Shock Flashcards
Definition of shock
Hypoxia at cellular level
Most common type of shock is
Hypovolemic shock
What kind of injury can never give rise to hypovolemic shock?
Isolated head injury/isolated head bleed 
Bleeding nature, when there is transaction of the artery
Vasospasm ; less bleeding
Bleeding nature, when there is laceration of the artery
Vasospasm opening increases therefore more bleeding
How does patient present when the bleeding source is venous in nature,
Gradual ooze - more time for body to compensate- late presentation
How does reactionary hemorrhage a occurs?
It occurs 4 to 24 hours after surgery due to increase in BP or slippage of knot (grannies knot🪢 )
What is the earliest indicator of hypovolemia?
tachycardia(release of adrenaline and noradrenaline)
Best indicator to determine the amount of fluid required in shock
PCWP > CVP
Because PCWP will give us a idea about left sided heart pressure and CVP gives idea about right sided heart pressure.
Best indicator of fluid resuscitation in shock
Urine output ; in adults >0.5 ML/KG/HR. children >1 ML/KG/HR.
What is the most sensitive in GIT to hypovolemic insult
Gastric mucosa (stress, ulcers)
Best end point of fluid resuscitation
MVOS
Best clinical endpoint
Urine output
Accurate measurement of MVOS can be done by drawing blood from a catheter in the
Right atrium
What is a normal value of MVOS?
50-70 %
High MVOS seen in
Septic shock
Modified shock index is equal to
HR/MAP ( MOST SENSITIVE INDICATOR )
RAPE rate overpressure difference=
= PR/ PP .
< 3 stable Patient.
>3 decompensated hemorrhagic shock.
Complications of massive blood transfusion
• Hypothermia.
• Citrate is the anticoagulant used
Chelates Ca & Mg
-> Hypocalcaemia, hypomagnesemia
- citrate toxicity.
• Hyperkalaemia/ HypoKalaemia:
* Hyperkalaemia: Stored RBCs can lyse -> K* release.
Acidosis increases K*.
* Hypokalaemia: RBCs, after transfusion, can actively take in K+
• metabolic alkalosis : Due to citrate toxicity
Later on metabolic acidosis is seen.
• Blood transfusion reactions : Febrile (mc) anaphylactic reaction
•TACO & TRAIL
MCC of death in massive blood transfusion is
Coagulopathy
How to overcome coagulopathy
Ratio of PRBC : FFP : Platelets should be 1:1:1 should be maintained
Scores that help in deciding massive blood transfusion
ABC score
TASH score
Blood substitutes
1st generation: Perfluorocarbon.
2nd generation: stroma-free Haemoglobin.
• Next-generation:
Polyethylene glycol (PEG) hemoglobin.
• Hemospan A/K/A MP4OX - PEG conjugated human hemoglobin.
Pyridoxylated hemoglobin polyoxyethylene conjugate (PHP)
In head injury there is
Bradycardia + Hypertension (cushing reflexes)
In neurogenic shock there is
Bradycardia + Hypotension
Inflammation markers are
IL-1 , IL-6 , TNF-α
Parameters of SIRS
•Temprature <36 c or > 38°C
• WBC (< 4000 or >12000 or
>10% band forms in Peripheral smear.)
•RR > 20/min (or) pCO2 <32mmHg
• PR > 90 /min
Any 2 Parameters are present: SIRS.
Sepsis =
SIRS + known foci of infection
Sepsis =
SIRS + known foci of infection
Septic shock=
Sepsis + hypotension (which fails to respond to fluid)
SOFA SCORE
Sequential (sepsis related ) organ failure assessment score
SOFA >= 2 + known foci of infection : sepsis
qSOFA SCORE
• SBP < 100 mmHg.
• Altered mental status.
• RR > 22/ min (tachypnea).
A score of >=2 : poor outcome.
During the first 6 hours of resuscitation, the goals of initial resuscitation of sepsis induced hypoperfusion should include all the following as a part of a treatment protocol:
- CVP :8 - 12 mmig.
- MAP: > = 65 mmHg.
- urinary output : >=0.5ml/kg/hr.
- MVOS: >=65%
- Normalize lactate.
Which metabolic abnormality is seen in massive blood transfusion
Metabolic acidosis
The capillary refill time is prolonged in all type of shock except
Septic shock
Definition of massive transition
Massive transfusion (MT) is defined as the replacement by transfusion of 10 units of pRBCs in 24 hours or more than 4 units of pRBCs in one hour.
In patient with head injury with solution is contraindicated
5% dextrose
Which fluid is given in severe head injury
Hypertonic saline
Fogarty catheter is used in
Acute limb ischemia