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HHD 2 and Pharma > Shock > Flashcards

Shock Flashcards

1
Q

What the 6 types of shock

A

Types of shock : SHOCAN
1. Hypovolaemic
2. Septic
3. Obstructive
4. Neurogenic
5. Cardiogenic
6. Anaphylactic

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2
Q

What is the definition of Shock

A

“Acute circulatory failure, with inadequate tissue perfusion causing cellular hypoxia”

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3
Q

Will pt with shock always have abnormal blood pressure

A

No - can have normal BP

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4
Q

Clinical features vary dependant on ….
Is “Hypotension” and “shock” interchangeable

A

Clinical features vary dependant on the mechanism
- “Hypotension” and “shock” are NOT interchangeable

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5
Q

What are pre and after-load?

A

Pre-load: before the heart
After-load : after the heart

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6
Q

AETIOLOGY:
Which types of shock are pre-load and give examples

A

Hypovolaemia:
- Haemorrhage
- Fluid loss
- Dehydration

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7
Q

Which types of shock involve the heart and give examples

A

Cardiogenic:
- MI
- CCF
- Arrhythmia

Obstructive - prevent the contraction
- PE
- Tamponade
- Pneumothorax

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8
Q

Which types of shock are after-load and give examples

A

Vasodilatory: prevents blood (or leaking) from reaching tissues and organs
- Sepsis
- Neurogenic
- Anaphylactic
- Adrenal insufficiency - this is y SNS is impor.

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9
Q

PATHOPHYSIOLOGY:
What are the initial steps in the shock cascade

A

*Circulatory failure leads to hypoperfusion which causes hypoxia

*Cells switch to anaerobic energy production –> lactic acidosis

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10
Q

PATHOPHYSIOLOGY:
What are the compensatory steps in the shock cascade?

A
  • Body attempts to rectify hypoxia and lactic acidosis by:
    –> * hyperventilation - to raise pH
    —> *release of adrenaline and noradrenaline from adrenals - to increase pressure
    —> *renin-angiotensin system activation (RAAS) - stimulates a rise in BP and so kidneys increases water retention
  • Blood diverted to essential organs (heart, brain, lungs) and away from the skin, GI tract
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11
Q

PATHOPHYSIOLOGY:
What are the progressive steps in the shock cascade?

A

*Compensatory mechanisms begin to fail.

  • Decreased perfusion of the cells leads to Na+/K+ pump failure
    –> Intracellular sodium increases and potassium leaks out - cells can’t function
  • Leakage of water/protein into surrounding tissues –> Blood viscosity increases
  • Essential organs now compromised due to reduced perfusion
  • If the gut is compromised, bacteria may enter the bloodstream, resulting in the release of endotoxins - usually gram- negative bacteria
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12
Q

PATHOPHYSIOLOGY:
What happens in the refractory step of the shock cascade?

A

*Essential organs fail
–> brain damage
–> multiorgan failure
–> death

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13
Q

Which step in the shock cascade must medicine be successful when treating shock

A

must be successful during the compensatory step to prevent progression to multi-organ failure

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14
Q

Which are the 5 clinical features of shock can we can observe?

A

Observations of shock:
1. Tachypnoea
2. Tachycardia
3. Hypotension
4. Hyper or hypothermia
5. Poor urine output - good indicator to increase fluid intake

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15
Q

What are the 7 clinical SIGNS OF DECREASED TISSUE PERFUSION in pt with shock?

A
  1. Cool peripheries
  2. Poor filling of peripheral veins
  3. Cool to the touch
  4. Warm to the touch —> sepsis/neurogenic shock
  5. Metabolic acidosis
  6. Elevated lactate
  7. Restlessness or decreased conscious level
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16
Q

what are the 3 steps in the GENERAL APPROACH TO SHOCK

A
  1. Resuscitate
  2. Diagnose
  3. Treat underlying cause
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17
Q

What are the general principles used to manage sick patient

A

ABCDE principle
A = Airway and oxygenation
B= Breathing and ventilation
C = Circulation and shock management
D = Disability due to neurological deterioration
E = Exposure and examination

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18
Q

What is common cause of shock

A

HYPOVOLAEMIC SHOCK

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19
Q

What is Hypovolaemic shock?

A

Low cardiac output direct reflection of reduced venous return (preload) - low blood volume so the cardiac output is low

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20
Q

How do we measure Hypovolemic shock

A

By measuring the cardiac out
CO = SV x HR

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21
Q

How do we measure Hypovolemic shock

A

By measuring the cardiac out
CO = SV x HR

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22
Q

What are the 4 causes of hypovolemic shock?

A
  1. Haemorrhage
  2. Loss of GI fluid
  3. Burns
  4. Renal loss - the distal tubule and collecting duct
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23
Q

HYPOVOLAEMIC SHOCK - HAEMORRHAGE:
What are the 4 ways of losing blood via haemorrhages other than visual blood loss

A

‘Blood on the floor and four more”
1. Intrathoracic
2. Retroperitoneal - beyond the abdomen - kidney and aorta
3. Pelvis
4. Intrabdominal

24
Q

What are the 4 HYPOVOLAEMIC SHOCK - HAEMORRHAGE classifications and what are the percentages of blood loss in each class?

A

Classification of shock:
I). 15% (<500ml blood loss)
II). 15-30% (500-1000ml blood loss)
III). 30-40% (1000-2000ml blood loss)
IV). >40% (>2000ml blood loss) - reversibility is uncertain

25
Q

HAEMORRHAGE MANAGEMENT:
What are the 3 HAEMORRHAGE MANAGEMENTs

A
  1. Advanced Trauma Life Support (ATLS) algorithm if the history of trauma - most of western world deals with trauma
  2. Trauma CT “the afghanogram”
  3. Baseline (and multiple repeat)
    lactate, pH and haemoglobin levels
26
Q

What are the 5 principles of haemorrhage management?

A

Principles of haemorrhage management:

  1. ID the source of the haemorrhage - pelvis, brain blood on the floor and 4 more
  2. Stop haemorrhage (pressure, tourniquet, surgical intervention)
  3. Replace blood products (1:1:1 resuscitation)
  4. Tranexamic acid - prevent clotting
  5. Avoid using lots of crystalloids (adds to haemodilution and have no clotting ability - have to balance)
27
Q

HYPOVOLAEMIC SHOCK - LOSS OF GI FLUID :
What are the 3 methods of losing GI fluid ?

A
  1. Vomiting & diarrhoea
  2. Fistulae - an abnormal connection between two body parts or an organ and the external body
  3. Sequestration of fluid in bowel lumen due to obstruction - not in circulation
28
Q

What is the DEHYDRATION MANAGEMENT:

A

Assess pt with the ABCDE approach

29
Q

what are 5 DEHYDRATION MANAGEMENTs

A
  • Baseline obs (HR, b/p, central capillary refill)
  • Gain IV access
  • Baseline bloods including lactate & electrolytes
  • Fluid challenge intake (crystalloid)
  • Monitor urine output hourly- aim for >0.5ml/kg/hr
30
Q

What are the 3 main types of fluids used in dehydration management? and name a pro for each one.

A

ISOTONIC:
- NaCl 0.9%
Pro: Corrects ECF loss

  • Ringer’s Lactate
    Pro: Generates Bicarbonate - reduces risks of hyperchloraemia and is a physiological
  • Dextrose 5%
    Pro: Glucose is rapidly metabolised
31
Q

HYPOVOLAEMIC SHOCK - BURNS:
What are the three degrees of burns and the extent of skin damage

A
  1. Superfical - 1st degree
    only in the epidermis layer
  2. Partial thickness - 2nd degree
    in the epidermis and dermis layers
  3. Full-thickness - 3rd degree
    in the epidermis, dermis and the subcutaneous layer and almost in the muscle
32
Q

HYPOVOLAEMIC SHOCK - BURNS:
Burns management ?

A

ABCDE assessment of patient
–> remember that airways swell rapidly in inhalation injury

Assess the percentage of burns using Lund & Browder chart

33
Q

What is the formula used for burns fluid resuscitation?

A
  • Use Parkland formula for fluid resuscitation:

4ml x Burns Surface Area (%) x weight (kg) = total crystalloid volume

  • Give 1⁄2 of the volume in the first 8hrs
  • Give 1⁄2 of the volume in subsequent 16hrs
34
Q

what is CARDIOGENIC SHOCK

A

Primary impairment of cardiac function may result from myocardial infarction/ischaemia, acute arrhythmias, acute cardiomyopathy, acute valvular lesions and myocardial contusion (blunt trauma to the chest)

35
Q

What are the PRESENTATIONs of CARDIOGENIC SHOCK

A
  • Chest pain,
    palpitations,
    syncope - fainting bcs of low BP

No reduction in circulating volume leads to additional features:
- Elevation of central jugular venous pressure - vein is bulky
- Pulmonary oedema

36
Q

What does an acute myocardial infraction cause

A

acute myocardial infarction results in a reduction in SV and CO and increased Left ventricular end-diastolic pressure LVEDP, Pulmonary edema and hypoxia
These cause the release of inflammatory biomarkers and catecholamines
which then causes Vasoconstriction –> increasing myocardial work and oxygen demand resulting in Cardiogenic shock!

37
Q

What are the medicine steps used during an acute myocardial infarction to prevent it lead to shock

A

Inotropes, vasopressors and MCS: prevent HTN and the reduction of SV and CO

Revascularisation: to prevent ischemia

Oxygenation and mechanical ventilation: prevent increase in LVEDP, P.edema and Hypoxia

38
Q

Which histories can cause Cardiogenic shock ?

A

History may indicate the cause of cardiogenic shock:

  • PMHx of angina,
    MI,
    HTN, hypercholesterolaemia, T2DM
39
Q

Cardiogenic shock Management?

A

Assess pt using the ABCDE approach

Baseline bloods (including troponin)
ECG
Avoid large volumes of IV fluidwill lead to overload May need ionotropic support
Treat underlying cause

40
Q

What is OBSTRUCTIVE SHOCK?
Name 3 examples of Obstructive shock

A

Secondary impairment to cardiac function results from physical obstruction to cardiac output

  1. Cardiac tamponade - space in the cardiac lining - myocardial cavity is filled with blood- heart is squashed so it cant expand
  2. Tension pneumothorax - the heart is getting squashed
  3. Major pulmonary embolism -blockage in the pulmonary artery
41
Q

PRESENTATION OBSTRUCTIVE SHOCK

A

Tamponade and tension pneumothorax are usually associated with a history of thoracic trauma

(usually penetrating but can happen in blunt mechanisms)

*Remember the classical presentation of PE and risk factors

42
Q

What are the 3 factors in the cardiac tamponade : Beak Triad

A

Beak triad
- hypotension
- jugular venous distension
- Muffled heart sounds

43
Q

Cardiac tamponade and tension pneumothorax share 2 presentations but what is the main difference?

A

both present with - hypotension
- jugular venous distension
but with tension pneumothorax there are absent breath sounds whilst cardiac tamponade has muffled heart sounds

44
Q

What is NEUROGENIC SHOCK
What happens during neurogenic shock ?

A

Spinal transection/injury with loss of sympathetic outflow beneath the level of injury

  • Vasodilation
  • Rapid increase in size of the vascular bed - blood is in the peripheries not in the heard and organs
  • Reduced venous return - less tonal control
  • Reduced cardiac output
45
Q

NEUROGENIC SHOCK MANAGEMENT ?
What are the ABCDE management approaches ?

A

A. secure airway

B. if the injury affects C3-5, the diaphragm may become affected so “3 and 5 keep the diaphragm alive”
pt needs ITU admission, careful observation +/- mechanical ventilation

C. may be bradycardic, warm peripheries, hypotensive, use of inotropes & vasopressors on ITU

D. confused if brain perfusion affected, focal neurological signs (sensory or motor impairment)

E. remember to assess anal tone & perineal sensation

46
Q

What should be avoided in Neurogenic shock management?

A

Avoid large amounts of IV fluid- will lead to
pulmonary oedema

47
Q

ANAPHYLACTIC SHOCK:
What is the reaction mediated by ?
and what does it cause :

A
  • Reactions mediated by IgE from mast cell degranulation
    Causes :
    -> Release of histamine and serotonin
    -> Rapid vasodilation
    -> Fall in systemic vascular resistance
    -> Hypotension
48
Q

Presentations of Anaphylactic shock
Signs and symptoms:

A

Skin: itchy skin or a raised red skin rash (hives) and flushing
swollen eyes, lips, hands and feet.
CNS: feeling lightheaded or faint, unconsciousness, headache and anxiety

Swelling of the mouth, throat or tongue, which can cause breathing and swallowing difficulties.
wheezing.

GI: abdominal pain, diarrhoea, nausea and vomiting

Pelvic pain

Heart: Slow or fast HR and low BP

49
Q

People with a history of allergies and known triggers are more likely to experience which type of shock?

A

Anaphylaxis

50
Q

ANAPHYLACTIC SHOCK MANAGEMENT ?
What are the steps/actions used in ABCDE approach?

A

FIRST: Immediately remove the trigger

A = manoeuvres/adjuncts/early definitive airway

B = high flow O2, examine chest, nebulised bronchodilators

C= assess b/p, gain IV access, take bloods
Administer:
- IM adrenaline 1:1000 0.5mlrepeat every 5 mins
- IV chlorphenamine 10mg
- IV hydrocortisone 200mg
- IV fluids

D = assess GCS

E= rash, erythema, triggers

51
Q

SEPTIC SHOCK:
What if the CONSENSUS CONFERENCE DEFINITIONs for SEPSIS

A

Systemic Inflammatory Response Syndrome (SIRS)
Two or more of:
- Pyrexia (>38deg) or hypothermia (<36deg)
- Tachycardia (>90bpm)
- Tachypnoea (RR >20)
- White cell count >12 or <4
- Acutely altered mental state
- Blood glucose >6.6

Sepsis = SIRS + documented source of infection

52
Q

What is severe sepsis?

A

Severe sepsis = SIRS + altered organ perfusion/evidence of dysfunction
Including:
- CVS (lactate >1.2mmol/L)
- Resp (PaO2 <9.3kPa)
- Renal (urine output <120ml over 4 hours)
- CNS (GCS <15)

53
Q

What is sepsis shock?

A

Septic shock = refractory hypotension in addition to SIRS, in presence of invasive infection

54
Q

What are the signs/symptoms of sepsis shock?
and what are they caused by?

A

Signs/symptoms caused by the release of endogenous inflammatory mediators (nitric oxide, bradykinin, histamine, prostaglandins & cytokines)

–> Vasodilation
–>Vessel permeability
–>Myocardial depression

55
Q

History may give indication of infective source
What history of sign/symptoms are treatments can be used to identify sepsis shock?

A

–> Breathlessness, productive cough
–> Abdo pain, D&V
–> Frequency, dysuria, suprapubic pain
–>Headache, neck stiffness, coma
–> Recent surgery, trauma

56
Q

When should we call for help ?
SEPSIS acronym

A

S = slurred speak
E = extreme shivering and muscle pain
P = passing no urine
S = Severe breathlessness
I = It feels like you’re going to die
S = Skin mottled/ discoloured

57
Q

SEPTIC SHOCK MANAGEMENT:
what are the 6 steps?
“Sepsis six”

A

Doing these 6 steps within the first-hour help with survival
1. High oxygen flow
2. Take blood cultures
3. Give IV antibiotics
4. Give a fluid challenge
5. Measure Lactate
6. Measure urine output

HHD 2 and Pharma (2 decks)

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