolves as soft tissue swelling decreases
Reflexes in spinal shock
None below level of injury
May be priaprism
What is the triad of death?
Coagulopathy
Hypothermia
Metaolic acidosis
What is a superficial incisional SSI
INfection of skin and sct tissue of incision
What is a deep incisional SSI
Infection involving deep tissues such as mm/fascial layers
What is an organ/space SSI
Infection involving any site involved in the operation other than the incision
What is impetigo
Superficial purulent infection caused by staph/strep w/ a characteristic golden crust on an erythematous base
What is ecythma
Purulent ski infection caused by staph/strep, ulceration under a crust
What i s ecythma assoc w/
Poor hygiene + malnutrition
What is erythrasma
Mild itchy eruption betw toes or in flexures, caused for corynebacterium
Tx = TO miconazole or PO erythromycin
What is folliculitis
Caused by staph, pustules heal in 7-10 days in superficial folliculitis w/ PO fluclox
Staph Scalded skin syndrome
Fever
Irritable + skin tenderness before erythema
Skin blistering develops after 24-48 hr b/c toxins from S aureus
Mx scalded skin syndrome
Take swab
+ immediate IV fluclox + supportive measures
What is anaerobic gangrene caused by
Clostridium perfringens found in soil/faeces
Pathohpysiology of anaerobic gangrene
Arise from trivial injury
Intiially gas in tissues w/ oedema + spreading gangrene + systemic upset
Tx anaerobic gangrene
REsus
Aggressive debridement + IV penicillin + metronidazole
Pathophys synergistic gangrene
Aerobes + synergistic anaerobes infect initial wound/surgical site, –> severe wound pain + (g) in tissues
May be extensive subdermal gangrene
Tx synergistic gangrene
Debridement, ABx + systemic support
Steps in reviewing someone with a fever post op
Review obs + UO
Inspect wound for superficial infection/haematoma
Inspect cannula sites for thrombophlebitis/infection
Examine chest to excl infection, infarction, acute HF
Examine legs for DVT
Consider sources of infection - GI/urine
Common locations intra-abodominal abscess
Alongsidee the organ
Pelvic
Subphrenic
Features - intra-abominal abscess (5)
Malaise Anorexia Swinging pyrexia TachyC Possible mass
Ix intra-abdominal abscess
CT abdo/pelvis
Mx intra-abdo abscess
iv abx
radiological guided draining
HOw to drain an abscess
Under GA + strong analgesia
Point of max fluctuance = incised
Small - dry dressing
Deep -antiseptic ribbon gauze + packing to keep open until they have filled w/ granulation tissue
