Haemorrhage and shock Flashcards

1
Q

Define shock.

A

Acute circulatory failure with inadequate/inappropriate distributed tissue perfusion leading to cellular hypoxia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the signs of hypoperfusion? How does hypoperfusion occur?

A

Signs:

  • pallor
  • confusion
  • tachypnoea
  • tachycardia

Occurs when cardiac output and BP are not maintained

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How is BP calculated?

A

BP = CO x SVR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How can cardiac output decline?

A
  1. reduced HR
    - feedback from baroreceptors
    - will activate or inhibit medullary vasomotor centre
    - this will activate or inhibit the ANS
  2. reduced stroke volume
    - determined by preload/EDV and inotropy
    - Starling’s Law: when inotropy increases, EDV increases
    - inotropy can decrease due to: cardiac disease, hypoxia, hypercapnia, pH, electrolyte disturbance, BBs, CCBs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the vasoconstricting factors that determine SVR?

A
  1. Noradrenaline:
    - act on alpha receptors outside arterioles
  2. Angiotensin II
    - acts on AT1 receptors (on the endothelium of arterioles)
    - cause contract of SMCs
  3. Endothelin/Serotonin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the vasodilating factors that determine SVR?

A
  1. Prostacyclin (PGI2)
    - produced by endothelial cells from arachidonic acid
    - reduced Ca2+ entry into SMCs
    - reduces contractility of muscle
  2. NO
    - produced by endothelial cells from arginine
    - stimulates cAMP formation in SMCs
    - reduces Ca2+ and relaxes msucles
  3. Adenosine
    - released from endothelial cells and SMCs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What happens in shock (i.e. early and late stage)?

A
  • SVR is not maintained (no arteriolar constriction)
  • OR preload is reduced –> reduces stroke volume and thus reduced cardiac output

Initial stage: Compensation
- Increased HR –> increased CO –> increased BP

Later stage: Decompensation

  • arterioles cannot maintain constriction or preload reduction is too great
  • end organs are not perfused with oxygenated blood and fail
  • -> can be FATAL
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the different types of shock?

A
  1. Obstructive
  2. Distributive (loss of vasoconstriction/poor perfusion)
  3. Cardiogenic
  4. Hypovolaemic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What can cause obstructive shock? What are the signs?

A

Causes:

  • PE
  • Pneumothorax
  • Cardiac tamponade

Signs:

  • Tachycardia
  • SOB (PE)
  • Trachea deviates AWAY from affected side (PT)
  • Absent breath sounds (PT)
  • Chest pain, if pleuritic = PE
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What can cause distributive shock? What are the signs?

A

Causes:

  • sepsis
  • anaphylaxis
  • neurogenic

Signs:

  • low BP
  • tachycardia
  • fever + chills
  • nausea and vomiting
  • difficulty breathing
  • anxiety/confusion
  • inflammation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What can cause cardiogenic shock? What are the signs?

A

Causes:

  • MI
  • heart failure
  • arrhythmias
  • ventricular septal rupture
  • ischaemic cardiomyopathy
  • valvular disease

Signs:

  • chest pain
  • SOB
  • nausea + vomiting
  • diaphoresis (excessive sweating)
  • pulmonary oedema
  • acute circulatory collapse
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What can cause hypovolaemic shock? What are the signs?

A

Causes:

  • Haemorrhage
  • burns
  • surgery/trauma
  • loss of fluid + electrolytes from the gut

Signs:

  • cold
  • low BP
  • clammy skin
  • slow capillary reflex
  • greyish pallor
  • increased HR
  • oliguria
  • absent bowel sounds
  • confusion/anxiety
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the different physiological responses to hypovolaemic shock?

A

CV system:

  • activates SNS
  • increased HR, inotropy, peripheral vasoconstriction

Haematologic system:

  • Platelets activated (via TXA2) = immature clot forms
  • -> coagulation cascade + vasoconstriction activated via TXA2

Renal system:

  • increase in aldosterone = increased Na+ and water reabsorption = oliguria
  • increase in renin, therefore, increase in angiotensin II = peripheral vasoconstriction and stimulates aldosterone secretion

Neuroendocrine system:

  • increased reabsorption of water and NaCl
  • release of ADH (post. pituitary) = increase BP and reduced Na+ in plasma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the compensatory response to hypovolaemic shock?

A
  1. Immediate:
    a. arterial:
    - reduced BP (detected by baroreceptors)
    - reduced preload and ANP
    - release of ADH
    - reduce urine flow and Na+ excretion
    b. venous:
    - reduced BP causes reduced preload, SV and CO
    - increase sympathetic drive
    - increase HR and inotropy
    - constriction of large veins = more blood out of reservoir –> restore preload
  2. Long-term (hours - days)
    - increased renin release = increased angiotensin II = increased aldosterone
    - thirst stimulated = increased water intake
    - water and Na+ retention increased = restored blood volume
    - stimulation of albumin and other plasma protein synthesis in liver
    - fibroblasts in peritubular cells are sensitive to hypoxia = increased EPO = increased RBC production
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How much blood loss is considered life-threatening?

A

Acute loss of >40%/2 litres

–> Sympathetic NS will attempt to maintain O2 supply to the heart and brain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the different stages/classes of hypovolaemic shock (HS)?

A

Class I, II, III, IV

17
Q

What are the signs of Class I HS? How should the patient be managed/ what is the prognosis?

A
  • Blood loss: <750 ml/<15%
  • Pulse: <100
  • BP: normal
  • PP: normal
  • Resp rate: 14-20
  • Urine output: >30 ml/hr
  • CNS: slightly anxious

*will usually fully compensate, may feel slightly fatigued, just rest and maintain fluid intake

18
Q

What are the signs of Class II HS? How should the patient be managed/ what is the prognosis?

A
  • Blood loss: 750-1500 ml/15-30%
  • Pulse: >100
  • BP: normal
  • PP: reduced
  • Resp rate: 20-30
  • Urine output: 20-30 ml/hr
  • CNS: mildly anxious
  • will have cool clammy skin and delayed capillary refill
  • will usually fully compensate, may feel slightly fatigued, just rest and maintain fluid intake
19
Q

What are the signs of Class III HS? How should the patient be managed/ what is the prognosis?

A
  • Blood loss: 1500-2000 ml/30-40%
  • Pulse: >120
  • BP: reduced
  • PP: reduced
  • Resp rate: 30-40
  • Urine output: 5-15 ml/hr
  • CNS: confused and anxious
  • persistent decline in BP
  • normally require plasma volume expanders or blood transfusion
  • may have end-organ damage (esp kidneys)
20
Q

What are the signs of Class IV HS? How should the patient be managed/ what is the prognosis?

A
  • Blood loss: >2000 ml/>40%
  • Pulse: >140
  • BP: reduced
  • PP: reduced
  • Resp rate: >35
  • CNS: confusion, lethargy, unconscious
  • immediately life-threatening
  • blood transfusion should be initiated immediately
21
Q

What is septic shock?

A

Sepsis with hypotension

response to presence of pathogens in blood/organs

22
Q

What are the signs of septic shock?

A
  • temp.: >38 or <36
  • HR: >90
  • RR: > 20 breaths
  • PaCO2: <32 mmHg
  • WBC: >12 x 10^9/L
23
Q

What are the steps leading to septic shock (pathophys)?

A
  1. Bacterial infection
  2. Excessive immune response = reduced vascular resistance = abnormal vasoconstriction –> due to damaged endothelium or microvascular occlusion/thrombus formation
  3. Microvascualr (endothelial) damage
  4. reduced SVR
  5. low BP
24
Q

How is septic shock managed?

A
  1. If the cause is hypovolaemia:
    - restore blood volume with IV colloids (gelatines, dextrans etc) or crystalloids (isotonic or hypertonic saline)
    - restore preload
    - sue vasopressor drugs (dopamine, noradrenaline, phenylephrine, ADH) –> restore BP
  2. if the cause is sepsis then use antimicrobials
25
Q

What are the therapeutic goals in managing septic shock?

A

central venous pressure: 8-12 mmHg
MAP: >/=65 mmHg
urine output: 0.5mL/kg/hour
central venous or mixed venous oxygen saturation >/= 70%